Part 2 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder
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.
Immediate preoperative preparation includes clear liquids before surgery and a purgative bowel cleansing with laxatives, enemas, and an antibiotic bowel preparation (eg, oral erythromycin and neomycin). These interventions decrease microbial load in the bowel, just as with IAR.
Postoperatively, the patient requires comprehensive interdisciplinary care for good bronchial hygiene and pain control. Meticulous maintenance of all drains, especially those draining the neobladder so all suture lines can heal, is imperative. Because of the need for comprehensive care and monitoring, the patient usually stays in the ICU for the first 1 to 2 days. Following transfer to a surgical care unit, the patient likely will have continuous IV pain medication (PCA or epidural anesthesia), IV fluids, and IV antibiotic coverage for several days.
Initially, the patient will have a nasogastric tube (and possibly gastric tube) placed during surgery. Only after bowel sounds return and the patient passes flatus are the tubes removed and the patient started on liquids, progressing to a house diet.
Pelvic drains (eg, Jackson Pratt and Penrose drain) are left in the patient until the drainage becomes minimal. Persistent drainage in either drain may signify leakage of urine from the new bladder reservoir. A Foley catheter with bilateral stents drains the reservoir through the urethra. This tube must remain patent to avoid over-distention of the reservoir. Usually, the Foley is irrigated every 2 hours with 40 cc to 60 cc of saline. Eventually, this frequency decreases to every 6 hours. The frequent irrigation is necessary because the bladder substitute (ileum) makes mucus and can obstruct free urine flow through the outlet.18 Some physicians insert a mushroom catheter - a 24 Fr to 26 Fr Malecot - into the reservoir as a "bail out" tube in case the Foley becomes blocked to prevent possible rupture of the neobladder from overdistention.18
Three weeks to 1 month following the surgery, the patient returns to the radiology department for a pouchogram. The neobladder is instilled with contrast fluid and x-rays are taken to assess for extravasations. Patients also must be taught about Kegel exercises preoperatively and postoperatively. When performed appropriately, these exercises help strengthen the lower pelvic muscles that support continence.42
Potential complications related to neobladder occur in two phases, either early (up to 3 months) or later (beyond 3 months). Early complications include urinary tract infection, bacteriuria, ileus, delayed healing of anastomoses, wound deshiscence or evisceration, small bowel obstruction, deep vein thrombosis, myocardial infarction, and pulmonary embolism. Later complications include ureteral stricture, urethral stricture, malabsorption, refractory incontinence, urolithiasis, metabolic acidosis, hernia, and tumor recurrence.43
Nursing and Healthcare Professional Implications: IAR and Neobladder
The implications for patient care and patient education are substantial for both IAR and neobladder because the surgery is only the beginning of learning to live with a newly constructed rectum or neobladder. In general, care issues relate to realistic substantive preoperative preparation, comprehensive care during surgery and immediate postoperative phase, and longer-term adaptation processes.
Ileoanal reservoir. Ileoanal reservoir patients must be thoroughly educated about the procedure - whether it will be one stage or two stages and what events are involved in each stage - so they can reach a realistic understanding of ultimate functional outcomes and potential complications. In a helpful "evidence-based report card," Gray and Colwell2 analyzed the available literature on those two critical areas. In general, the IAR has a low mortality rate (0% to 1%). However, the morbidity is much greater. The most commonly reported complications include small bowel obstruction, sepsis, anastomotic stricture, pouchitis, and, most severely, pouch failure that requires excision. Pouch failure and removal can occur in from 6% to 10% of cases. In addition, the patient must be taught that the procedure does not create bowel patterns that mimic those of persons with intact colons and rectums. Research supports that this "new normal" can be acceptable but that IAR results are good but "not quite a cure."19
Patients should be thoroughly educated preoperatively that selected functional issues accompany the creation of an IAR: stool frequency ranges from five to seven stools in 24 hours; fecal incontinence is present in 21% to 23% of persons with an IAR; and fecal spotting can be experienced in up to 42% of patients. Altered male and female sexual function (erectile dysfunction in men and dyspareunia in women) may occur. Fertility rates in women approach that of population norms provided they do not develop pouch sepsis and/or failure.2
Special note should be made of pouchitis, the most commonly occurring complication of IAR. In an "evidence-based report card," Gray and Colwell2 report that the literature supports that pouchitis occurs more frequently in patients with a history of CUC rather than FAP. People facing IAR should be well informed about this potential issue before they undergo the surgery because it affects up to 50% of IAR patients with CUC and from 2% to 8% of patients with FAP.44 Kienle and colleagues44 studied the role of blood supply in the generation of pouchitis of IAR patients. They found that pouch hypoperfusion was a risk factor for the development of pouchitis and local septic complications. More aspects of pouchitis treatment follow.
Another longer-term issue is surveillance of the IAR pouch for dysplasia. Previously, once-yearly pouch surveillance was a mandatory component of follow-up care. More recent reports suggest that the development of pouch dysplasia is rare. In a recent study, Herline et al45 surveyed the pouches of 160 patients - over a mean of 8.4 years, only one patient developed dysplasia. The researchers suggested that evidence to support routine biopsy of the ileal mucosa in ulcerative colitis patients with an IAR is scant.
From a wound, ostomy, continence (WOC) and staff nursing perspective, several issues are important: infection, pouchitis, the diverting ileostomy, skin care, diarrhea, fecal incontinence (especially nocturnal), bowel obstruction, and sexuality concerns.22 Infection issues are of greatest significance during the surgical period and thereafter. Because the intestine undergoes significant manipulation, the risk for pelvic and pouch sepsis is notable. If an abscess adjacent to the pouch develops, often it can be drained percutaneously following a gastrografin enema to determine its location. In addition, wound infections can occur. Prompt coverage with antibiotics is necessary for both situations. Pelvic sepsis that does not respond to therapy may result in removal of the pouch and necessitate a permanent (usually high output) loop ileostomy.
As previously noted, pouchitis is a continuing threat to IAR. Many theories have been presented as to its cause but no definitive reasons have been identified. Gray and Colwell46,47 discussed the usual treatments, including pharmacological agents such as metronidazole (Flagyl, SCS Pharmaceuticals, Chicago, Ill.), ciprofloxacin (Cipro, Bayer Corporation, West Haven, Conn.), steroid enemas (budesonide), glutamine suppositories, allopurinol, butyrate suppository, and bismuth carbomer foam enemas. An oral probiotic, VSL-3, has been used in some studies to attempt to prevent recurrence of pouchitis symptoms. Some authors strongly support the use of probiotics in IBD and pouchitis.48 However, no substantive evidence is extant in the nursing literature that supports use of dietary and lifestyle alterations to treat pouchitis effectively.47
Conversely, Thompson-Fawcett and colleagues49 remind health providers that some persons with IARs suffer from IAR dysfunction most often related to early pouch sepsis. They caution care providers to avoid over-blaming poor function on pouchitis as "waste basket diagnosis." They submit that pouch function can be fine-tuned by diet, medication, and lifestyle.
A special component of good preoperative instruction for both IAR and neobladder patients is teaching them to perform Kegel's exercises. These will help strengthen the pelvic floor muscles and the urinary and anal sphincters.42
Patients must be thoroughly educated about what to expect with their high output ileostomy. Although the diversion is only temporary, research suggests that managing this stoma is one of the most difficult aspects of Stage I events.19 Extended-wear barriers and especially convexity may be necessary for good seal.
Skin care is a critically important issue once the reservoir starts to function. Fecal effluent from the anus initially will be liquid and irritating due to enzymatic content. Over time the pouch will enlarge but in the interim intensive perianal skin care is critical. Patients must be advised to avoid "polishing their anus"22 with each bowel movement. Rather, a baby wipe or wet facial tissue should be used to clean the feces after which a protective barrier ointment should be applied.
Diarrhea and fecal incontinence also will be critical issues for patients. Initially, bowel movements will occur up to 20 times per day. Dietary manipulation to thicken stool (foods that thicken the stool) and pharmacologic agents such as diphenoxylate hydrochloride with atropine sulfate (Lomotil, G.D. Searle + Company, Chicago, Ill.) and loperamide HCl (Imodium, McNeil Consumer Healthcare, Fort Washington, Pa.) may be used. Bulking agents such as psyllium husk (Metamucil, Procter + Gamble, Cincinnatti, Oh.), methyl cellulose (Citrucel, Glaxo SmithKline, Research Triangle Park, NC) and calcium polycarbophil (Fibercon, Wyeth, Madison, NJ) also will help thicken stool.
Nocturnal fecal spotting may occur. Patients should be advised to make the evening meal smaller than previously and not to eat 4 to 6 hours before sleep. Taking anti-diarrhea medications before bedtime also may help.
Bowel obstruction may occur, especially small bowel obstruction. This may be related to an anatomic blockage requiring re-operation or a neurologic dysfunction requiring anal muscle re-education. Some patients develop a web-like structure near the anus. A digital examination usually helps break this open.22
Due to nerve damage, sexuality issues are always a potential concern to patients undergoing complex pelvic surgery. The temporary ileostomy and changes in sexual function (impotence, dyspareunia) will impact body image and sexual self-image. Sexuality is of enormous concern to patients before, during, and after the IAR experience.19
Neobladder. Nursing and health professional issues related to the neobladder are also substantial. Patients will need to be sited by a WOC nurse in the event the neobladder cannot be constructed. The need for this siting must be thoroughly explained - ie, it is done as a precaution. Research suggests that neobladder patients who are not well educated by caregivers "feel like a target," and this increases anxiety level.50
Some neobladder patients can void spontaneously while other neobladder patients void by sitting down and performing a valsalva maneuver. However, all neobladder patients should learn clean intermittent catheterization (CIC) in the event they cannot void spontaneously.
A major aspect of care related to teaching is care of the drainage tubes. Most patients have pelvic drains and ureteral stents removed before hospital discharge (usually 7 to 10 days). The patient or family member must understand how to irrigate the Foley catheter and the mushroom (Malecot) catheter. Signs/symptoms of reservoir over-distention, such as lower abdominal pain, feelings of fullness, bloating or nausea, also must be taught. Severe over-distention can result in neobladder rupture.
Patients should be taught signs and symptoms of urinary tract infection (ie, malaise, flank pain, fever) and be informed that mucus in the urine is not an abnormality because the neobladder is made from intestine. Mucus production will decrease over time.
After Foley catheter use is discontinued (in 2 to 3 weeks), patients will need to be taught to void spontaneously. They are usually instructed to void every 3 to 4 hours regardless of perceived need. Men will find it necessary to sit to void. At night, the Malecot is left unclamped to drain urine in a collection bag so the patient can sleep.
After irrigations of the Foley catheter (and possibly suprapubic tube) for several weeks (3 to 4 weeks), the neobladder is assessed for intactness. If intact, the Foley catheter is removed and patients begin spontaneous voiding using sitting, straining of abdominal muscles, and double-voiding techniques. The voiding intervals lengthen from every 2 hours up to every 6 hours. Patients should be instructed to set the alarm clock to void every 4 hours at night and wear a safety pad to catch "drips."
Bowel resection of the distal ileum can lead to vitamin B12 malabsorption, so long-term monitoring may be necessary. Patients need to be monitored for B12 deficiency that can lead to anemia, neurological problems, and anorexia.42
Sexuality and sexual activity are topics that must be broached with both female and male patients. The potential for ED in men and dyspareunia in women must be described. Even with nerve sparing procedures, 15% to 50% of men will experience ED, and 30% to 40% of women will experience painful intercourse.18 Recent research maintains that the primary area of self-reported distress in cystectomized bladder cancer patients was compromised sexual function.51
Health promotion is also critical for neobladder patients. Smoking cessation is critical to continued good health of the new bladder, ureters, and kidneys. Research suggests that some neobladder patients continue to smoke even after experiencing the restorative surgery.50
Given the many substantial adjustment issues inherent in both IAR and neobladder surgery and adaptation, a highly successful nursing intervention is suggesting involvement in a support group. The healthcare provider (often a WOC nurse) can arrange meetings for fellow patients to facilitate learning and adjustment issues. Research suggests that support groups play a critical role in positive adaptation in both IAR and neobladder patients.19,50
Future Research Issues
Questions remain about the IAR and neobladder. Because both procedures have been developed and refined in the last 20 to 30 years, long-term consequences of this "body parts substitution" are unknown. How long will these structures last without degeneration in function? Will cancer develop in the IAR or neobladder over decades of use? Will malabsorption be a problem in the future?
Future research will have to answer the questions as to which surgical technique or techniques are "best." Will new surgical techniques improve the neobladder or IAR even further? Will medical treatment for IBD and bladder cancer improve so that IAR and neobladder become less necessary? Answers to these questions must wait until research targeting them is conducted.
The 20th century witnessed the introduction of two new innovations for persons with severe intestinal or urinary bladder disease: the IAR and orthotopic neobladder. In the new millennium, newer techniques and approaches likely will continue to improve treatment choices and quality of life for persons with CUC, FAP, and muscle-invasive bladder cancer. Nurses and healthcare professionals will need to be prepared in order to provide comprehensive care for people experiencing emerging technologies.
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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.
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