About 40,290 patients will be newly diagnosed with. Irrigation Practices in Long-Term Survivors of Colorectal Cancer With Colostomies.

Transcription

1 Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, To purchase high-quality reprints, CNE Article Irrigation Practices in Long-Term Survivors of Colorectal Cancer With Colostomies Marcia Grant, RN, DNSc, FAAN, Carmit K. McMullen, PhD, Andrea Altschuler, PhD, Mark C. Hornbrook, PhD, Lisa J. Herrinton, PhD, Christopher S. Wendel, MS, Carol M. Baldwin, PhD, RN, CHTP, AHN-BC, and Robert S. Krouse, MD, FACS For some patients diagnosed with rectal cancer, surgery will involve the creation of a temporary or permanent ostomy. When the colostomy is located in the sigmoid or descending colon, regulation of fecal output can occur through irrigation, a procedure that involves instilling fluid into the bowel to flush out gas and fecal material. When successfully used, irrigation can prevent fecal output between irrigations, providing some control over colostomy output. The purpose of this article is to describe participants of a large, multisite, multi-investigator study of health-related quality of life in long-term colorectal cancer survivors who answered questions about colostomy irrigation and reported the potential advantages and disadvantages of the procedure. The article John Bavosi/Photo Researchers, Inc. also will explore healthcare professionals role in ensuring patients and family members are educated and well informed about their options regarding temporary or permanent ostomies. Marcia Grant, RN, DNSc, FAAN, is a professor and director at the City of Hope National Medical Center/Beckman Research Institute in Duarte, CA; Carmit K. McMullen, PhD, is an investigator in the Center for Health Research at Kaiser Permanente Northwest in Portland, OR; Andrea Altschuler, PhD, is a senior consultant at the Kaiser Permanente Medical Care Program in Oakland, CA; Mark C. Hornbrook, PhD, is chief scientist in the Center for Health Research at Kaiser Permanente Northwest; Lisa J. Herrinton, PhD, is a research scientist at the Kaiser Permanente Medical Care Program; Christopher S. Wendel, MS, is a biostatistician at the Southern Arizona Veterans Affairs Health Care System in Tucson; Carol M. Baldwin, PhD, RN, CHTP, AHN-BC, is an associate professor and director in the College of Nursing at Arizona State University in Tempe; and Robert S. Krouse, MD, FACS, is a staff general and oncologic surgeon at the Southern Arizona Veterans Affairs Health Care System and in the College of Medicine at the University of Arizona in Tucson. The authors take full responsibility for the content of the article. This research was funded by a grant from the National Cancer Institute (R01-CA106912). Resources and facilities were provided by Southern Arizona Veterans Affairs Health Care System and the City of Hope Comprehensive Cancer Center. Krouse was a member of the Steering Committee for Malignant Bowel Obstruction trial for Novartis Pharmaceuticals. The content of this article has been reviewed by independent peer reviewers to ensure that it is balanced, objective, and free from commercial bias. No financial relationships relevant to the content of this article have been disclosed by the independent peer reviewers or editorial staff. Grant can be reached at mgrant@coh.org, with copy to editor at CJONEditor@ons.org. (First submission December Revision submitted February Accepted for publication March 4, 2012.) Digital Object Identifier: /12.CJON About 40,290 patients will be newly diagnosed with rectal cancer in 2012 (American Cancer Society, 2012). Surgery may involve the creation of a temporary or permanent ostomy, and they will join more than 700,000 people in the United States who have an ostomy (United Ostomy Association of America, 2011). A permanent intestinal stoma occurs during surgery for rectal cancer when an anastomosis (reconnection) of the remaining bowel is not an option. Permanent colostomies are most common for low rectal cancers and usually created from the sigmoid or descending colon. The presence of a colostomy has a major impact on patients health-related quality of life (HRQOL) (Altschuler et al., 2009; Baldwin et al., 2009; Grant et al., 2004; Krouse et al., 2007, 2009; McMullen et al., 2008). A pouch or bag is worn over the colostomy to collect the fecal output. Colostomy care usually involves emptying the pouch daily, multiple times a day, or every other day. The skin surrounding the stoma is cleaned, and the wafer is typically changed every three to seven days. Specific colostomy concerns include odor or gas, leaking, and skin problems (Grant et al., 2004). Physical challenges involve difficulty sleeping, decreased strength, and fatigue (Krouse et al., 2007). Psychological problems include depression, anxiety, uncertainty, fear of cancer recurrence, appearance changes, and the need for privacy (Krouse et al., 2007). Of special concern are the social challenges that make it difficult for some patients with colostomies to participate in social events such as eating out, traveling, developing new relationships, and participating in intimate activities (Krouse et al., 2009; Mitchell et al., 2007). Spiritual challenges involve changes in the meaning of life and developing and maintaining a sense of inner peace and hopefulness (Baldwin et al., 2008). Some of those concerns may be related to the uncontrolled output of stool from the ostomy. Because several kinds of pouches and pouching systems are available, patients learn with experience which system works 514 October 2012 Volume 16, Number 5 Clinical Journal of Oncology Nursing

2 best for them, and how to apply and use the various systems. Trial-and-error learning is common as patients learn the relationship of food intake and colostomy output. Concerns for a proper fit, prevention of leaks and resulting skin irritation, and regular emptying or replacement of the pouch are part of the routine care (Toth, 2006). However, even with daily care and a proper fitting pouch, sudden fecal output and odors are not uncommon (McMullen et al., 2008). Colostomy irrigation involves the instillation of 500 1,500 ml of tap water into the colon via the stoma to wash out fecal matter. Irrigation is generally carried out daily or every two to three days and results in little or no stool evacuation from the stoma until the next irrigation (Varma, 2009). The procedure takes as long as an hour and includes a short (about 6 10 minutes) instillation period followed by evacuation for as long as an hour. Irrigation is an old method of continence control, described in 1793 by a French surgeon who used the procedure on an infant (O Bichere, Sibbons, Doré, Green, & Phillips, 2000). It was taught and used regularly on patients with colostomies (Gabriel, 1927; Gabriel & Lloyd-Davies, 1935) until nine colonic perforations and eight deaths related to use of an irrigation catheter were reported (Gabriel, 1945). Equipment improvements in the 1970s and 1980s (use of a cone rather than a straight catheter) have eliminated the occurrence of perforations. Reports on people with colostomies who irrigate are variable across countries and over the years, with 5% of 85 British patients (Wade, 1989), 82% of 270 American patients (Jao, Beart, Wendorf, & Ilstrup, 1985), and 62% of 31 Turkish patients (Karadag et al., 2003). O Bichere et al. (2000) reported that the vast majority of people with colostomies do not irrigate. Eligibility of patients includes regular bowel patterns before surgery, sigmoid or descending colostomy, mentally alert, good dexterity, and a good prognosis (Rooney, 2007; Watt, 1977; Woodhouse, 2005). Colostomy irrigation increases the quality of life (QOL) of those who use it regularly (Jao et al., 1985). Positive effects include less leakage, better sleep, less anxiety, less isolation, increased social comfort, feeling more clean, feeling more confident in intimate situations, and reduced odor (Carlsson et al., 2010; Gervaz et al., 2008; Karadag et al., 2003; O Bichere, Green, & Phillips, 2004; Varma, 2009). Considering how long colostomy irrigation has been used, research on various aspects of the procedure is limited. Published studies have focused on bowel activity during and after irrigation (Christensen, Olsen, Krogh, & Laurberg, 2002), effects of different solutions (Doran & Hardcastle, 1981; O Bichere, Bossom, Gangoli, Green, & Phillips, 2001; O Bichere et al., 2004), responses to different amounts of fluid (Gattuso, Kamm, Myers, Saunders, & Roy, 1996; Meyhoff, Andersen, & Nielsen, 1990), and positive results from stomatherapy visits or clinics (Karadag et al., 2003; Terranova, Sandei, Rebuffat, Maruotti, & Bortolozzi, 1979). Despite the advantages of colostomy irrigation, healthcare professionals continue to express concerns about the potential for perforation, mucosal burning, stricture, and loss of bowel tone, although research on those topics has not been reported (Varma, 2009). No studies were found on the preparation of nurses or generic nursing program content regarding the procedure. More information is needed on what is included in patient education and rehabilitation regarding colostomy irrigation, when it occurs, and what preparation healthcare professionals have for providing preoperative and postoperative care for patients who receive permanent colostomies. Irrigation provides a way to evacuate all or most of the large bowel contents. Following irrigation, it generally takes hours before the bowel fills again and evacuation of fecal material through the stoma occurs (Rooney, 2007). With successful irrigation, it may be possible to use only a cap, mini-pouch, or patch to protect the stoma, making the colostomy less visible through clothing. In addition, leaks and odors are minimized or completely prevented. With this added control over bowel output, the potential for increased independence, decreased work challenges, and increased social activities can again become a part of daily living. Using information gathered from a large population of colorectal cancer (CRC) survivors (greater than five years postsurgery), this article will describe survivors current irrigation use, their characteristics and needs, and the advantages and disadvantages of irrigation as reported by them. Methods This large multisite, multi-investigator study involved a cross-sectional, mailed survey inclusive of demographic data and the modified City of Hope Quality of Life Ostomy (mcohqol-o) survey (Mohler et al., 2008). Reports of the overall study and methods have been published elsewhere (Krouse et al., 2009; Mohler et al., 2008) and will be summarized here. Eligibility for participation included being a current member of the Kaiser Permanente Health Maintenance Organization located in Northern California, Oregon, or Hawaii; 18 years of age or older; diagnosed with CRC at least five years prior to the survey; and history of a major gastrointestinal procedure including major resection of the colon or rectum that did (cases) or did not (controls) result in an intestinal stoma. The mcohqol-o consisted of general and ostomy-specific questions. Open-ended optional questions on the mcohqol-o questionnaire related to ostomy equipment problems, irrigation practices, and the greatest challenge encountered in having an ostomy. Only those survey responses among cases related to irrigation are reported in this article. In one of the sites, information about irrigation practices was collected in telephone interviews (see Figure 1). To obtain more in-depth information about challenges associated with living with a colostomy, focus groups were conducted. Participants in the focus groups were eligible if they scored in the top and bottom quartiles on the overall QOL score on the quantitative survey. Focus groups were divided by gender and by high and low QOL scores. Gender differences in focus groups analysis have been reported elsewhere (Grant et al., 2011). u Do you irrigate your colostomy? If yes, the following issues were addressed. u How often do you irrigate? u Please tell the reasons why you irrigate. u Please describe how irrigating your stoma has changed your quality of life and anything else you would like to say about irrigating your ostomy. FIGURE 1. Telephone Interview Questions Clinical Journal of Oncology Nursing Volume 16, Number 5 Irrigation Practices in Colorectal Cancer Survivors 515

3 Analysis included descriptive statistics for quantitative data and content analysis of qualitative data. Qualitative data from the interviews of participants who answered yes to the question on irrigation in the mcohqol-o questionnaire or who participated in the telephone interviews included information on why they irrigated and how, if at all, it changed their lives. Data were transcribed, assigned for review by the investigative team, and categorized using content analysis. At least two of the investigators reviewed and categorized each comment. Results were shared and coding reviewed by the entire team. Discrepancies were discussed and resolved. For the focus group qualitative data, content was transcribed, separating data into the four groups by gender and by high and low QOL scores on the mcohqol-o. Analysis of the content followed the same format as the questionnaire and interview data. Results A total of 101 CRC survivors with ostomies completed surveys, including questions on irrigation (a response rate of 58%). Of those respondents, 50% never irrigated, 30% irrigated every one to three days, 4% irrigated more than once a day, 5% irrigated sporadically, and 11% had irrigated for a number of years and then quit. For comparison of characteristics by irrigation status, irrigations were put in one group regardless of frequency of irrigation and compared with former irrigators and those who never irrigated (see Table 1). Age was similar in all three groups, and ranged from years. Time elapsed since surgery was significantly longer in current (p = 0.002) and former (p < 0.001) irrigators compared to participants who never irrigated. A significantly higher proportion of participants who currently irrigate spent more than 60 minutes in daily ostomy care time compared to participants who never irrigated (p < 0.001). Survey comments from each of these groups illustrate both positive and challenging aspects of irrigation. Examples of positive comments often mentioned controlling output, gas, odor, and functioning with only a bandage over the stoma. I have a descending sigmoid colostomy, which allows me to irrigate... exercise some control over my bowel movements. In this regard, the greatest challenge has been to maintain regularity, which I have achieved approximately 80% of the time. I can t say that my ostomy has presented any serious challenges. Perhaps a short time while learning to irrigate but I was soon able to function normally with only a [bandage] covering the stoma. I irrigate my colostomy every day. Therefore, I imagine I have less problems with odor and gas than those who do not irrigate daily. However, this means my morning irrigation and then shower... [can] take up two hours of time but this is what I choose. Participants negative comments all related to the time involved in completing the irrigation procedure. The greatest challenge has been in keeping myself regular, so that my irrigations function properly and I won t go around with an odor. I tried not doing enemas... irrigation, but couldn t tolerate that. It s not always possible to attend anything that is scheduled too early in the morning because of the time it takes to irrigate. The quality of my life otherwise has been excellent, aside from the nuisance of daily irrigation. TABLE 1. Sample Characteristics by Irrigation Status Characteristic X Never (N = 51) SD Current a (N = 39) Former b (N = 11) Age (years) Years since surgery Total quality of life Characteristic n % n % n % Male Partnered Charlson score less than Ostomy care time minutes Ostomy care time 60 minutes or longer a p = compared to never b p < compared to never c p = compared to former; p = compared to never X c SD X SD Participants who had irrigated for years, but had subsequently quit, related this change primarily to retiring, moving into assisted living, or not having to go to work every day. Participants who said that they had never irrigated displayed a complete lack of knowledge about irrigation and its purpose. For participants who irrigated, neither gender nor work affected irrigation frequencies. The researchers also found that older patients were more likely to irrigate. The longer the time since surgery, the more likely irrigation occurred. Ten participants added additional comments on the mcohqol-o open-ended question in relation to irrigation. Comments included positive and challenging 516 October 2012 Volume 16, Number 5 Clinical Journal of Oncology Nursing

4 aspects of irrigation, as well as comments from individuals who did irrigate, but have since stopped (see Figure 2). Positive comments included control over colostomy output and maintaining regularity. Challenges were related to the time involved in carrying out the procedure. Focus groups included 33 CRC survivors in four groups: 12 men in the high QOL group, 10 women in the high QOL group, 5 men in the low QOL group, and 6 women in the low QOL group. Positive qualitative comments again related irrigation to controlling for odor and gas, and only needing a bandage to cover the stoma between irrigations. I still irrigate. When I first started this and after I got the regime down, all I wore was a Band-Aid across my stoma. I did that for years and years and years until I retired from work. I irrigated for a while and I loved it. I did it at night. And actually I only had to do it every other night because that was the way I went to the bathroom before. Anyway, so, and I loved it. I mean, I went in there and told everybody to leave me alone. But it was just great because you just had to wear this little round thing and I didn t worry about it. There were a lot less of the other problems like the odor problems and the gas problems and I just really liked it, but I just can t do it anymore. I think everybody should try it, if they can. Challenges included needing as long as two hours to complete the irrigation procedure and having difficulty carrying out the procedure when out of town and traveling. I did irrigate for five years. I retired in December of 1983, and I haven t irrigated a day since. It s twice as nice. I think of all of those years I sat on that toilet and it s ridiculous. Irrigating... it can have pros and cons. I mean, you can be in places where you cannot irrigate. Some participants who were not irrigating expressed an interest in knowing more about irrigation as something they might implement. Discussion The results revealed that many positive aspects of irrigation were described by the participants of the survey and the focus groups. Although frequency of irrigation varied among participants, the control of output and the elimination of the pouch were identified as positive aspects of irrigation by all of the participants. For participants who were working, irrigation was used to maintain control during work hours. Participants who irrigated indicated that the routines for irrigation were very stable for many years. Those results are similar to other reports of irrigation practice. In a study by Karadag, Mentes, and Ayaz (2005) on the use of colostomy irrigation in 25 cases in Turkey, QOL improved significantly in patients who irrigated versus patients who did not. The improvements included achieving fecal continence and improvements in physical problems, social functioning, and emotional problems. In the current study, cancer survivors who irrigated had more years pass since their initial surgery than participants who did not use irrigation. Participants who no longer irrigated Positive Aspects of Irrigation I irrigate every morning.... We have traveled all over, even to Europe. I have had no problems with irrigating. I have suffered constipation all my life. I irrigate every morning so I will be regular. I irrigate every evening for over 30 years. It s a pain in the butt, but it s trained... and you live with it. I do not wear a bag. I use a patch. I irrigate every day... have less problems with odor and gas. I irrigate and function with only a Band-Aid covering the stoma. I irrigate for convenience... like golfing, I irrigate the night before. Challenging Aspects of Irrigation I irrigate any time of the day, usually the afternoon. It limits me going places and the time I go. It takes too long to irrigate. I only irrigate when I will be away from home. I need 1.5 hours to irrigate. This has disrupted my life. Used to Irrigate, But Quit I used to irrigate every day until... I moved into an assisted living facility. I irrigated every day for about 15 years because I was working. Now I am at home all the time and do not irrigate. I irrigated at 5:30 am every day before I went to work. Never Irrigated Never irrigated, never was shown how, and never needed to. What is irrigating? Why would anyone irrigate? I would like to learn how to do this. FIGURE 2. Comments From Telephone Interview Participants had the most time elapsed since surgery, indicating that their surgical procedure and initial teaching about ostomy care occurred an average of 21 years prior (SD = 9.1 years). For participants who used irrigation during their working years, the reason for quitting was related to the time it took for the entire procedure. Results indicate that irrigation can control symptoms of output, gas, and odor, and eliminate use of a pouch. Participants who quit irrigating were retired or no longer working and, therefore, were in a home setting where fecal output, odor, gas are more tolerated. Others participants quit irrigation after they got older, had reduced functional ability, or moved into a nursing facility. They were no longer able to perform irrigation themselves and support for the procedure was not available in the new setting. None of the participants who stopped irrigating reported any problems when reverting to natural evacuations. Results showed that 50% of the 101 participants never irrigated their colostomy. Of those participants, 3% said they had Exploration on the Go The Oncology Nursing Society offers the Site-Specific Cancer Series: Gastrointestinal Cancer online course for nurses looking to expand their knowledge in a convenient format. To access, open a barcode scanner on your smartphone, take a photo of the code, and your phone will link automatically. Or, visit bit.ly/om6int. Clinical Journal of Oncology Nursing Volume 16, Number 5 Irrigation Practices in Colorectal Cancer Survivors 517

5 Implications for Practice u Colostomy irrigation can increase quality of life in patients who are able to undergo the procedure. u All colostomy patients suitable for irrigation should be given an opportunity to learn about it. u Colostomy irrigation can decrease skin problems and sleep disturbances, and increase comfort in social situations. never heard of irrigation. Colostomy irrigation is most likely to be taught, if at all, by the ostomy nurse in the clinical setting or by a home-care nurse in patients homes. Initial postoperative teaching may cover this aspect briefly, waiting until a bowel pattern is established postoperatively before irrigation is begun. It also is likely that irrigation is no longer taught. Although demonstrating and implementing irrigation may need to take place in the home, it should be introduced prior to hospital discharge. Whether irrigation is included in the routine teaching of eligible patients is unknown. Ways to provide this education postdischarge from the hospital need to be explored. In this era of decreases in healthcare support, providing this education may be challenging (Toth, 2006). Wound, ostomy, and continence (WOC) nurses (n = 61) and patients (n = 39) in Sweden were surveyed by Carlsson et al. (2010), and interviews were conducted with three patients who used irrigation. Positive aspects were reported by 97% of the participants and included feeling secure in social settings, having an empty pouch, increased feelings of freedom, enhanced bowel control, feeling cleaner, feeling confident in intimate situations, and having decreased odor and anxiety. Difficulties associated with colostomy irrigation were identified by the nurses, and included chronic diarrhea from radiation or chemotherapy, irritable bowel syndrome, liquid consistency of stool, slow transit time, age, small toilet size, and emotional distress associated with carrying out the procedure. Also mentioned was peristomal hernia, although no evidence exists to associate that with irrigation. Only 64% of the WOC nurse responders always informed their patients about irrigation, 23% said they do not regularly teach patients to perform irrigation, and 13% stated they do not practice it at all (Carlsson et al., 2010). Patients interviewed in the Carlsson et al. (2010) study were introduced to irrigation (95%) by the WOC nurses, with two patients informed by the physician. Directions for irrigation included using this procedure every other day, with tap water at 37 C and instillation lasting 5 30 minutes. The total amount used was 500 1,000 ml for 3 10 minutes. Conclusion Education and use of irrigation by patients with colostomies has decreased over the years. One of the potential obstacles to the provision of this education is the need to wait until the bowel has recovered and a pattern of evacuation has been established. However, reasons for the decrease in colostomy irrigation remain unexplored. Studies are needed that describe what teaching is provided, when it is provided, and by whom. Research also is needed to examine concerns by nurses who are reluctant to teach colostomy irrigation. The results of this article point to the need for additional information regarding teaching patients who have had a colostomy about irrigation as a method to control output and its potential to improve the quality of patients lives, particularly while they are still in the work force. References Altschuler, A., Ramirez, M., Grant, M., Wendel, C., Hornbrook, M.C., Herrinton, L., & Krouse, R.S. (2009). The influence of husbands or male partners support on women s psychosocial adjustment to having an ostomy resulting from colorectal cancer. Journal of Wound Ostomy and Continence Nursing, 36, doi: /won.0b013e3181a1a1dc American Cancer Society. (2012). Cancer facts and figures. Atlanta, GA: Author. Baldwin, C.M., Grant, M., Wendel, C., Hornbrook, M.C., Herrinton, L.J., McMullen, C., & Krouse, R.S. (2009). Gender differences in sleep disruption and fatigue on quality of life among persons with ostomies. Journal of Clinical Sleep Medicine, 5, Baldwin, C.M., Grant, M., Wendel, C., Rawl, S., Schmidt, C.M., Ko, C., & Krouse, R.S. (2008). Influence of intestinal stoma on spiritual quality of life of U.S. veterans. Journal of Holistic Nursing, 26(3), doi: / Carlsson, E., Gylin, M., Nilsson, L., Svensson, K., Alverslid, I., & Persson, E. (2010). Positive and negative aspects of colostomy irrigation. Journal of Wound Ostomy and Continence Nursing, 37, doi: /won.0b013e3181edaf84 Christensen, P., Olsen, N., Krogh, K., & Laurberg, S. (2002). Scintigraphic assessment of colostomy irrigation. Colorectal Disease, 4, Doran, J., & Hardcastle, J.D. (1981). A controlled trial of colostomy management by natural evacuation, irrigation and foam enema. British Journal of Surgery, 68, Gabriel, W.B. (1927). Discussion on colostomy. Proceedings of the Royal Society of Medicine, 20, Gabriel, W.B. (1945). Discussion of the management of the permanent colostomy. Proceedings of the Royal Society of Medicine, 38, Gabriel, W.B., & Lloyd-Davies, O.V. (1935). Colostomy. British Journal of Surgery, 22, 520. Gattuso, J.M., Kamm, M.A., Myers, C., Saunders, B., & Roy, A. (1996). Effect of different infusion regimens on colonic motility and efficacy of colostomy irrigation. British Journal of Surgery, 83, Gervaz, P., Bucher, P., Konrad, B., Morel, P., Beyeler, S., Lataillade, L., & Allal, A. (2008). A prospective longitudinal evaluation of quality of life after abdominoperineal resection. Journal of Surgical Oncology, 97, doi: /jso Grant, M., Ferrell, B., Dean, G., Uman, G., Chu, D., & Krouse, R. (2004). Revision and psychometric testing of the City of Hope Quality of Life Ostomy questionnaire. Quality of Life Research, 13, Grant, M., McMullen, C.K., Altschuler, A., Mohler, M.J., Hornbrook, M.C., Herrinton, L.J.,... Krouse, R.S. (2011). Gender differences in quality of life among long-term colorectal cancer survivors with ostomies. Oncology Nursing Forum, 38, doi: /11.onf Jao, S.W., Beart, R.W., Wendorf, L.J., & Ilstrup, D.M. (1985). Irrigation 518 October 2012 Volume 16, Number 5 Clinical Journal of Oncology Nursing

6 management of sigmoid colostomy. Archives of Surgery, 120, doi: /archsurg Karadag, A., Mentes, B.B., & Ayaz, S. (2005). Colostomy irrigation: Results of 25 cases with particular reference to quality of life. Journal of Clinical Nursing, 14, doi: /j x Karadag, A., Mentes, B.B., Uner, A., Irkörücü, O., Ayaz, S., & Ozkan, S. (2003). Impact of stomatherapy on quality of life in patients with permanent colostomies or ileostomies. International Journal of Colorectal Diseases, 18, Krouse, R., Grant, M., Ferrell, B., Dean, G., Nelson, R., & Chu, D. (2007). Quality of life outcomes in 599 cancer and non-cancer patients with colostomies. Journal of Surgical Research, 138, doi: /j.jss Krouse, R.S., Herrinton, L.J., Grant, M., Wendel, C.S., Green, S.B., Mohler, M.J.,... Hornbrook, M.C. (2009). Health-related quality of life among long-term rectal cancer survivors with an ostomy: Manifestations by sex. Journal of Clinical Oncology, 27, doi: /jco McMullen, C.K., Hornbrook, M.C., Grant, M., Baldwin, C.M., Wendel, C.S., Mohler, M.J.,... Krouse, R.S. (2008). The greatest challenges reported by long-term colorectal cancer survivors with stomas. Journal of Supportive Oncology, 6(4), Meyhoff, H.H., Andersen, B., & Nielsen, S.L. (1990). Colostomy irrigation: A clinical and scintigraphic comparison between three different irrigation volumes. British Journal of Surgery, 77, Mitchell, K.A., Rawl, S.M., Schmidt, C.M., Grant, M., Ko, C.Y., Baldwin, C.M.,... Krouse, R.S. (2007). Demographic, clinical, and quality of life variables related to embarrassment in veterans living with an intestinal stoma. Journal of Wound Ostomy and Continence Nursing, 34, doi: /01.won e Mohler, M.J., Coons, S.J., Hornbrook, M.C., Herrinton, L.J., Wendel, C.S., Grant, M.,... Krouse, R.S. (2008). The health-related quality of life in long-term colorectal cancer survivors study: Objectives, methods and patient sample. Current Medical Research and Opinions, 24, O Bichere, A., Bossom, C., Gangoli, S., Green, C., & Phillips, R.K. (2001). Chemical colostomy irrigation with glyceryl trinitrate solution. Diseases of the Colon and Rectum, 44, O Bichere, A., Green, C., & Phillips, R.K. (2004). Randomized cross-over trial of polyethylene glycol electrolyte solution and water for colostomy irrigation. Diseases of the Colon and Rectum, 47, O Bichere, A., Sibbons, P., Doré, C., Green, C., & Phillips, R.K. (2000). Experimental study of faecal continence and colostomy irrigation. British Journal of Surgery, 87, doi: / j x Rooney, D. (2007). Colostomy irrigation: A personal account of managing a colostomy. Phoenix, 2 5. Retrieved from Terranova, O., Sandei, F., Rebuffat, C., Maruotti, R., & Bortolozzi, E. (1979). Irrigation vs. natural evacuation of left colostomy: A comparative study of 340 patients. Diseases of the Colon and Rectum, 22, Toth, P.E. (2006). Ostomy care and rehabilitation in colorectal cancer. Seminars in Oncology Nursing, 22, doi: /j.soncn United Ostomy Association of America. (2011). New patient guide: Colostomy. Retrieved from ostomy_info/pubs/colostomynpg2011.pdf Varma, S. (2009). Issues in irrigation for people with a permanent colostomy: A review. British Journal of Nursing, 18(4, Suppl.), S15 S18. Wade, B. (1989). A stoma is for life: A study of stoma nurses and their patients. London, England: Scutari Press. Watt, R.C. (1977). Colostomy irrigation. Yes or no? American Journal of Nursing, 77, Woodhouse, F. (2005). Colostomy irrigation: Are we offering it enough? British Journal of Nursing, 14(16, Suppl.), S14 S15. Receive Continuing Nursing Education Credits Receive free continuing nursing education credit* for reading this article and taking a brief quiz online. To access the test for this and other articles, visit After entering your Oncology Nursing Society profile username and password, select CNE Tests and Evals from the left-hand menu. Scroll down to Clinical Journal of Oncology Nursing and choose the test(s) you would like to take. * The Oncology Nursing Society is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s COA. Clinical Journal of Oncology Nursing Volume 16, Number 5 Irrigation Practices in Colorectal Cancer Survivors 519