SOCIODEMOGRAPHIC AND CLINICAL CHARACTERIZATION OF PATIENTS UNDERGOING INTESTINAL TRANSIT RECONSTRUCTION: A CROSS-SECTIONAL STUDYABSTRACT
Objective: to analyze the sociodemographic and clinical data of patients with temporary stomas who underwent intestinal transit reconstruction.
Method: this is a cross-sectional study based on the medical records of all patients at a tertiary hospital in Teresina-Piauí, between September/2021 and June/2023. The data was tabulated in Microsoft Excel and analyzed in IBM SPSS (version 20.0), using absolute (n) and relative (%) frequencies, mean, standard deviation, Shapiro-Wilk test, Mann-Whitney U test, chi-square test and Spearman's correlation. The significance level adopted was 5%.
Results: among the 90 patients analyzed, the majority were men (71.1%), black (84.4%), single (54.4%) and without a high school education (54.4%). The mean age was 45.7 years. The most prevalent stomas were loop colostomies (27.8%) and Hartmann stomas (24.4%), most of which were in the lower right (48.9%) and lower left (44.4%) quadrants of the abdomen and were caused by appendicitis (17.8%), firearm perforation (14.4%) and colorectal cancer (12.2%). The majority had no comorbidities (58.9%) and no post-operative complications (74.4%). Among the 23 (25.6%) with complications, seven (7.8%) had their surgery redone and eight (8.9%) required intensive care, with two (2.2%) deaths. Post-surgical complications were associated with a longer post-operative stay (p<0.001).
Conclusion: there was a predominance of black men, with no high school education and a mean age of 45.7 years old. The most frequent stomas were of the loop colostomy and Hartmann's type. Appendicitis, colorectal cancer and firearm perforation were the main reasons. Post-surgical complications were significantly associated with a longer post-operative stay.
DESCRIPTORS:
Digestive system surgical procedures; Colostomy; Ileostomy; Gastrointestinal transit; Post-operative care
RESUMO
Objetivo: analisar dados sociodemográficos e clínicos de pacientes com estomias temporárias, submetidos à reconstrução de trânsito intestinal.
Método: trata-se de um estudo transversal a partir dos prontuários de todos os pacientes de um hospital terciário, em Teresina-Piauí, entre setembro de 2021 e junho de 2023. Os dados foram tabulados no Microsoft Excel e analisados no programa IBM SPSS (versão 20.0), utilizando frequências absolutas (n) e relativas (%), média, desvio padrão, teste Shapiro-Wilk, teste U de Mann-Whitney, teste qui-quadrado e correlação de Spearman. O nível de significância adotado foi de 5%.
Resultados: dentre os 90 pacientes analisados, predominaram homens (71,1%), negros (84,4%), solteiros (54,4%) e sem ensino médio completo (54,4%). A média de idade foi de 45,7 anos. As estomias mais prevalentes foram colostomia em alça (27,8%) e Hartmann (24,4%), que, majoritariamente, estavam nos quadrantes direito inferior (48,9%) e esquerdo inferior (44,4%) do abdômen e tinham como motivações apendicite (17,8%), perfuração por arma de fogo (14,4%) e câncer colorretal (12,2%). A maioria não tinha comorbidades (58,9%) e não apresentou complicações pós-operatórias (74,4%). Dentre os 23 (25,6%) com complicações, sete (7,8%) tiveram cirurgia reconfeccionada e oito (8,9%) necessitaram de terapia intensiva, havendo dois (2,2%) óbitos. Complicações pós-cirúrgicas associaram-se a maior tempo de permanência no pós-operatório (p<0,001).
Conclusão: predominaram homens negros, sem ensino médio completo e com média de idade de 45,7 anos. As estomias mais frequentes foram do tipo colostomia em alça e Hartmann. Apendicite, câncer colorretal e perfuração por arma de fogo foram as principais motivações. Complicações pós-cirúrgicas associaram-se significativamente à maior permanência no pós-operatório.
RESUMEN
Objetivo: analizar datos sociodemográficos y clínicos de pacientes con ostomías temporales sometidos a reonstrucción del tránsito intestinal.
Método: estudio transversal, basado en las historias clínicas de todos los pacientes de un hospital de tercer nivel, en Teresina-Piauí, entre septiembre de 2021 y junio de 2023. Los datos fueron tabulados en Microsoft Excel y analizados en el programa IBM SPSS (versión 20.0), utilizando frecuencias absolutas (n) y relativas (%), media, desviación estándar, prueba de Shapiro-Wilk, prueba U de Mann-Whitney, chi-cuadrado y Correlación de Spearman. El nivel de significancia adoptado fue del 5%.
Resultados: entre los 90 pacientes analizados predominaron los hombres (71,1%), negros (84,4%), solteros (54,4%) y sin educación secundaria completa (54,4%). La edad promedio fue de 45,7 años. Las ostomías más prevalentes fueron colostomía en asa (27,8%) y Hartmann (24,4%), que se realizaron principalmente en los cuadrantes inferior derecho (48,9%) e inferior izquierdo (44,4%) del abdomen y los motivos fueron apendicitis (17,8%), herida de bala (14,4%) y cáncer colorrectal (12,2%). La mayoría no presentó comorbilidades (58,9%) ni complicaciones postoperatorias (74,4%). Entre los 23 (25,6%) que tuvieron complicaciones, siete (7,8%) tuvieron cirugía reconstruida y ocho (8,9%) requirieron cuidados intensivos, con dos (2,2%) muertes. Las complicaciones posquirúrgicas se asociaron con estancias postoperatorias más prolongadas (p<0,001).
Conclusión: predominaron los hombres de raza negra, sin educación secundaria completa y con una edad promedio de 45,7 años. Las ostomías más frecuentes fueron la colostomía en asa y tipo Hartmann. Los principales motivos fueron apendicitis, cáncer colorrectal y heridas de bala. Las complicaciones posquirúrgicas se asociaron significativamente con estancias posoperatorias más prolongadas.
DESCRIPTORES:
Procedimientos quirúrgicos del sistema digestivo; Colostomía; Ileostomía; Tránsito gastrointestinal; Cuidados postoperatorios
INTRODUCTION
The stoma (from the Greek stóma), the mouth or opening of an orifice that allows a hollow organ to communicate with the external environment, is constructed through a surgical procedure called a stoma, which is performed when there is a need to divert the elimination of effluents from organs such as the intestine and bladder, treating different pathologies in these regions and improving patient survival1-3.
Intestinal stomas are made using different surgical techniques and can be made by externalizing the small intestine (ileostomy) or the large intestine (colostomy) through the anterior abdominal wall, and can be made permanent or temporary. Very commonly used in emergency settings today, this procedure can also be done on an elective basis. It is estimated that in the United States alone, more than 130,000 intestinal stomas are performed every year to treat conditions such as colorectal cancer, inflammatory bowel diseases, radiation injuries, colonic diverticulitis and fecal incontinence, among others4.
However, in addition to the challenges of the illness process itself, people with stomas also face many difficulties related to adapting to and accepting their new condition, and are often not properly instructed in the period prior to the procedure. The resulting physical changes can have an impact on the emotional and social spheres, worsening the health situation due to the lack of adequate care and even the deprivation of social spaces and mechanisms. In this sense, it is essential that there is comprehensive care for the demands of these people, in which nurses, doctors, psychologists, social workers and nutritionists aim for full and early rehabilitation from the moment the possibility of the stoma is defined until the post-operative period, taking into account that the creation of the stoma aims to improve the patient's quality of life5.
Intestinal transit reconstruction surgery, performed in cases of temporary ostomies in order to improve the patient's autonomy, is considered difficult to perform and has a morbidity rate of between 0% and 50% and a mortality rate of between 0% and 4.5%. Different individual factors converge in the development of complications, such as the surgeon's experience, the primary disease, the stoma's location, the surgical technique and the length of time between the stoma and its closure, among others6-7.
Considering that intestinal transit reconstruction is a surgery that has a high percentage of complications with the possibility of death, it is important to carry out a broader analysis of the variables that may be involved in the occurrence of these complications, allowing for improvements in the care provided at an individual and collective level. Therefore, this study aimed to analyze the sociodemographic and clinical data of patients with temporary stomas who underwent intestinal transit reconstruction.
METHOD
This is a cross-sectional study and the research report was prepared using the STROBE tool (STrengthening the Reporting of OBservational studies in Epidemiology). Sociodemographic and clinical data from the medical records of all patients with temporary intestinal elimination stomas treated at a tertiary teaching hospital (a regional reference in intestinal transit reconstruction) located in Teresina-Piauí were used. All the consultations took place between September 2021 (when the service began) and June 2023, and were covered by the Unified Health System (Sistema Único Saúde, SUS).
The study had a population of 91 participants, who were people with temporary intestinal elimination stomas and had been attended to by the end of the collection date (June/2023).
Data collection took place between June 2022 and June 2023 and was carried out by resident doctors from the service and a scientific initiation scholarship student with prior training. The data was collected using an electronic form (Google Forms) made up of four blocks, in which all the answers had to be completed. A list was drawn up in alphabetical order of the names of all the patients who made up the study population, which was given to all the previously trained researchers. A numerical code is assigned to each patient between 01 and 91, respecting their position on the list.
In Block I, there was identification of the research and those responsible, as well as instructions regarding data collection. In this block, the researcher responsible should be identified by their full name and contact e-mail address. Block II included the code associated with each patient and sociodemographic variables (gender, skin color, marital status, education and age). In Block III, the clinical variables (stoma type, stoma site, reason for the stoma, need (or not) for intensive care in the post-operative period, length of stay after intestinal transit reconstruction, comorbidities, complications of the surgery, failure (or not) of the procedure and occurrence (or not) of death). In Block IV, an open space was reserved for the inclusion of possible general observations regarding the collection of that patient.
At the end of the collection, the data was exported to a Microsoft Excel spreadsheet, allowing for subsequent statistical analysis using the IBM Statistical Package for the Social Sciences (version 20.0). Absolute (n) and relative (%) frequencies were used to characterize the participants for the qualitative variables, and means and standard deviation for the quantitative variables, as well as the Shapiro-Wilk test to check whether the data followed a normal (Gaussian) distribution. The difference between the quantitative variables was verified by the Mann-Whitney U-test. The association between the qualitative variables was analyzed using the chi-square test. The relationship between the quantitative variables was verified by Spearman's correlation. The significance level adopted was 5%.
The research was approved by the Research Ethics Committee of the State University of Piauí, Teresina-Piauí, and complied with the standards of Resolution 466/12 of the National Health Council.
RESULTS
The study investigated a population of 91 patients who underwent intestinal transit reconstruction due to a temporary ostomy. During the data analysis, one participant was excluded due to missing data and the final sample consisted of 90 participants.
As shown in Table 1, the 90 participants analyzed were predominantly male, black, single and with low education levels. The mean age of the patients was 45.7 years old.
In terms of clinical characterization (Table 2), the most prevalent stoma types were loop colostomies and Hartmann stomas. The stomas were mostly located in the lower right and lower left quadrants of the abdomen. The main reasons for having a stoma were appendicitis, firearm perforation, colorectal cancer, blunt abdominal trauma, Fournier's syndrome, sigmoid volvulus, diverticulitis, intestinal perforation, stab wounds, obstruction and perineal trauma. Most of the patients had no comorbidities and no postoperative complications. There were two deaths, one of which was due to complications from Covid-19 acquired in the postoperative period and not a direct result of complications from the surgery.
Clinical characterization of patients undergoing intestinal transit reconstruction. Teresina, PI, Brazil, 2023. (n=90)
Analysis of the relationship between age, length of stoma, length of post-operative stay and comorbidities with the presence (or not) of post-operative complications (Table 3) showed that the presence of these complications was significantly associated with a longer length of post-operative stay (p<0.001).
The dispersions relating to the patients analyzed showed that there was no significant association (p>0.05) between the age of the patients and length of post-operative stay and length of stoma, as well as between length of stoma and length of post-operative stay.
DISCUSSION
Due to various challenges, such as the complex territorial extension, the lack of records and the difficulty of communication between services, there is a deficit of epidemiological data on ostomized people in Brazil8. However, the Ministry of Health estimated that there were 207,000 people with stomas in the country in 2018. This figure takes into account a projection made by the International Ostomy Association that there is one person with an ostomy for every thousand inhabitants in countries with a good level of care5. This condition requires coordinated, multi-professional care to guarantee the patient's autonomy and adaptation, even after discharge from hospital9-12. Comprehensive care for these patients must encompass all dimensions of the individual, such as biological, psychological, emotional, aesthetic, social, cultural, economic, political and religious13.
Temporary stomas are performed to protect an anastomosis and are a therapeutic approach that reduces mortality. However, living with an intestinal stoma is a difficult process, causing a number of changes in various individual dimensions and with a consequent reduction in quality of life. It is therefore essential to provide these patients with full and early rehabilitation in the preoperative period, during the procedure and in the postoperative period, in order to minimize these impacts. From this perspective, effective nursing has a central role to play in ensuring a multidimensional care plan5,14-17.
The sociodemographic characterization of this study showed a predominance of men, with a low education level and a mean age of 45.7 years, which is in line with the literature on patients undergoing intestinal transit reconstruction. However, single marital status predominated18-21. The majority of patients were black or brown. Although this fact is related to the ethnic composition of Piauí, which has around 73% of its population who are black or brown, according to data from the 2010 Demographic Census of the Brazilian Institute of Geography and Statistics22, it may also be related to social conditions that the black population still faces in the country, such as income issues, since these patients are treated exclusively via the SUS. Of the 150 million users who depend exclusively on the SUS, 67% are black or brown23.
In this study, we opted for a broad approach to clinical variables in order to better characterize the population. An analysis of patients with quantitative and qualitative characteristics very similar to those presented in this study also showed a predominance of loop colostomies and Hartmann stomas1. It should be noted that the location of the stoma in the abdomen depends on the surgical technique used. There was a predominance of appendicitis, firearm perforation and colorectal cancer as reasons for the stoma. It is believed that the large number of patients with appendicitis and firearm perforation as reasons for the stoma was due to the referral nature of the service for this profile of patient referred from the General Surgery emergency service of another hospital in the city. Colorectal cancer, which is classically the main reason for a stoma24, also had a significant number of cases in this series.
As a previous study showed, in this study most of the participants analyzed were under 60 years of age, which may have influenced the lower incidence of comorbidities25. What's more, among the comorbidities presented, those most prevalent in the Brazilian population prevailed, according to the Vigitel 201926 survey. Similarly, the post-surgical complications that occurred in this study occurred in a similar way to other studies in the literature1,6,25,27-28.
The literature associated with intestinal transit reconstruction shows high morbidity and mortality rates. Another survey showed values for morbidity percentages varying between 0% and 50% and for mortality percentages between 0% and 4.5%1. In a previous study, for example, the percentage of clinical complications was 58.4% and surgical complications was 35.5%, even though the majority of patients were under 60 years of age and had no comorbidities25. Therefore, this study showed quite acceptable percentages of morbidity (25.6%) and mortality (2.2%), even more so taking into account the analyses, in which age, length of time with the stoma and the presence of comorbidities did not prove to be determining factors for the presence (or not) of complications. On the other hand, patients who had complications had a significantly longer postoperative hospital stay, which was also the case in another study1.
Age and length of stoma were not associated with a longer postoperative hospital stay, nor was age associated with a shorter or longer length of stoma, suggesting a more decisive role for the presence of complications in a longer postoperative hospital stay, which implies higher hospital costs and a greater workload for the healthcare team29-30. It should be noted that there is the possibility of reverse causality, inherent in cross-sectional studies, limiting the association found by the fact that little can be said about what was the cause and what was the consequence. However, it was observed that post-surgical complications in the patients analyzed often culminated in procedures that prolonged the length of hospitalization, such as the indication of intravenous antibiotic therapy, surgical re-approach and intensive clinical support, for example.
The main limitations of this study are its retrospective nature and the fact that it was carried out in a single center, making it impossible to generalize it to other locations.
CONCLUSION
The results of this study showed that the patients analyzed were predominantly male, black, single, with a low education level and a mean age of 45.7 years. In terms of clinical characteristics, the most prevalent types of stoma were loop colostomies and Hartmann stomas. The stomas were mostly located in the lower right and lower left quadrants of the abdomen. The main reasons for having a stoma were appendicitis, firearm perforation and colorectal cancer. Most of the patients had no comorbidities and no postoperative complications. There were two deaths and one was due to complications from Covid-19 acquired in the postoperative period. The presence of complications was significantly associated with a longer postoperative stay after intestinal transit reconstruction, increasing hospital costs and the burden on the healthcare team.
This study addresses a population with various physical and biopsychosocial challenges resulting from the stoma, in addition to the considerable burden of morbidity and mortality associated with the intestinal transit reconstruction procedure, which requires a meticulous multidisciplinary and nursing care plan at various levels and times. In this sense, the data presented, in addition to allowing the sociodemographic and clinical characterization of patients in a subject that has been little explored in the literature (intestinal transit reconstruction), will help future studies to gain a better understanding of the variables that should be taken into account for the comprehensive care of these patients, especially in populations of a similar nature.
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NOTES
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ORIGIN OF THE ARTICLE
Extract from the scientific initiation project - Complications related to intestinal transit reconstruction surgery in a reference service linked to the State University of Piauí, between the years 2022 and 2023.
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APPROVAL OF ETHICS COMMITTEE IN RESEARCH
Approved in the research Ethics Committee of the State university of Piauí, opinion No. 4,915,239/2021, and Certificate of Presentation for Ethical Appraisal No. 47853221.8.0000.5209.
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TRANSLATED BY
Agência Latintrad - Leonardo Parachú.
