Prehabilitation for the Future Ostomy Patient

In the United States, approximately    100 000 persons undergo ostomy surgery every year.¹ Because colorectal cancer is the third most common cancer in the US, we can expect to see many more ostomies in our future. Creation of an intestinal stoma (ostomy) results in enormous challenges for personal care and toileting. Long-term consequences such as peristomal skin damage, disturbed sleep, dehydration, sexual dysfunction, and social isolation are common.² Many ostomy patients complain about the lack of ostomy education provided in the hospital, with or without a certified ostomy nurse. Compounding this issue is the fact that few home care agencies and rehabilitation facilities employ certified ostomy nurses. New ostomates end up learning stoma care via trial and error, the internet, and social media. 

Under the Enhanced Recovery After Surgery³ (ERAS) model, colorectal surgical patients have anticipated hospital stays of 3 to 4 days. Preoperative education typically occurs within 7 days of surgery per the ERAS model and includes one nursing visit for stoma site marking and brief ostomy education. The Wound Ostomy Continence Nursing Society’s⁴  best practice guideline, “Discharge planning for the patient with a new ostomy,” includes 7 concepts that should be taught before discharge: emptying the pouch, changing the pouch, diet and fluid management, signs and symptoms of complications, medications affecting the ostomy, gas and odor management, and ordering supplies. Emptying the pouch, changing the pouch, and all the other nuances of living with an ostomy are unrealistic goals to accomplish in 3 days. Most people are not in a “teachable” state of mind after major surgery. Patients with a new ostomy also are coping with an altered body image and may be psychologically distressed, anxious, and depressed. Many absolutely refuse to look at their stoma. Counseling, compassion, and empathy from a trained ostomy nurse is critical to their acceptance of their new bodies and their ability to adapt to life with a stoma. 

By the time many colorectal and bladder cancer patients are diagnosed, they are already in poor physical condition, malnourished, and depressed, which contributes to poor surgical outcomes. In addition, they might also smoke cigarettes and drink alcohol. According to Carli et al,⁵ “Traditional rehabilitative approaches to perioperative cancer care have focused on the postoperative period to facilitate the return to presurgical baseline conditions. However, there is some realization that the preoperative period can be a very effective time for intervention as the patients are more amenable to target their physiological condition to prepare to overcome the metabolic cost of the surgical stress.” 

Cancer prehabilitation has been defined by Silver and Baima⁶ as “a process on the cancer continuum of care that occurs between the time of cancer diagnosis and the beginning of acute treatment.” Prehabilitation can include physical, nutritional, and psychological assessments and interventions to improve preoperative status and ultimately reduce postoperative complications and improve quality of life. Interventions are provided 3 times per week for 4 to 6 weeks and include dietary modifications, physical therapy, stress-reduction management, smoking cessation, and counseling to abstain from alcohol consumption. Outcomes are evaluated according to surgical complications, length of stay, recurrence rates, rehospitalizations, and quality of life. Research on prehabilitation for the colorectal and bladder cancer population is scant at best, with more being done in Europe than in the US. 

The model of prehabilitation for colorectal and bladder cancer patients needs to expand to include ostomy management skills. Because the new ostomate faces a major body-altering surgery that changes the way a person defecates or urinates, lifelong toileting and personal hygiene procedures must be relearned. It seems logical that ostomy care be included in the prehabilitation model. This major surgery results in the patient having to use an ostomy pouch for toileting and to contain the incontinent output of feces or urine from the stoma. Independence in ostomy management (toileting) is critical to a person’s self-esteem and quality of life. These patients need extra attention and specialists to teach them how to adapt to life wearing an ostomy bag on their belly.  The ideal time to teach ostomy management skills is preoperatively when patients are alert.  Learning how to manage an ostomy and all the unique challenges of living with a stoma is imperative to living a “normal” life.  These tasks take time and practice to learn, very similar to a toddler being potty trained. 

As clinicians, we need to be more proactive about the care of the ostomy population. Referrals for multidisciplinary prehabilitation services should be made at the time of diagnosis. Patients can be seen at either outpatient clinics or through home health care services. In a home health care modality, the patient can receive physical therapy, nursing and nutritional services, and social work interventions at home that include ostomy education. After a patient has completed prehabilitation and is in an improved physical, nutritional, and psychological state, he/she is admitted to the hospital for the planned surgery. During hospitalization, ostomy care will be taught again with a functioning stoma, but now the patient will have had experience working with an ostomy pouch. Upon discharge, the patient returns to home care and continues ostomy education and rehabilitation care with the same team.  

Research by Curtis et al⁷ has shown that taking the extra time to implement a prehabilitation program for an individual does not compromise oncological outcomes. Although this research was done on patients undergoing laparoscopic surgery for colorectal surgery, the hope is that it can be replicated for persons undergoing open abdominal surgery. A proactive approach might just be the edge the new ostomy patient needs to adapt to a new life.

REFERENCES

1.  Goldberg M, et al; and the Ostomy Guidelines Task Force. Management of the patient with a fecal ostomy: best practice guideline for clinicians. J Wound Ostomy Continence Nurs. 2010;37(6):596–598.

2. Shiow-Ching S. Cancer prehabilitation for patients starting from active treatment to surveillance. Asia-Pacific J Oncol Nurs. 2016;3(1):37–40. 

3. Miller D, Pearsall E, Johnston D, Frecea M, McKenzie M. Executive summary: enhanced recovery after surgery. J Wound Ostomy Continence Nurs. 2017;44(1):74–77. 

4. Prinz AC, Colwell JC, Cross HH, Mantel J, Perkins JR, Walker CA. Discharge planning for a patient with a new ostomy: best practice for clinicians. J Wound Ostomy Continence Nurs. 2015;42(1):79–82. 

5. Carli F, Gillis C, Scheede-Bergdahl C. Promoting a culture of prehabilitation for the surgical cancer patient. Acta Oncologica. 2017;56(2):128–133. 

6. Silver JK, Baima J. Cancer prehabilitation: an opportunity to decrease treatment-related morbidity, increase cancer treatment options, and improve physical and psychological health outcomes. Am J Phys Med Rehabil. 2013;92(8):715–727. 

7. Curtis NJ, West MA, Salib E, et al. Time from colorectal cancer diagnosis to laparoscopic curative surgery- Is there a safe window for prehabilitation? Int J Colorect Dis. 2018;33(7):979–983.