Outpatient-Inpatient Rehabilitation of Patients with Colostomy

The research is dedicated to the development and justification of a system of outpatient-inpatient rehabilitation for patients with colostomy resulting from surgical treatment of colorectal and bladder cancer. The relevance of the study is determined by the rising incidence of colorectal and bladder cancer, the increasing number of stoma-forming operations, and the need to create an effective comprehensive rehabilitation program for stoma patients. The work develops standards for the volume of stoma therapy care, the structure of a stoma therapy service, and criteria for evaluating the effectiveness of the rehabilitation process, including adequate information provision, preoperative preparation, postoperative care, and outpatient follow-up.

Relevance of the topic. Colorectal cancer (CRC) and bladder cancer (BC) are an urgent problem of modern oncology in connection with the relentless increase in morbidity and mortality. Approximately 800,000 cases of colorectal cancer and up to 200,000 new cases of bladder cancer are registered worldwide annually [Chisov V.I., Starinsky V.V., 2001; Borden L.S.Jr. et al., 2003; Greenlee R.T. et al., 2000]. The dynamics of morbidity and mortality for intestinal and bladder cancer has a characteristic tendency toward growth. Thus, the average annual growth rate of CRC was 3.35%, of the rectum - 2.83%, and of BC - 3.34%. In connection with the growth of morbidity by malignant neoplasms, the role of medical, occupational, and social rehabilitation significantly increases [Aksel E.M. et al., 2001].

The widespread introduction into clinical practice of various diagnostic, treatment, and monitoring schemes has made it possible to substantially improve the prognosis and life expectancy of patients with both forms of cancer. Nevertheless, approximately 70% of CRC and BC patients receive treatment in oncological hospitals already at the third and fourth stages of the disease, which in most cases includes, alongside surgical intervention, the creation of a stoma [Petrov V.P. et al., 2003; Prokopov V.V. et al., 2002; Bailey S.M. et al., 2003]. In recent years, there has been a steady tendency toward an increase in the number of stoma patients, in whom the colon and urinary tract have been surgically brought to the anterior abdominal wall. It must be emphasized that by the totality of the bulkiness of surgical interventions and socio-medical problems in the postoperative period, tumors of the colon and bladder can be justifiably classified as diseases with a distinctly pronounced subsequent social degradation, which in turn requires the conduct of an effective rehabilitation process and an individual approach to subsequent observation and monitoring of this category of patients [Pereverzev A.S., Petrov S.B., 2002; Pugachev A.V. et al., 1999; Bartha I. et al., 1995].

The fundamental distinction of this population group is the impossibility of preserving a customary lifestyle after surgical treatment. Despite the fact that modern clinical oncology is characterized by a comprehensive approach to solving treatment tasks, the underestimation of the principles of postoperative rehabilitation of stoma patients often becomes the cause of their premature disability. Associated early disability, in some cases rather forced than justified, entails serious economic losses. At the same time, as the experience of developed countries shows, the presence of an effective rehabilitation system allows such patients, virtually without changing their lifestyle, to preserve their work, family, and hobbies [Black R., 2002; Camilleri-Brennan J., Steele R.J., 2002].

Methods of treatment of malignant tumors lead to pronounced anatomical and functional disturbances, which significantly affect the work capacity of patients in the subsequent period. Up to 50% of patients with cancer of the rectum and sigmoid colon throughout the rest of their lives have an artificial anus [Collett K., 2002; Furlani R., Ceolim M.F., 2002]. The prospect of living after surgery with a colostomy already in the preoperative period manifests itself as depression in the majority of patients, and more than 50% of refusals from surgical treatment are associated with a negative attitude toward the creation of an artificial anus. Patients often become disabled not only due to the onset of anatomical and functional disturbances but also due to negative emotional factors. The social, psychological, and functional consequences of these operations are so distressing and numerous that combating them requires the creation of a specialized medical service. Important conditions for returning these patients to work include the absence of complications from the colostomy and signs of progression of the underlying disease, the restoration of rhythmic bowel emptying, and maximum adaptation of patients to new conditions of existence [Blokhin N.N., 1981; Duchesne J.C. et al., 2002].

According to WHO, the number of stoma patients per 100,000 population is in the range of 100-150 people. In Saint Petersburg, among newly identified patients with malignant neoplasms of the colon alone, the number of stoma patients annually amounts to 4,000-4,500 people. At the same time, a significant growth of neoplasms in children and adolescents is observed, as well as an increase in the level of trauma and congenital pathology of the intestine.

Thus, the growth of morbidity, the increase in the number of stoma-forming operations, the lack of accounting for stoma patients and the production of modern domestic stoma care supplies, as well as a well-structured system of medical and social assistance, call for the development and implementation of a comprehensive rehabilitation program for stoma patients. At present, a number of practical and theoretical questions related to the comprehensive rehabilitation of stoma patients and their adequate monitoring remain not fully resolved and require further research.

RESEARCH OBJECTIVE

Improving the quality of life of stoma patients through the development of a program and system of comprehensive rehabilitation.

RESEARCH TASKS

1. To define the concept of comprehensive rehabilitation and the model of the rehabilitation process of a stoma patient, and to identify criteria for its effectiveness.

2. To develop standards for the volume of stoma therapy care and a complex of rehabilitation measures for stoma patients.

3. To develop the structure of a stoma therapy service.

4. To assess the capabilities of modern information systems in the organization of care for stoma patients.

5. To study the frequency and structure of early and late postoperative surgical complications in stoma patients and to evaluate their impact on the course of the rehabilitation process.

6. To develop recommendations for the organization and technology of managing stoma patients taking into account modern requirements.

SCIENTIFIC NOVELTY

The concept of comprehensive rehabilitation of stoma patients has been defined, as well as the model of the rehabilitation process of a stoma patient and the criteria for its effectiveness have been identified.

It has been proven that the proposed model of the organization of the rehabilitation process of stoma patients meets all criteria of its effectiveness and can be recommended for wide application in clinical practice.

Standards for the volume of stoma therapy care have been developed, including adequate information provision, preoperative preparation, postoperative care, and outpatient follow-up for stoma patients.

It has been established that psychological preparation of the patient for the upcoming stoma-forming operation is the most important element of stoma therapy care.

It has been established that the rehabilitation process of a stoma patient provides for the phased use of developed standards of the rehabilitation process throughout the entire life of the stoma patient.

It has been proven that the rehabilitation process begins long before the surgical intervention, with the early detection of symptoms of diseases leading to the creation of a stoma, which increases the effectiveness of the entire rehabilitation process.

The necessity of wide use of modern information systems in the organization of care for stoma patients has been proven.

The structure of the stoma therapy service has been developed.

The frequency and structure of early and late postoperative complications in stoma patients have been studied, their impact on the course of the rehabilitation process and methods of correction have been evaluated.

The most indicative and diagnostically significant criteria for evaluating the course of the rehabilitation process of stoma patients depending on the type of stoma and surgical complications have been determined.

PRACTICAL SIGNIFICANCE

A system of comprehensive rehabilitation of stoma patients has been created, linking medical and non-medical structures in a defined manner, implementing an effective rehabilitation process in accordance with the chosen model.

The developed structure of the stoma therapy service, including the urban stoma therapy service, the urban center of reconstructive and restorative surgery, the stoma therapist training school, seminars for the improvement of surgeons and non-medical participants in the rehabilitation process, allows for the effective implementation of the rehabilitation process for stoma patients.

It has been established that the effectiveness of the rehabilitation process depends on numerous factors, however, the first necessary condition for its effectiveness is the choice of an appropriate model of the rehabilitation process.

The developed standards for the volume of stoma therapy care make it possible to ensure a guaranteed minimum volume of stoma therapy care for each patient, regardless of the place, time, and circumstances of stoma formation.

It has been established that the conduct of dynamic observation and accounting of stoma patients is practically impossible and unproductive without the use of modern technical means of information processing and storage in combination with telecommunications tools, which allow ensuring the timeliness of information exchange and maintaining the relevance of data.

The developed criteria for dividing patients into monitoring groups depending on the type of operation and stoma allow for dynamic observation of stoma patients at optimal intervals and for timely adequate therapeutic interventions in case of progression or complications.

MAIN PROVISIONS PRESENTED FOR DEFENSE

1. Outpatient-inpatient rehabilitation of stoma patients represents a continuous, sequential process based on the phased use of developed rehabilitation standards.

2. The effectiveness of outpatient-inpatient rehabilitation of stoma patients is determined not only by timely diagnostic and therapeutic medical measures but also by socio-medical and psychological components.

3. Timely, early psychological preparation of the patient for the stoma-forming operation makes it possible to achieve full adaptation of the patient to the presence and functioning of the stoma, full restoration of social and role status in the family, as well as readiness of the patient for the restoration of work capacity.

4. The developed standards for the volume of stoma therapy care in the preoperative and postoperative periods meet the criteria of effectiveness of the rehabilitation process and make it possible to significantly reduce the percentage of complications in stoma patients.

5. The culminating stage of comprehensive rehabilitation of stoma patients is outpatient follow-up, based on the principle of continuity of stoma therapy care and continuing throughout the patient's entire life.

PRESENTATION OF THE RESEARCH

The main provisions of the dissertation research were reported and discussed at: the Russian-German Seminar on Stoma Therapy (Russia, Saint Petersburg, April 1993), the Russian Conference "Actual Problems of Proctology" (Russia, Saint Petersburg, October 1993), the IV All-Russian Congress of Oncologists (Russia, Rostov-on-Don, October 1995), the International Symposium "Actual Questions of Oncology" (Russia, Saint Petersburg, May 1996), the XI International Congress of Stoma Therapists (Israel, Jerusalem, June 1996), the City Conference dedicated to the International Stoma Patients Day (Russia, Saint Petersburg, October 1996), the IV European Congress of Stoma Therapists (Belgium, Brussels, June 1997), the City Seminar "Comprehensive Rehabilitation of Stoma Patients" (Russia, Saint Petersburg, November 1997), the XII International Congress of Stoma Therapists (Great Britain, Brighton, June 1998), the Russian Scientific-Practical Conference "Surgical Rehabilitation of Patients with Intestinal Fistulas and Colostomies" (Russia, Saint Petersburg, October 1998), the V European Congress of Stoma Therapists (Denmark, Copenhagen, May 1999), the Norwegian-Russian Seminar on Stoma Therapy (Russia, Saint Petersburg, September 1999), the International Scientific Forum "Oncology at the Turn of the XXI Century. Opportunities and Prospects" (Russia, Moscow, October 1999), the Russian Conference dedicated to the International Stoma Patients Day (Russia, Moscow, October 1999), the XIII International Congress of Stoma Therapists (Singapore, July 2000), the 5th All-Russian Conference "New Technologies in Surgery" (Russia, Ufa, May-June 2001), the VI European Congress of Stoma Therapists (Hungary, Budapest, June 2001), the XIV International Congress of Stoma Therapists (Italy, Florence, July 2002), the International Seminar "Rehabilitation of Stoma Disabled" (Belarus, Minsk, October 2002), the Interregional Scientific-Practical Conference "Modern Problems of Palliative Oncology" (Russia, Smolensk, November 2002), the Norwegian-Russian Seminar on Volunteer Work Among Stoma Patients (Russia, Saint Petersburg, June 2002), the XVII Session of the International School of Sociology of Science and Technology "High Technologies and Quality of Life of the Population" (Russia, Saint Petersburg, June-July 2002), the Conference with international participation "Rehabilitation of Stoma Patients" (Russia, Moscow, January 2003), the VII European Congress of Stoma Therapists (Germany, Munich, June 2003), the Scientific-Practical Conference "Social and Medical Aspects of Rehabilitation of Patients with Intestinal Stomas" (Russia, Ryazan, November 2003), the First Russian Congress of Coloproctologists with international participation (Russia, Samara, September-October 2003); the V All-Russian Pirogov Congress of Doctors (Russia, Moscow, April 2004); the III Congress of Oncologists and Radiologists of the CIS (Belarus, Minsk, May 2004), the Norwegian-Russian Seminar "Psychosocial and Medical Aspects of Life of Stoma Patients in Saint Petersburg" - (Russia, Saint Petersburg, September 2004).

IMPLEMENTATION OF THE RESEARCH RESULTS

The results of the research have been implemented in the practice of the City Clinical Oncological Dispensary of Saint Petersburg, in the scientific and clinical activities of diagnostic and clinical departments of the Moscow Research Institute of Oncology named after P.A. Herzen, and in the educational process of the Department of Oncology of the Saint Petersburg Medical University named after academician I.P. Pavlov.

The developed rehabilitation program for stoma patients is recommended for use in the practice of urban and regional specialized oncological institutions and departments.

VOLUME AND STRUCTURE OF THE DISSERTATION

The dissertation is presented in 238 pages of typed text and consists of an introduction, a literature review, 3 chapters, a conclusion, findings, practical recommendations, and appendices. The bibliography includes 133 domestic and 224 foreign sources. The work is illustrated with 45 tables, 1 scheme, and 40 figures.