Part 2 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder
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Continued from Part 1
Medical/Surgical Care Issues: IAR
Multiple medical and surgical care issues need to be addressed in the preoperative period. The patient is experiencing major pelvic surgery and must be prepared accordingly. Chronic diseases such as diabetes must be controlled and nutritional status should be maximized as much as possible. Steroids should be tapered before surgery, but this is often not possible because some patients experience a worsening of symptoms of the disorder.
Attention to preoperative preparation is critical to perioperative health and long-term outcomes. A phenomenological study of IAR patients was conducted.19 A major theme emerging from the study was "seeking control." Participants suggested preparing to be in the best health before entering surgery. Several counseled "if you can control it, don't get sick" before experiencing this surgery.
Other research substantiates the patient's perceptions. Heuschen et al39 found that select factors were associated with a greater incidence of pouch-related septic complications (PRSC) in CUC and FAP patients. Patients with CUC who were younger, had more severe proctitis, lower preoperative hemoglobin levels, and were receiving corticord medications had higher risk for PSRC. The higher the dose of daily steroid medication, the higher the risk of PSRC. Patients with FAP had higher risk of PRSC only if anastomotic tension had occurred.
For Stage I, patients receive a bowel cleansing regimen to remove feces from the GI tract and antibiotic coverage to lower microbial count. Postoperatively, they have multiple drains and require comprehensive pain control (epidural or patient-controlled analgesia). They also will have a nasogastric tube in place until bowel sounds return.
Patients can expect multiple drains postoperatively, including a Foley catheter, pelvic drains, and high output ileostomy. Because of the intense nature of the surgery, patients will likely have a short ICU stay. The high output ileostomy can be quite traumatic to the patients' quality of life if they are not adequately prepared for it.19
Several weeks after the Stage I procedure, the patient will have a radiological study of the IAR. If the reservoir is intact, the surgeon and patient can proceed to Stage II. At this point, the reservoir starts functioning and the patient can expect multiple bowel movements daily.
The risk of mucosal pouch atrophy and neoplastic transformation is a longer-term issue associated with the IAR. Research suggests that the risk for both issues is increased when patients have ulcerative colitis or a history of primary sclerosing cholangitis.40
Research also has examined the histology of the IAR pouch over time. Tianen and colleagues41 found that in 64 IPAA patients, all had inflammatory changes in the pouch over time. Persons with chronic pouchitis have both acute and chronic inflammation that spreads over the entire pelvic pouch.
Medical/Surgical Care Issues: Neobladder
Similar significant medical and surgical issues need to be addressed in the perioperative period for the neobladder patient. Like IAR, neobladder is major pelvic surgery but neobladder involves both the genitourinary and gastrointestinal tracts. All chronic diseases experienced by potential candidates have to be as well controlled as possible before surgery is performed.
Another major preoperative issue for the neobladder patient is ensuring that he/she is a good candidate - that is, free from metastatic disease and with bladder cancer that does not involve the urethra so it can remain the continence mechanism. This screening will involve radiologic and cystoscopic studies.
39. Heuschen NA, Hinz U, Allemeyer EH, et al. Risk factors for ileoanal J-Pouch related septic complications in ulcerative colitis and familial adenomatous polyposis. Annals of Surgery. 2002;235(2):207-216.
40. Stahlberg D, Veress B, Tribukhait B, Broome V. Atrophy and neoplastic transformation of the ileal pouch mucosa in patients with ulcerative colitis and primary sclerosing cholangitis - a case control study. Diseases of Colon + Rectum. 2003;46:770-778.
41. Tianen J, Matikainen M, Aijola P, Hiltunen K, Mattila J. Histological and macroscopic changes in the pelvic pouch: long-term follow up after restorative proctocolectomy for ulcerative colitis (UC). Colorectal Disease. 2001;3:28-32.
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