Introduction

Stoma creation may cause discomfort in acceptance of the new physical and psychological condition [1]. Stoma-related complications occur in 20–70% of patients and it is believed knowledge and skills on behalf of the patients reduce such problems [2,3,4]. The stoma-therapeutic education currently represents an effective arm when provided by experienced and trained nurses, within a multidisciplinary team [5,6,7].

Recently, with the diffusion of enhanced recovery protocols (ERAS), the hospital stay, notably after colorectal surgery, is somewhat reduced. Despite this, stoma creation represents a condition that could delay the hospital discharge and several authors indicate this condition as a frequent reason for readmission [8,9,10].

A rigorous stoma-therapeutic-care pathway (STCP) (from the preoperative assessment to the period after discharge) could prevent and reduce the stoma-related complications [11].

The aim of this study was to evaluate the impact of adherence to the STCP with strong educational component of patients undergoing colorectal surgery in ERAS context.

Methods

The study population included all consecutive patients operated on for colorectal disease and first stoma creation at the Division of Oncologic and General Surgery of Mauriziano Hospital in Turin, from January 2017 to December 2020. All patients enrolled joined the ERAS protocol and were divided into two groups. In group A, the patients were unable to fully complete the STCP, and in group B, the patients demonstrated full compliance for the STCP (over 70% of all items of the pathway). The items evaluated are shown in the Table 1.

Table 1 Items considered to assess the STCP compliance
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The reasons for low compliance against the STCP were various: clinical, logistical, and occasionally due to difficulties in acceptance of new behavior. In most cases (70%), logistical reasons are related to problems in organization of counselling especially for patients who live far from the hospital. Patients whose operations fall on Fridays have to wait until Monday for the first postoperative counselling session. At least 30% did not attempt the STCP because of clinical reasons like nausea or difficulty in early enteral feeding in the first postoperative days.

Exclusion criteria were as follows:

  • condition of mental or physical incapacity

  • discharge to another hospital

  • disagreement in attendance at follow-up

Clinical data from the Stoma Care Center were retrospectively extracted from a prospectively maintained institutional database that collects 60 variables including patients’ history and characteristics like gender, age, body mass index (BMI), kidney failure, insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM), pulmonary disease, heart diseases, smoking habit, dietary path, and also the presence of rod bridge, level of independence in looking at the stoma and emptying the pouch, ability in stoma care, adherence to the STCP, hospital stay, 1-month readmission, and 3-month postoperative complications and stoma-related complications.

The study was approved by the local institutional review board.

Stoma-therapeutic pathway

The STCP team includes the stoma therapist nurse and the surgeon, and takes care of the patients before admission.

The pathway provides:

  • a first counselling (in pre-hospitalization assessment), aimed to expose to the patient and to the caregiver the educational objectives and providing instructions on the management of the stoma. The patients are told about their own role in rehabilitation so that they understand the importance of their own efforts. Pictures of stoma could be shown and the interviewer tries to highlight the importance of changes in relationships, sexual activity, and daily activities such as bathing and showering. During this examination, a first planning of the stoma site is made and reported on the clinical chart with anthropometric measurements. The duration of the first counselling is about 45–60 min.

    Information about stoma surgery are also given during a prior surgical examination.

  • the day before surgery the stoma site marking is made.

  • in postoperative day 1 (PD1), or the same day of surgery, the patient looks at the stoma for the first time and listens to instructions on how to change the pouch. In this specific counselling, the stoma therapist proposes an “educational agreement” aimed on focusing the goals. An informative booklet is provided as well.

  • in PD 1 or 2, new session on teaching about real life with the stoma and first attempt at emptying the pouch under the direct supervision of the nurse.

  • in PD 2–3, session on nutrition and physical activity. The patient changes the pouch on his own (under supervision too).

  • in PD 4–5 session on early stoma-related complication and check of the knowledge, the patient is autonomous in management of the stoma device.

After discharge, the follow-up schedule provides:

After 3–4 days, the patient calls the stoma therapist according to the protocol and gives details on the trend of the stoma.

After 7–10 days, surgical and stoma-therapeutic examination

After 20–30 days, new stoma-therapeutic examination and dietological assessment

Every 3 months after surgery until stoma reversal or 1 year later with a stoma-therapeutic examination

The STC unit was created in 2003 and has grown close to the ERAS protocol. Each year, the stoma-therapeutic group takes care of 1300 patients operated on for major colorectal surgery. The team also includes the urologist, the gastroenterologist, the dietician, the psychologist, a social worker, and nurses. From 2016, the team had formalized a rehabilitation program with a strong educational component dedicated to patients with stoma. The team offers patients an informative brochure specific for colostomy or ileostomy and for different shapes (end or loop stoma) and inherent to contacts to facilitate the counselling program, new body scheme, disease-related items, how to clean the stoma, how to manage the stoma devices and how to empty the bag, “real-life” problems (job, travels, clothing, showering), nutritional aspects, and indications for “patients’ associations.”

The primary endpoint was the length of hospital stay. The discharge criteria were postoperative pain controlled with per-oral medication (VAS < 4), autonomy in mobilization, and out of bed more than 6 h/day, appropriate bowel function with accurate output counting and ability to tolerate solid food without nausea, and absence of conditions requiring in-hospital treatment.

Secondary endpoints were achieving autonomy in the management of the pouch (so that the patient is proficient enough) readmission rate and stoma-related complications.

Statistical analysis

Categorical variables were compared using the chi-square test or Fisher’s exact test, as appropriate. Continuous variables were compared between groups using the Wilcoxon test. The Kaplan–Meier estimator, with no censored event, was used to estimate time to event probabilities, which were compared using the log-rank test. All P values were two-sided, and values of P < 0.05 were considered statistically significant. All statistical analysis was performed using SPSS Statistics.

The ethics committee approved data auditing and the study has been reported according to the Strengthening the Reporting of Observational Studies in Epidemiology [12].

Results

Overall, among patients undergoing major colorectal surgery at the authors’ institutions between 2017 and 2020, 143 patients underwent a first stoma creation. Patients were divided into two groups. Fifty-six patients (40%) did not completely follow the STCP (group A); 87 patients (60%) demonstrated strict compliance for the STCP (group B).

Patient characteristics

Table 2 summarizes patients’ history and characteristics. The two groups were similar in terms of gender, body mass index (BMI), kidney failure, insulin-dependent diabetes mellitus (IDDM) or non-insulin-dependent diabetes mellitus (NIDDM), pulmonary disease, heart diseases, smoking habit, dietary path, surgical procedures, type of stoma (ileostomy, colostomy, end, loop), and presence of supporting rod. The median age was significatively lower in group B (58) than in group A (66) (p = 0.006).

Table 2 Baseline characteristics
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Statistically significant differences were observed in the hospital stay (8 days in group B vs 11.5 in group A, p = 0.001), in the postoperative day the patient was able to look at the stoma (1 day in group B vs 3 days in group A, p < 0.001), in the postoperative day the patient was able to empty the pouch (2 days in group B vs 5 days in group A, p < 0.001), and in the postoperative day the patient was able to change the pouch (3 days in group B vs 6 days in group A, p < 0.001).

Stoma-related complications did not show significant differences and were 9 (16.1%) in group B and 16 (18%) in group A (p = 0.82). Thirty-day readmission rate was 10.1% (6 patients) in group B and 11.5% (10) in group A (p = 1.000) (Table 3).

Table 3 Results
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Time-to-event estimates of the same items are reported in Fig. 1.

Fig. 1
figure 1

Time-to-event estimates of length of hospital stay in days (A), the postoperative day the patient was able to look at his stoma (B), the postoperative day the patient was able to empty the pouch (C), and the postoperative day the patient was able to change the pouch (D)

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Discussion

The creation of the stoma is related to a wide range of complications and implications and new stoma patients have to face significant physical, psychological, and body image settings [13], all this in addition to the concern caused by the disease itself. It could be difficult for the ward nursing staff to properly assist the patients during the hospital stay as well as after the discharge.

The strong application of STCP showed better results in terms of the length of hospital stay and the level of independence when compared with patients who did not attempt the path despite the inclusion in the ERAS protocol.

Chaudhri published in 2005 the first randomized trial comparing the application of an intensive, community-based stoma education–based pathway with traditional postoperative care. The intensive stoma educational pathways were planned through counselling at the home of patients and improved all outcomes measured, including time to stoma proficiency, hospital stay, and unplanned stoma-related community intervention [14].

A recent paper describes a “clinical 4-day in-hospital educational stoma pathway.” This pathway hesitated in improving the “level of independence” (LOI) of new stoma patients and significantly reducing the need for “home nursing care services” with an impact on cost–benefit analysis [15]. In this paper, however, the authors did not analyze data about hospital stay or readmission. The data collected demonstrates that a close adherence to STCP hesitated in better results in terms of hospital stay and management of the stoma. The aforementioned paper stated that nurses were instructed to engage patients and caregivers in their “stoma care pathway” and guide them to become independent as soon as possible. Our STCP, instead, is carried out by dedicated stoma therapists. This evidence could represent a limitation to reproducibility in other non-specialized surgical settings, but is an advantage for patients in this contest and after the discharge from the hospital. These considerations, focused on educational objectives and adapting to the new condition, were already described by other authors [16] as being key to justifying the active presence of stoma therapist.

The readmission rate was not significatively reduced by the strict adherence to the path but remains much lower than that observed in the literature [17]. The reason for this evidence is that the STCP protocol includes a close telephone follow-up made by the stoma therapist after the discharge and focused on the assessment of stoma patients’ water balance. Based on the balance, the stoma therapist, following the protocol and under the supervision of the physician, manages the condition in order to reduce the necessity of readmission [18].

Stoma-related complications did not differ among the two groups but the global count (16.1% in group A and 18.4% in group B, p = 0.823) is much lower than that observed in the literature [19, 20]. Out of 143 patients, just 5 did not receive the preoperative site mark of the stoma (3%). In a large number of papers, the preoperative site marking is significatively associated with lower rate of stoma-related and skin complications [21]. Baykara et al. published a multicenter retrospective study and found higher complication rates among patients without stoma site marking than among those whose stoma site had been marked [22]. Furthermore, the quality of life for the patients whose stoma sites had been preoperatively marked was significantly better than that of the unmarked patients as shown by a recent systematic review [23].

The rod bridge was rarely used in our center (5%) and patients without the rod are immediately suitable of close STCP. In the two groups, the rod was placed in 6 patients in group B (10.7%) and in 2 (2.3%) in group A. The presence of the rod prevents the possibility of early educational direction and increases the risk of peristomal skin complications [24].

A recent controlled, randomized trial compared patients treated with ERAS program and extended stoma education and patients treated with standard care and current stoma education. The authors concluded that the length of stay after elective colorectal surgery with the need for stoma creation can be reduced significantly with perioperative education and guidance by dedicated stoma nurses as part of an ERAS care pathway if compared to current stoma education in a traditional standard care pathway [25]. The substantial difference between this study and previous studies is that the reduction in hospital stays observed is completely due to adherence to the STCP because all patients analyzed had followed the ERAS protocol with all its items.

The present study has several limitations. First, it was a retrospective analysis, even if data were collected prospectively. The other bias is the younger age observed in group B, where patients were largely in finer physical shape for early discharge from the ward and more willing to comply with autonomous management of the stoma. However, even if age represents a risk factor for stomal and peristomal complications [26], there are no significant differences between the two groups in terms of complications; thus, the better outcomes observed seem to be related to a possible protective role of the STCP.

In conclusion, the STCP demonstrated to have had a protective role in making the patient and the caregiver (if present) autonomous and reducing the length of hospital stay. Event if not significatively, the stoma-related complications, and the readmission rates appear much lower than those showed in recent papers.