To the Editor:

We read with great interest the article by Nakagawa and Misao,1 evaluating the effects of stoma location on the incidence of surgical site infections in colorectal patients. While concluding that stoma location (relative to the midline) was not significantly associated with surgical site infection risk in patients, we would like to highlight special considerations relating to stoma location in colorectal patients of Islamic faith.

Muslims practicing the Islamic faith comprise nearly a quarter of the global population.2 Muslim patients can be averse to stomas, often reporting religious and cultural difficulties in living with a stoma resulting in poor quality of life.3 These observations have been supported by others who have demonstrated that faith-related factors can key drivers of morbidity in this population.4,5 Muslims hold strict hygiene requirements pertaining to the 5 times daily prayers. Impurities termed najees (in Arabic), such as feces, prevent some ostomates from praying in congregation.4

In 2010, after considering these issues, our institution commissioned a local fatwa (a ruling on an issue based upon an interpretation of Shariah Law given by a recognized Islamic authority) that aimed to offer tailored advice to Muslim ostomates. Interestingly, the fatwa (written in accordance to Sunni scholarship) advised colorectal specialists to site stomas on the left side of the abdomen in Muslim patients. According to Shariah Law, acts deemed "dirty," including washing impurities after defecation, are instructed to be performed with the left hand. Furthermore, as Muslims are religiously advised to sleep on the right side, a right-sided stoma may prove uncomfortable and restrictive. Following this fatwa, when asking Muslim patients with experiences of stomas on both sides, the left-sided stoma was reported to be more compliant with religious instruction, easier to manage during ritual ablution, and easier to clean with the left hand. The fatwa ruling was made conditional upon the surgeon agreeing that no extra risk was posed as a result of siting a stoma on the left. The fatwa went on to assure those Muslims with right-sided stomas that they were exempt from penalties as medical necessity had removed their choice.

There is vast clerical diversity when considering fatwa-based advice on medical issues.2 Islam is not a monolithic religion particularly when considering contemporary issues such as the one presented. It is for these reasons, that some Muslims may not consider this to be an important issue or agree with the fatwa advice. Further qualitative research investigating the opinions of Muslim ostomates on this issue, ideally from a larger global cohort, is warranted. Until this is available, we advise our colorectal colleagues to consider the impact of stoma location in Muslim patients carefully and to discuss this specifically at the preconsent stage. From our own experiences, Muslims may prefer left-sided stomas when asked specifically.

Fareed Iqbal, MRCS (Eng), MBChB, BMedsc (Hons)

Research Fellow, School of Cancer Sciences

University of Birmingham, Edgbaston

Birmingham B15 2TT, UK

[email protected]

Shafquat Zaman, MBChB, BMedsc

Core Surgical Trainee

Heart of England NHS Foundation Trust

Bordesley Green, Birmingham B9 5SS, UK

Douglas M. Bowley, FRCS (Gen Surg), MBChB

Consultant Colorectal Surgeon

Heart of England NHS Foundation Trust

Bordesley Green, Birmingham B9 5SS, UK

References