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- Näsvall, Pia, 1967-
(författare)
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Parastomal hernia : investigation and treatment
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundParastomal hernia is a common stoma complication causing the patient considerable inconvenience. The patient becomes aware of a bulge around the stoma, but a bulge is not always a parastomal hernia and diagnostics must be performed to enable differential treatment. It is difficult to distinguish between a bulge and a hernia. Results based on clinical examination and computerised tomography (CT) in the supine position, have not been convincing. Three-dimensional intrastomal ultrasonography (3D US) is a novel technique shown to be promising in the assessment of stoma complaints. Two studies were performed to determine inter- and intra-observer reliability as well as the validity of 3D US as an alternative to CT when assessing stoma complaints.There are numerous options for the treatment of parastomal hernia, but none has been shown superior. In the recent decades the use of mesh in the repair of incisional and inguinal hernia has become routine. New materials must be evaluated as there are potential morbidity and even mortality risks with mesh repair. As recurrence of a parastomal hernia is an even greater challenge, the method of choice should have a low risk for recurrence. A prospective multicenter study was performed to evaluate safety and recurrence rate when using Parastomal Hernia Patch BARDTM (PHP), a mesh specially designed for parastomal hernia repair.A stoma has a profound impact on the patient´s daily life, both physical and psychological. A parastomal hernia with its associated risk for leakage and incarceration worsens the situation. Patient driven assessment of healthcare outcome is important if we are to improve medical care. A quality of life (QoL) survey was performed to assess the impact of parastomal bulging and hernia on the patient´s daily life.MethodsForty patients were investigated and the 3D US images were twice evaluated by two or three physicians to assess inter- and intra-observer reliability. Totally 20 patients with stoma complaints requiring surgery were examined with CT and 3D US prior to surgery. The findings were compared with the intraoperative findings – regarded as the true outcome.Fifty patients with parastomal hernia requiring surgery were enrolled from three hospitals. Patients were followed up one month and one year after repair using PHP.Patients still alive in 2008 who had been operated between1996 and 2004 for rectal cancer in Uppsala/Örebro-, Stockholm/Gotland-, and Northern Regions (986 patients) and registered in the Swedish Rectal Cancer Registry (SRCR) were invited to fill in four QoL questionnaires.ResultsInter-observer agreement using 3D US reached 80% for the last 10 patients examined, with a kappa value of 0.70. Intra-observer agreement for two examiners was 80% and 95%. The learning curve levelled out at 30 patients. Both CT and 3D US showed high sensitivity and specificity when compared with intraoperative findings.After surgery for parastomal hernia with a PHP, the complication rate at one month was 30% and recurrence rate at one year was 22%. Twelve patients were reoperated within one year.In the QoL study, 31.5% of the patients with a stoma reported a bulging or a hernia. 11.7% had been operated for parastomal hernia. A hernia or a bulge gave rise to significantly more pain and impaired stoma function. Overall QoL was inferior in patients with a permanent stoma compared to a group without a stoma.
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| 2. |
- Näverlo, Simon, 1991-
(författare)
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Stomas from a rural perspective : an evaluation of characteristics, differences and improvement opportunities
- 2020
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: Stoma-related complications are common and consequences for the individual patient may be considerable. In rural areas, competence regarding stoma-related problems is largely absent. Since the aim of a publicly funded healthcare system is good healthcare on equal terms regardless of where one lives, studies evaluating differences and possible areas of improvement in rural areas are important. An evaluation of stoma-related characteristics, geographic differences and improvement opportunities from a rural perspective has not been done previously. The characteristics and differences studied in this thesis are: stoma reversal; occurrence of permanent stoma; and quality-of-life (QoL).Methods: Epidemiological methods applied to register data were used in Study I. Data extracted from the National Rectal Cancer Register together with socioeconomic data from Statistics Sweden were used. Study II was a cross-sectional study using surveys matched with data from the National Rectal Cancer Register. Study III was based on data from a double-blind randomised controlled trial. Patients were randomised to either a prophylactic mesh or no mesh in order to prevent parastomal hernia (PSH). Quality-of-life was assessed by grouping and comparing results of questionnaires answered by the patients included. In Study IV, a qualitative explorative method was applied to describe the quality of life of rural living stoma patients. Qualitative content analysis was used to analyse data.Aims and Results: Study I investigated whether distance by road to hospital had an impact on the following outcomes: stoma reversal rate; time from index operation to stoma reversal; and occurrence of permanent stoma after rectal cancer surgery. Longer distance to hospital had no effect on these outcomes in a multivariate model. In the univariate logistic regression model results indicated the opposite; patients living closest to the operating hospital had a higher likelihood of no reversal (OR 0.3; 95% CI 0.12–0.76). In northern Sweden, 77 % of all stoma reversals were delayed more than 6 months after index surgery. Stoma reversal was performed up to 1557 days after index surgery, and the shortest time to reversal was 82 days (median 287 days).Study II investigated the impact of distance to nearest hospital on the QoL of rectal cancer patients who had received a stoma at index surgery. Patients living in rural areas reported more pain and sore skin compared to those living closer. When only considering patients who still had a stoma, global QoL was reduced and stoma-related problems were also affected negatively in the rural group.Study III Investigated whether a prophylactic mesh when creating an end colostomy affected QoL. No effect on global QoL was seen at one-year follow up. In several other QoL-parameters mesh patients scored superior compared to non-mesh patients, even when excluding those with a parastomal hernia (PSH).Study IV investigated experiences of living with a stoma in a rural setting, how the process of seeking healthcare was experienced and the problems that occur. Results show that living with a stoma was experienced as a process; an initial sense of hopelessness, especially when suffering from stoma-related problems, progressing to the crucial acceptance of their situation. Stoma leakage was frequently described and experienced as unpleasant and unpredictable. Experiences of seeking healthcare in a rural district varied, some spoke warmly about the care given at the cottage hospital while other expressed dissatisfaction.Conclusions: The notably high rate of delayed reversal of a defunctioning stoma in northern Sweden leads to unnecessary suffering for patients. In view of the long delay in reversal times seen, future studies must have considerably longer follow-up. Rural living rectal cancer patients who receives a stoma reported more pain than those living closer to the nearest hospital. Rectal cancer patients who still had a stoma reported an inferior quality-of-life and more stoma-related problems compared to their town counterparts. Results from the studies in this thesis show that the use of a prophylactic mesh when forming an end colostomy has no impact on subsequent global QoL. Rural living stoma patients commonly experience problems related to their stoma that affect their everyday living. Improved patient education shortly after receiving a stoma could help these patients in coming to terms with their situation.
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