w w w . j c o l . o r g . b r
Journal
of
Coloproctology
Original
Article
Children
and
adolescents
ostomized
in
a
reference
hospital.
Epidemiological
profile
夽
Orlando
José
dos
Santos
a,b,∗,
Euler
Nicolau
Sauaia
Filho
a,c,
Allan
Kardec
Duailibe
Barros
Filho
d,
Vanessa
Sousa
Desterro
c,
Maryjom
Venicius
Teixeira
Silva
c,
Rosa
de
Paula
e
Silva
Prado
e,
Cleres
Helena
Santos
Sauaia
eaRedeNordestedeBiotecnologia(RENORBIO),Recife,PE,Brazil
bDepartmentofMedicine,UniversidadeFederaldoMaranhão(UFMA),SãoLuís,MA,Brazil
cHospitalUniversitárioPresidenteDutra,UniversidadeFederaldoMaranhão(UFMA),SãoLuís,MA,Brazil
dDepartmentElectricalEngineering,UniversidadeFederaldoMaranhão(UFMA),SãoLuís,MA,Brazil
eUniversidadeCeuma(UNICEUMA),SãoLuís,MA,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received22December2015 Accepted27March2016 Availableonline13April2016
Keywords:
Surgicalstomas Colostomy Ileostomy Children Adolescents
Epidemiologicalprofile
a
b
s
t
r
a
c
t
Objectives: Toassesstheepidemiologicalprofileofchildrenandadolescentswithintestinal stoma,assistedatthePresidenteDutraUniversityHospital(HUPD),SãoLuís(MA).
Methods:Observational,descriptive,retrospective,andindividuatedstudy.Datawere col-lectedfrom110childrenandadolescentswitheliminationintestinalstoma,fromJanuary 2006toFebruary2013.Thefollowingvariableswereanalyzed:age,gender,patientorigin,and stomataindication,type,andtemporalcharacter.Afterdatacollection,descriptiveanalysis wasmadebyBioestat5.0program.
Results:Of110patients,78.2%weremaleand21.8%female.Theaverageagewas9.4years old.55.5%camefromtheMaranhãostatecountryside,and44.5%fromthecapital,SãoLuís. Regardingstomatype,colostomiesmadeup88.2%,andwere11.8%ileostomies,all tempo-rarystoma.Themaincausewastrauma(42.7%),withfirearmabdominalpuncturebeing themostfrequentcause(71.5%ofthecategory);followedbycongenitalanomalies(38.2%), andobstructive(5.4%)andinflammatory(4.5%)causes.
Conclusion: Studiedchildrenandadolescentsweremostlymale,fromMaranhãostate coun-tryside.Themaincausewastrauma,andcolostomywasthemostcommonstomatype.
©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileirade Coloproctologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
夽
ResearchperformedatDepartmentofMedicine,SchoolofMedicine,UniversidadeFederaldoMaranhão(UFMA),SãoLuís,MA,Brazil.
∗ Correspondingauthor.
E-mail:orlanddojs@hotmail.com(O.J.dosSantos).
http://dx.doi.org/10.1016/j.jcol.2016.03.005
Perfil
epidemiológico
de
crianc¸as
e
adolescentes
estomizados
em
hospital
de
referência
Palavras-chave:
Estomascirúrgicos Colostomia Ileostomia Crianc¸as Adolescentes Perfilepidemiológico
r
e
s
u
m
o
Objetivos: Avaliaroperfilepidemiológicodecrianc¸aseadolescentesportadoresdeestomas intestinaisatendidosnoHospitalUniversitárioPresidenteDutra(HUPD)emSãoLuís(MA).
Métodos: Estudoobservacional,descritivo,retrospectivoeindividuadoemqueforam cole-tados dadosde110crianc¸ase adolescentescomestomas intestinaisde eliminac¸ãode janeirode2006afevereirode2013.Analisaram-seasvariáveis:idade,sexo,procedência dospacientes,indicac¸ão,tipoecarátertemporaldosestomas.Apóscoletadosdados,foi feitaanálisedescritivapeloprogramaBioestat5.0.
Resultados: Dos110pacientes,78,2%eramdosexomasculinoe21,8%dosexofeminino. Aidademédiafoide9,4anos.55,5%eraprocedentedointeriordoEstadodoMaranhãoe 44,5%dacapital,SãoLuís.Comrelac¸ãoaotipo:88,2%eramcolostomiase11,8%ileostomias, todososestomastemporários.Acausaprincipalfoiotrauma(42,7%),sendoaperfurac¸ão abdominalporarmadefogoamaisfrequente(71,5%dacategoria);seguidopelasanomalias congênitas(38,2%),causasobstrutivas(5,4%)einflamatórias(4,5%).
Conclusão: Ascrianc¸aseadolescentesestudadoseram,emsuamaioria,dosexomasculino, provenientedointeriordoEstadodoMaranhão,tendocomoprincipalcausaatraumáticae acolostomiacomootipodeestomamaiscomum.
©2016PublicadoporElsevierEditoraLtda.emnomedaSociedadeBrasileirade Coloproctologia.EsteéumartigoOpenAccesssobalicençadeCCBY-NC-ND
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Ostomies are a provisional or definitive character surgical therapeuticmeasurefor many diseases shown bychildren andadolescents,suchas:congenitalmalformations, intesti-nalobstruction,neoplasia,andtrauma.Itspurposeistofeed oreliminate.1
Thetermcomesfrom the Greekword“stoma”, meaning hole.Itcorrespondstotheconstructionofa“mouth”,which communicatesthehollowviscustotheexternalmediumby creatinganewpath.Foodintakeorstool,gases,andurine out-put,dependingonthelocationandstomatype,areitsmain uses.Disposalstomataaredividedinto:ileostomy,which con-sistsoftheunionoftheileumportiontotheabdominalwall; andcolostomy,whichdesignatestheunionofacolonportion totheabdominalwall.1
Theirphysicalcharacteristicsregardingtype,location,size, shape,surface, contour,and protrusioncan varyaccording totheusedsurgicaltechnique,theexternalizedsegment,the rootcause,andpermanencetime.2
Regardingepidemiology,therearenodefinitiveandtimely dataonostomynumberinBrazil.Santosreports,basedonthe 2000censusandwithmembersoftheInternationalOstomy Association, which in Brazil have about 170,000 ostomy. Regarding the estimate based on data from the Brazilian OstomyAssociation(ABRASO)of2005showedanapproximate numberof34,262people,afigurefarbelowtheinternational estimate.1
Eachyear,1millionand400,000surgicalostomyprocedures are conducted,ata costof153 millionreais(Brazilian cur-rency);fromJanuarytoAugust2009,forexample,18million were spent only in the purchase of collector, safety, and
security equipment (collecting bags and synthetic skin protectivebarriers).3
Exclusive epidemiological data on stomata in children are also scarce. Nevertheless, it is known that in child-hood (0–10 incomplete years old, according to the WHO definition) stomata are mostly temporary, performed in the neonatal period, mainly for congenital megacolon (Hirschsprung’sdisease),intussusception,intestinalvolvulus, agenesis, and anorectal atresiaadjuvant treatments. How-ever, this condition residence time may be of months or years,dependingonthedisease andtheoperationamount that the individual issubjected lifelongfordamaged areas reconstruction.4
Inadolescents(10toincomplete20yearsold,WHO),these dataareevenrarer.However,traumaticetiology,mainlydue toautomobileordomesticaccidents,ishighlighted.5
In the state of Maranhão, there are few systematic informationandscientificpublicationswithinthestomized population, making it difficult to characterize their epi-demiologicalandsocio-demographicprofile.Thiscanhinder hospital andmanagement planning activities, which could allocateresourcestoimprove assistanceforthis significant populationportion.
Thus,thepresentstudyassessedchildrenandadolescents withintestinal eliminationstomataepidemiologicalprofile. They were treated at the Coloproctology Service Stomized AssistanceProgram(PAESC),PresidenteDutraUniversity Hos-pital(HUPD), oneofthemainpublichospitalsinthe State of Maranhão. The aim of this study was to contribute to Maranhãoostomizedpopulationepidemiologicalprofile con-struction.
Table1–Distributionofpatientsaccordingtosexand agegroup.
Sex <5yearsold 5–10yearsold 10–15years 15–20years
Male 33 7 8 38
Female 15 2 1 6
professionalstechnicalandscientificperformance,and inter-ventionseffectiveness.
Methods
Thestudywasobservational,descriptive,retrospective,and individuated,conductedwithstomizedchildrenand adoles-centsfromtheHUPDColoproctologyService,locatedinSão Luís,MA.DatawereobtainedfromSocialService computer-izeddatabases(“SurgicalClinic–Coloproctology”section)and fromthehospitalOrthotics andProstheticsTechnical Com-mittee(CTOP).
Patient records with esophageal, stomach, duodenum, jejunum,andurinarytractstoma,patientsover20yearsold, andostomypatientswithincompletedata,exceptforraceand color,wereexcludedfromtheanalysis.
110patientswithintestinalstomawereincluded,all pos-sessingcomplete dataandbeingyoungerthan20yearsold (children and adolescents), from January 2006 to February 2013. Analyzed variables were: age, gender, color or race, origin(SãoLuísor thecountryside), stomatype(colostomy orileostomy),stomataindication,andtheirtemporalnature (permanentortemporary).
DatawereorganizedinExcelspreadsheetsandanalyzed byBioEstat5.0program.Onlydescriptiveanalysiswas per-formed(meanandmedianforquantitativevariables,absolute andrelativefrequenciesforqualitativevariables).
The project was approved by the HUPD Research Ethics Committee, with protocol number 003040-2013-30. Thus, it was submitted to Brazil Platform with CAAE: 24297513.6.0000.5086. The issued opinion No. 492,614 approvedtheresearch.
Results
110 stomized children and adolescents’ records were ana-lyzed,attendedfromJanuary2006toFebruary2013.Ofthese, 86(78.2%)weremaleand24(21.8%)female,withaverageageof 10.5yearsoldinmales(rangingfrom1monthto20yearsold, median=13.5yearsold),andof6yearsoldinfemales(ranging from1monthto19yearsold,median=2yearsold);overall averagewasof9.45yearsold,withamedianof8yearsold
(Table1).
Regardingorigin,49patients(44.5%)werefromSãoLuís, and 61 (55.5%) were from the state countryside. As for
Table2–Distributionofpediatricpatientsbytypeof
ostomystoma(%).
Colostomy 88.2
Ileostomy 11.8
Table3–Stomatacausesofpediatric(%).
Traumatic Congenital Obstructive Inflammatory Others
42.7 38.2 5.4 4.5 9.2
race\color,60patients(54.5%)werebrown,11(10%)white,10 (9%)black,and29(26.5%)wereunidentified.
Ofthe110analyzedstomata,97(88.2%)werecolostomies, andonly13(11.8%)wereileostomy(Table2).
Consideringstomaestimatedpermanencetime,110(100%) wereclassifiedastemporary.
Analyzing stomata indicationcauses, therewas trauma predominance,with47cases(42.7%ofthecauses). Firearm-bullet abdominal puncture (FB) was the predominant type in24cases,accountingfor51%ofthiscategory,followedby abdominaltraumaandotherlessfrequentcauses.
The congenital anomalies group was the second most frequent cause,with 42 cases (38.2%). Ofthese, there was congenitalmegacolonprevalence,with24cases,followedby imperforateanus,with12cases(Table3).
There was higher difference between congenital and traumaticcausesinageextremes.Congenitalcauses predomi-natedinpatientsunderfiveyearsofage(92.68%),andtrauma accountedfor100%ofcasesinpatientsagedfrom 15to20 yearsold(Table4).
Obstructive causes, with 6 cases (5.4%), and inflamma-tory,with5cases(4.5%),correspondedtothethirdandfourth causeinfrequency,respectively.Theothercausesareshown
inTable3.The“other”causesgroupencompassesawide
vari-etyoflesscommondiagnoses,themainbeingsuppurative(3 cases),rectovaginalfistula(3cases),necrotizingenterocolitis (2cases),abdominalneoplasia(1case),andanalprolapse(1 case).
Discussion
Inthepresentstudy,therewasmalegeneralpredominance (78.2%),withthesepatientsmeanagebeingof10.5yearsold. SimilargenderdistributionwasfoundbySilvaonananalysis of11stomizedchildren(between2011and2012,inthe Brazil-ianFederalDistrict),where73%males,18%females,and9% ambiguousgenitaliacaseswerefound.6InastudybyBarreire
etal.,conductedonurinaryandintestinalstomawith20 chil-drenfrom4to12yearsoldinSãoPaulo,prevalencebetween genderswasof50%each.7SameproportionfoundbyBarbosa
etal.,inastudywith30childrenundertheageof10yearsold,
Table4–Distributionofcauses(Traumatic×Congenital)accordingtoagegroup.
Causes <5yearsold 5–10yearsold 10–15yearsold 15–20yearsold
Traumatic 3 5 5 34
where50%wasfoundforbothgenders,withmeanageof5 yearsold.8
In this study there was no ambiguousgenitalia patient presence.Allpatientrecordshadmaleorfemaledefinition. Inaddition,genderdistributionwassimilartothatfoundby Silva(2013).However,itmustbeconsideredthatthepresent studyincludedadolescentsinthestudypopulation,andthese werepredominantlymales,whatcontributedtotheincreased prevalenceand averagemaleage(10.5years old),against6 yearsoldoffemales.6
Regardingpatientorigin,55.5%werefromMaranhãostate countryside,and44.5%werefromthestatecapital,SãoLuís. ThesenumbersnotonlynoteHUPDimportanceasreference forstomizedchildrenandadolescentscare,butalsoindicate healthservicecentralizationinthestatecapital,showingthat Brazilian health careis concentrated incapitals and large cities.9
Withregardtocolor,54.5%ofchildrenandadolescentsin thisstudywerebrown,10%white,and9%black.Fora signif-icantportion,therewasnoinformation(26.5%).Incontrast, Barreireetal.(studythatincludedintestinalandurinary sto-mata)found55%whiteand45%blackintheirresearchwith 20patientsagedbetween4and12yearsold.However,this studydatacanbeexplainedbytheBrazilianInstituteof Geog-raphyandStatistics(IBGE)2010census.Itrevealedthat66.5% ofMaranhãopopulationwasbrown,22%white,and9%black, thatis,thesedatacorroboratetheimmensemixingof Maran-hãopeople,whichisreflectedonthestudiedpopulation.7
Analyzing stomata type, this study found 88.2% colostomies and 11.8% ileostomies. Silva et al. found 81% colostomiesamongintestinal stoma,9.5%ileostomies,and 9.5% duodenojejun ostomies. Barbosa et al., inan analy-sis of 30 patients, obtained 76.7% colostomies and 23.3% ileostomias.8 Barreireet al.conductedastudy involving20
childrenwithintestinalandurinarystomata,inwhich8had intestinal stoma. Of these, 6 (80%)had colostomies and 2 (20%)ileostomy.7Theproportionfoundisconsistentwiththe
literature.However, the fact that research was carried out withchildrenonlymustbeconsidered.6–8
When stomatype analysis extends to adults, the ratio is maintained. In the study published by Luz et al., con-ductedwith19patientsfromtheageof18,theyfound84.21% colostomies and 15.79%ileostomies.10 Santos et al., inthe
analysis of 178 stomized patients, found 152 colostomies (84.5%) and only 21 ileostomies (11.8%). Valverde et al., in an analysis of 388 patients with intestinal stoma, found colostomy predominance (74.7%) compared to ileostomy (11.3%)andurostomy(7.2%).11,12 PaulaandPaula,inastudy
onostomypatientsepidemiologyprofile,foundfrequencies of45.9%colostomyand6%ileostomy.Otherconsulted stud-ies haveconfirmed colostomy predominance inrelation to ileostomy.13
Asfortemporalcharacter,100%ofcasesweretemporary. Consideringstomacauses,thisstudyfoundtwomajor etio-logicalgroups.Theyare:trauma,with42.7%,andcongenital anomalies,with38.2%,beingpredominantinadolescentsand children,respectively.Analyzingthetotalnumberofpatients, traumagroupprevailed,withtheprincipalcausebeingfirearm bulletabdominalperforation(51%ofcases).Thiscorroborates
withWHOdata,showing83%oftraumaaffectingadolescent agedbetween10and20yearsold.14
Withregard tocongenitalanomalies,96% ofcaseswere infants(<2yearsold)andpreschoolers(2–6yearsold),with congenitalmegacolonbeingthemainrepresentative(57%of thegroup’scauses).Silvaetal.,with11childrenwithintestinal stoma,foundthat55%ofstomatacauseswerebasedon con-genitalmegacolon.6Sánchezetal.,insurgicalpatientstudy,
showednearlyhalfofthesamplediagnosedwithcongenital megacolon(48.3%)asstomamotivator.15However,Barbosa
etal.,inastudywith30childrenunder10yearsold,found anorectal malformations (53.2%) asthe mainstomacause, withmegacolon(13.3%)beingthesecondcauseinfrequency.8
Carvalho et al.stated that, amongostomy numerous indi-cations, congenitalanomalies are pediatricsmostfrequent causes.16
Itisobservedthat,inmoststudies,congenitalmegacolon isthemostprevalentchildrenstomacause,whatcorroborates withthisstudy.However,thesestudieswereconductedwith thesamplelimitedtopediatrics.Thisstudyincluded adoles-cents,andthatiswhycongenitalanomaliesrankedsecond, losingtheposttotrauma,whichcorrespondedto8casesin childrenand39casesinadolescents.Thus,theimpactcaused bytraumainadolescentswasfundamentalfortheir signifi-cantstomanumber.
Obstructive (6%) and inflammatory (5%) causes were observed in lower proportions. The “other” causes group encompassedawidevarietyoflesscommondiagnoses,the main being suppuration (3 cases), recto vaginal fistula (3 cases),necrotizingenterocolitis(2cases),abdominal neopla-sia(1case),andanalprolapse(1case).
Regardingpsychosocialaspects,itisworthmentioninglife qualityimprovementsandpatientintegralcareimportance, throughamultidisciplinaryteamofdoctors,nursesand psy-chologists. Inthe110records assessedinthis study,topics relatedtothisaspectwerenotfound.Itisknownthatostomy changes causednotonlyaffectpatientphysicalaspect, but alsoemotionalandpsychologicalaspects.17
Elimination stomamaking leadsto physiologic elimina-tionsvoluntarycontrolloss,andcoexistencewithacollecting bagattachedtotheabdomen,whichreceivesgasesandfeces, producingnoiseandodor,andcausingsocialembarrassment. Contentleakagefearispredominant,andanyqualityorsafety failurecantriggerit.Libertyandleisureactivitiesdeprivation, bodyimagenegativechange,self-esteemloss,isolation,grief anddepressionarethusgenerated.17
Qualityoflifeisrelatedtothepatientsatisfactiondegree, i.e., the adaptation level tonew lifewitha stoma, and its proper administration. Thosevariables research and appli-cationmethodsdevelopmentare necessarytocontributeto stomizedindividuals’epidemiologicalprofile,leadingto qual-ityoflifemaintenancestrategies.18
Duetosamplecomplexity,it isnecessary todeepenthe studyonthesepatients,byaddressingofqualityoflifeand socioeconomicstatusaspects,foramorecomplete charac-terizationandcomprehensivecare.Thus,patientfiledrecord improvementsareneeded,withqualityoflifevariablessurvey inclusion, regarding population socioeconomic and demo-graphicconditions.
Conclusion
Childrenand adolescents populationselected in the study assessment pointed to predominance of males, from the Maranhãocountryside,withcolostomybeingthemost com-monstomatype,andtraumabeingthemaincause.Stomized children and adolescents epidemiological profile analysis isrelevant to planning,promotion, prevention,and health demands action, being fundamental forstrengthening the healthcarenetwork,withaneffectiveintervention.
Funding
FAPEMA.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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