Permanent colostomy wound: Aeromedical disposal

INTRODUCTION

According to the Indian Council of Medical Research (ICMR) consensus document for the management of CRC 2014, the annual incidence rate of colon cancer and rectal cancer in Indian male population is 4.4 and 4.1/100,000, respectively.^[1] Surgery is the primary treatment for such cancers and they are mostly curative. Multimodal therapy with neoadjuvant chemotherapy and radiotherapy is done to improve the survival rates. The latest reports published by the National Comprehensive Cancer Network for Rectal Cancer, Version 2.2018, Clinical Practice Guidelines in Oncology indicate that the total mortality rate is currently down by 50% due to better treatment modalities.^[2] Depending on the site of primary tumor, the surgery might leave the patient with either a temporary or permanent colostomy wound. Increasingly people are getting their lives back after permanent colostomy and are involved in high-risk jobs such as firefighting, policing, surfing, and contact sports such as professional boxing and flying. In December 2018, a test pilot of the Indian air force reported to the Institute of Aerospace Medicine (IAM) for aeromedical evaluation post-multimodal treatment for lower one-third of rectum with a permanent colostomy.

CASE REPORT

This 41-year-old pilot from the fighter stream in January 2016 reported with bleeding per rectum. The officer had complaints of intermittent episodes of bleeding per rectum which did not respond to symptomatic medication. In March 2016, the officer underwent a colonoscopy which revealed an ulceroproliferative lesion <2 cm inside the anal verge and extending 8 cm in the rectum. Tissue specimen taken for histopathology revealed moderately differentiated adenocarcinoma. Positron emission tomography (PET) scan done in March 2016 confirmed the diagnosis. The pilot underwent neoadjuvant concurrent chemoradiotherapy starting March 22, 2016. It consisted of 28 days of 50.40 gray external beam radiotherapy pelvis exposure with two cycles of chemotherapy (5 fluorouracil with injection leucovorin). This concluded by April 28, 2016. On June 28, 2016, abdominoperineal resection with descending colostomy was carried out. The post-operative period was uneventful and the pilot recovered well. Post-surgery period was followed by adjuvant chemotherapy 6 + 6 cycles of folinic acid, fluorouracil, and oxaliplatin-4 (oxaliplatin + leucovorin + folinic acid + fluorouracil) from August 4, 2016, to February 28, 2017. Thereafter, the pilot was under observation for recurrence and metastasis. During follow-up, a non-fluoro- D-glucose (FDG)-avid nodule in Rt lower lung was seen which was investigated with contrast-enhanced computed tomography in May 2017 and September 2017 and PET scan in October 2017 and August 2018. The lesion remained non- FDG-avid and hence was considered benign. As per the IAP 4303 (4^th ed.), the officer had completed 2 years in non-flying category since the initial diagnosis and was still advised regular follow-up; hence, he was opined a permanent non- flying status.

The officer had maintained a rigorous exercise regime post-surgery and appealed against the permanent non-flying status. His case was considered and required administrative approval of return to flying status was given. The officer was then sent to IAM for aeromedical evaluation.

DISCUSSION

For evaluation of return to flying status, the following were considered:

Permanent colostomy is an artificial opening made in the abdominal wall for the colon to divert feces and flatus outside the abdomen where they can be collected in an external device.^[3] Earlier such patients required a lot of medical and psychological support. Due to increase in number of colostomy resulting from rising number of perineal injuries, increasing incidence of CRC and inflammatory bowel disease, there has been a lot of development in the field of management of colostomy. A range of products is available for support and care and stoma and they allow the colostomies to lead a productive and healthy life. Concerns regarding a colostomy are mainly regarding the long-term complications such as stomal prolapse, stomal stenosis, parastomal pyoderma gangrenosum, and parastomal hernia.^[4]

Existing guidelines for reflighting a pilot with permanent colostomy are as follows:

1. USAF waiver guidelines updated in January 2018 state that the presence of colostomy or ileostomy is not compatible with military aviation.^[5]

2. FAA guidelines for aviation medical examiners (2017) state that applicant with ileostomy or colostomy may be considered if he or she has fully recovered from surgery and is asymptomatic.^[6]

3. Royal air force manual for the assessment of medical fitness AP 1269A (third edition, date of Publication 1/8/2016, page 454 para 5c) states that those with permanent stoma are to be graded A3 and unfit ejection seat aircraft and E3, i.e., unfit service outside base area. Their continued fitness to fly in other aircrafts will be decided by the supervising consultant and the PMB.^[7]

4. Australian Government Civil Aviation Safety Authorities designated aviation medical examiners handbook September 2011 state that the great majority of applicants with a stoma will not be restricted on the basis of the stoma.^[8]

CONCLUSION

During the detailed aeromedical evaluation done at IAM, extensive search for global precedence was done. There was no available record/published case report of any pilot being returned to the cockpit in military flying with a permanent stoma. Hence, this case is a first of its kind with respect to aeromedical decision-making. All the evaluations done including vibration stress and pressure changes were suitably modified to test this case. With mortality rates decreasing due to effective treatment for cancer, aeromedical decision in more such cases may be required in the future. This case will serve as a precedence in effectively returning trained aviators to the cockpit.