Part 1 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder
- 0 Comments
- 10398 reads
C ontemporary surgical techniques have revolutionized the therapy of persons affected by severe colorectal or urinary bladder disease. Two approaches, ileoanal reservoir (IAR) and orthotopic bladder reconstruction (neobladder), have become the new "gold standards" of definitive care because their functional outcomes have been so positive and they preserve patients' native sphincters. This article examines these two innovations, their surgical construction, indications, contraindications, medical and surgical care issues, and nursing implications. Research to discern optimal surgical techniques, assess the long-term outcomes of these procedures, develop definitive diagnostic instruments for Crohn's disease, and ascertain the potential effects of medical treatments for conditions such as inflammatory bowel disease and bladder cancer is needed.
Until the last decade or so, persons affected by familial adenomatous polyposis (FAP), severe chronic ulcerative colitis (CUC), or cancer of the urinary bladder were faced with a difficult choice. They could undergo a traditional noncontinent fecal or urinary diversion or face even longer surgery and adaptation by the creation of a catheterizable continent fecal or urinary diversion. Although research suggests that quality of life can be good for persons with an ileostomy or ileal conduit (urostomy),1 both involve wearing an external appliance for life. The alternative to a continent ileostomy or urostomy eradicates the need for an external "bag" but involves more intricate surgery and necessitates multiple daily intubations. In addition, the "nipple valve" continence mechanisms of the various continent fecal and urinary pouches can deteriorate over time and require surgical revision or conversion to a traditional diversion.
Improved anesthetic techniques and surgical technology (especially stapling devices) have empowered surgeons to accomplish one of the noteworthy developments in elimination surgery - a move away from permanent incontinent stomas. Now, IAR and neobladder innovations have become the "gold standard" or treatment of choice.2,3 Many of these complex surgeries now can be performed laparoscopically, further shortening recovery time. The enormous advantage is that trans-anal defecation or transurethral urination is preserved with near normal continence. For many persons with life-threatening diagnoses, the worst of times has become the best of times.
The IAR should be distinguished from two other procedures - ie, the coloanal reservoir performed for rectal cancer and the straight ileoanal pull-through for the treatment of CUC or FAP. In the former restorative procedure, a neo-rectum is constructed using descending colon, making a colonic pouch. The pouch is attached to the anal canal similar to the IAR approach. Many adaptation issues that IAR patients face are not present with the coloanal pouch because the entire colon is not removed.4
The IAR differs from the straight ileoanal pull-through - the pull-through involves a proctocolectomy and direct attachment of the ileum to the rectum. The pull-through is associated with much poorer outcomes, prolonged severe diarrhea, and fecal incontinence.5
Epidemiology and Pathophysiology: FAP, CUC, and Bladder Cancer
The IAR is known by several names, including restorative proctocolectomy, Park's Pouch (after Sir Alan Parks who first published about the IAR), and ileal pouch anal anastomosis (IPAA), among others.3 The two common indications for use include FAP and CUC. The negative consequences of both disorders mandate a surgical curative approach. The IAR offers definitive cure and spares the person's natural sphincter, allowing near-normal continence.
1. Colwell JC, Goldberg M, Carmel, J. The state of the standard diversion. Journal of WOCN. 2001;28(1):6-17.
2. Colwell JC, Gray M. What functional outcomes and complications should be taught to the patient with ulcerative colitis or familial adenomatous polyposis who undergoes ileal pouch anal anastomosis? Journal of WOCN. 2000;28(4):184-189.
3. Hocevar BJ, Remzi F. The ileal pouch anal anastamosis: past, present, and future. Journal of WOCN. 2001;28(1):32-36.
4. Young M. Caring for patients with coloanal reservoirs for rectal cancer. MEDSURG Nursing. 2000;9(4):193-197.
5. Choi JS, Wexner S. Secondary reconstruction of an ileal reservoir in patients with failed straight ileoanal pull-through: report of two cases. Techniques in Coloproctology. 2002;6:183-186.
6. FAP - Familial adenomatous polyposis. Resources for Genetic Counselors 2003. Available at: www.genesoc.com. Accessed February 25, 2004.
7. Familial Adenomatous Polyposis Sydrome. Generations - Hereditary Gastrointestinal Cancer Registry 2003. Available at: www.generations.HK.com. Accessed February 25, 2004.
8. DIY Medical Knowledge. Ulcerative Colitis. Available at: www.diy-medical-knowledge.com Accessed February 24, 2004.
9. Johns Hopkins Digestive Disease Library - Colon + Rectum: Ulcerative Colitis 2004. Available at: www.hopkins-gi.org. Accessed February 24, 2004.
10. Ulcerative colitis. National Digestive Diseases Information Clearinghouse 2004. Available at: www.digestive.niddk.nih.gov. Accessed February 25, 2004.
11. Rossi HL, Brand M, Saclarides TJ. Anal complications after restorative proctocolectomy (J-Pouch). American Surgeon. 2002;68:628-630.
12. Metcalf C. Crohn's disease: an overview. Nursing Standard. 2002;16(31):45-52.
13. American Cancer Society. What are the key statistics for bladder cancer: 2004? Available at: www.cancer.org. Accessed February 25, 2004.
14. Urinary bladder: U.S. racial/ethnic cancer patterns. National Cancer Institute. Available at: www.cancer.gov. Accessed February 25, 2004.
15. Bladder Cancer 2003. Cancersource.com. Available at: www.cancersource.com. Accessed February 25, 2004.
16. Pashos CL, Botteman MF, Laskin BL, Redaelli A. Bladder cancer: epidemiology, diagnosis, and management. Cancer Practice. 2002;10(6):311-322.
17. Bladder Cancer Statistics and Risk Factors 2003. www.bladder-cancer-symptoms.com. Accessed February 25, 2004.
18. Krupski T, Theodorescu D. Orthotopic neobladder following cystectomy: indications, management, and outcomes. Journal of WOCN. 2001;28:37-46.
19. Beitz J. The lived experience of having an ileoanal reservoir. Journal of WOCN. 1999;26:185-200.
20. Sercombe J. Surgical therapy for inflammatory bowel disease. Nursing Times. 2001;97(10):34-36.
21. Thirlby RC, Land JC, Fenster F, Lonborg R. Effect of surgery on health-related quality of life in patients with inflammatory bowel disease. Archives of Surgery. 1998;133:826-832.
22. Hull TL. Ileoanal procedures: acute and long-term management issues. Journal of WOCN. 1999;26(4):201-206.
23. Follett SB. From uninformed patient to CWOCN: my life with ulcerative colitis and the ileoanal reservoir. Journal of WOCN. 2003;30(1):4-6.
24. Pace DE, Seshadri PA, Chiasson MD, Poulin EC, Schlachta CM, Mamazza J. Early experience with laparoscopic ileal pouch-anal anastomosis for ulcerative colitis. Surgical Laparoscopy, Endoscopy + Percutaneous Techniques. 2002;12(5):337-341.
25. Gullberg K, Liljeqvist L. Stapled ileoanal pouches without loop ileostomy: a prospective study in 86 patients. International Journal of Colorectal Disease. 2001;16(4):221-227.
26. Choi H, Saigusa N, Choi J, Shin E, Weiss E, Nogueras J, Wexner S. How consistent is the anal transitional zone in the double stapled ileoanal reservoir? International Journal of Colorectal Disease. 2003;18:116-120.
27. Laureti S, Ugolini F, D'Errico A, Rago S, Poggioli, G. Adenocarcinoma below ileoanal anastamosis for ulcerative colitis: report of a case and review of the literature. Diseases of the Colon + Rectum. 2002;45(3):418-421.
28. Vieth M, Grunewald M, Niemeyer C, Stolte M. Adenocarcinoma in an ileal pouch after prior proctocolectomy for carcinoma in a patient with ulcerative pancolitis. Virchow's Archives. 1998;433(3):281-284.
29. Tulchinsky H, Cohen C, Nicholls R. Salvage surgery after restorative proctocolectomy. British Journal of Surgery. 2003;90(8):909-921.
30. MacLean AR, O'Connor B, Parkes R, Cohen Z, McLeod RS. Reconstructive surgery for failed ileal pouch - anal anastomosis. Diseases of Colon + Rectum. 2002;45(7):880-886.
31. Weiss EG, Wexner S. Surgical therapy for ulcerative colitis. Gastroenterology Clinics of North America. 1995;24(3):559-575.
32. Wei JT, Park J, Vallorosi C, Wood D, Montie JE. Gender differences in urinary function after orthotopic neobladder surgery. Contemporary Urology. 2001;7:50-64.
33. Kane A. Criteria for successful neobladder surgery: patient selection and surgical construction. Urologic Nursing. 2000;20(3):182-188.
34. Polt CA. The ins and outs of continent urinary diversions. Nursing Spectrum. 2003;12(22 PA):22-24.
35. Stein JP, Skinner DG. T-mechanism applied to urinary diversion: the orthotopic T-Pouch ileal neobladder and cutaneous double T-pouch ileal reservoir. Techniques in Urology. 2001;7(3):209-222.
36. McGuire S, Girmaldi G, Grotas J, Russo P. The type of urinary diversion after radical cystectomy significantly impacts on the patient's quality of life. Annals of Surgical Oncology. 2000;7(1):4-8.
37. Kulkarni J N, Pramesh CS, Rathi S, Pantvaidya GH. Long-term results of orthotpic neobladder reconstruction after radical cystectomy. BJU International. 2003;91(6):485-488.
38. Kucyk M, Machtens S, Bokemeyer C, et al. Surgical bladder preserving strategies in the treatment of muscle-invasive bladder cancer. World Journal of Urology. 2002;20:183-184.