Colostomy and ileostomy are essential surgical procedures that may be temporal or permanent. In Many occasions, the surgeon may need to perform them for a particular reason. A colostomy is usually indicated in situations like rectal or colonic tumors, rectovesical or rectovaginal fistulae, and rectal or bowel injury or perforation.
Despite being mandatory procedures on many occasions, colostomy and ileostomy are never free from complications. In addition to general surgery complications like wound infection, bleeding, retraction, prolapse, etc, we must not forget the psychological effects of a stoma. Thus, the main aim of this study was to assess the quality of life, levels of anxiety, and depression among Sudanese patients with a surgical stoma in Khartoum state, Sudan 2018–2019.
A total of 100 patients were approached in the study; however, only 80 participants took part in the study, resulting in an 80% response rate, this response rate is significantly high when compared with the other studies. For example response rate was 59% for a study conducted in California, 49% for United States study, and 39% for an Irish study (16–18).
The age was found to be equally distributed between three categories with 19 years as minimum age and 65 years as the maximum. The majority of participants were males who accounted for 61.3% of participants while females accounted for only 38.8%. This consists with other similar studies where males accounted for the majority (21, 22, 24). This is mainly because colorectal cancer -which is the commonest cause for ostomy surgery- is common among males despite equal risk factors to females. This is in comparison to an Irish study done on ileostomy association, the majority of the respondents were female 60.5% indicating that IBD commonly runs among females (17).
A considerable percentage of the patients lost their jobs after stoma operation. The job percentage dropped from 66.3–31.3%. This might be attributable to the fact that stoma affects the physical competence of the patients and the ability to adapt to the external environment. This corresponds to a study done in the Netherlands which revealed that social functioning self-efficacy had a great significance, a low adaptation level correlates positively with many stoma problems (26).
Regarding the educational level of participants, higher educational levels accounted less than high school educational level participants and illiterate participants.
For the majority of the participants who had a permanent colostomy, colorectal cancer was the most common diagnosis that led to stoma. These findings agree with other studies (16, 17, 22). The majority of the participants underwent a regular stoma nursery at the hospital before discharge (60%). Yet 40% of patients were found to have a direct family member who provides care to their ostomy immediately after the operation. This is a high percentage to be taken in mind as many studies have revealed the importance of precise nursery care for ostomates (28, 29). On the other hand, the majority of the participants had no contact with other ostomy patients (70%) and this is because support groups as a tool for psychotherapy are lacking here in Sudan with a shortage of doctors trained to meet the national mental health needs, yet support groups are a very strong tool for intervention in ostomy patients and many studies have revealed this (30, 31).
Patients' quality of life scores were low with a mean of 2.10 (below average), which corresponds with an Egyptian study where the mean was found to be 2.14 (24). Similarly in a study in Pakistan, the rescore 79.63 fell to 55.79 (22). A comparative study in Denmark stated that 22 out of 27 variables were poorer in ostomates compared to non-ostomates (20). An Indian study revealed the same (32). Yet this result is significantly low when compared with the other studies of Europe and California (16, 19).
Regarding the subscales, the lifestyle score was below the average of 1.96, this indicates ostomates have some problems in adjusting and adapting their lifestyle after stoma operation. This also indicates that impeding in their social life and activity is very poor, and this finding corresponds to many studies (17, 20). These results are low if compared to an Egyptian study that found lifestyle to be 2.21 (24).
Regarding the coping/behavior score was found to be 2.29 although it is below the average, the score is high when compared with the other quality of life subscales and it is also high when compared to an Egyptian coping/behavior score of 2.06 (24). An Irish study found that coping /behavior regarding the diet had been changed by 45% after stoma operation(17).
Depression/self-perception scale scored 2.41 this result considers at average and the score was found to be the best score if compared to the other quality of life subscales and its high if compared to the Egyptian study 2.38 (below the average)(24). This could be explained by the fact that Sudan's environment is very domestic to accept ostomy patients at least to the level that secures them from depression, this is very true if compared to other western studies (17, 20).
On the other hand, the embarrassment scale was found to be below the average of 1.98 and it is low if compared with other quality of life subscales but higher than the Egyptian score of 1.87 (24). A worth finding to mention is that the embarrassment score especially the sexual and self-image domains had always been low and statistically significant in a lot of studies (17, 18, 20, 23).
The lowest score found was the religious scale score and it is even low if compared with the Egyptian score of 2.18 (24). This raises an essential issue that ostomates were not aware of their religious legitimate excuse offered in such a situation and this is very clear during the data collection process. Yet many studies revealed that stoma adversely affects the religious aspects of the Muslim population and the spiritual QOL of all populations (22, 33, 34).
The lifestyle score was significantly correlated with coping/behavior score (p꞊.002) and with the total score (p꞊.001), this was a positive correlation meaning that when lifestyle scale score increases the score of coping behavior increase, this corresponds with the Egyptian study but unlike the Egyptian study no correlation was found with the depression, embarrassment and religious scales(24).
The coping behavior score was also found to be significantly positively correlated with depression/ self-perception score (p꞊.001), embarrassment(p꞊.001), and the total score(p꞊.001), this corresponded to the Egyptian study but unlike it, no correlation was found with the religious scale (24).
The depression/ self-perception score was found to be negatively correlated to the religious scale meaning that when the religious score increases the depression will decrease but this was not significant. On the other hand, depression scale score was significantly positively correlated to the total quality of life score (p꞊.001).
Embarrassment score in addition to the above correlation was significantly correlated with the total score (p꞊.001), and there was a significant negative correlation between it and the religious score (p꞊.02) as opposed to the Egyptian study which revealed a significant positive correlation between the embarrassment and the religious scale score (24).
The religious score in addition to its negative correlation with the embarrassment score (p꞊.02), was also found to be positively correlated with the total scale score (p꞊.01).
No significant differences were observed for age, gender, stoma history, or marital status. Age, gender, stoma history, and marital status were found independently related to the quality of life in stoma patients.
No association was found between ages, education, family income, and the total quality of life total and subscales scores. This corresponds to the Egyptian study but opposes other studies (17, 24, 35).
Another Egyptian study revealed that gender has a high statistical significance with the sexual and psychological alteration (13). Nevertheless, an Indian study revealed that gender has no significant correlation with the quality of life (32).
For anxiety, 23.8% were found to be abnormal, 25% borderline and 7% were severely anxious. For depression, the situation was worse with 28.8% abnormal and 26.3% borderline. These results correspond to many other studies (1, 12, 20, 25, 27).
No significant differences were observed for gender, age, gender, stoma history, or marital status. Age, gender, stoma history, and marital status were found independently related to anxiety and depression levels in stoma patients.
Age, educational level, and income were found to be non-associated with neither anxiety level nor depression level this corresponded to a study done in Pakistan which revealed that anxiety level was not significantly associated with gender, age, type, and disease led to stoma (22).