Ileal Pouch Anal Reconstruction

Transcription

1 Patient Education Ileal Pouch Anal Reconstruction Ileal pouch anal reconstruction is a surgical technique designed to allow removal of the entire colon and rectum, yet preserve the anus and the normal route of bowel function. This is a technique designed to allow patients to avoid a permanent ileostomy. Patients with ulcerative colitis and familial polyposis who require surgical removal of the colon and rectum are the most common candidates for this type of procedure. Definitions Anastomosis The word anastomosis means to make a surgical connection between two hollow organs like two ends of bowel or two ends of a blood vessel. Ileal Pouch (Ileal Pouch Anal Anastomosis IPAA) After surgery for disorders that require removal of the entire colon and rectum, a new rectum can be constructed using a pouch made out of small bowel. Although most pouches are formed by folding the bowel on itself like a J, some are folded into S and W conformations, hence the terms J, S, and W pouches. J pouches have twice the volume of a normal loop of bowel, while S pouches have three times the volume, and W pouches, four times the volume, simply because of the way the bowel is folded, sewn together, and then opened to make one larger pouch. This pouch is attached in the deep pelvis to the inside of the anus so that the patient may eventually resume having bowel function in a manner that is close to normal, hence the term ileal pouch anal anastomosis or IPAA in the literature. Some surgeons use a surgical technique that requires one to strip the lining (or mucosa) of the very last portion of the rectum and leave the outer wall of the rectum (without mucosa) in place.

2 Page 2 IPAA (continued) This is done with the belief that it helps patients feel when the pouch is full and needs to be emptied. This technique is called a rectal mucosectomy and is commonly done through the anus. The pouch is then attached inside the cuff of rectal wall, either with sutures or surgical staples. In addition to potentially helping with sensation, another advantage of a rectal mucosectomy is that it minimizes the amount of rectal mucosa left in place. Retained mucosa (mucosa that is left behind) may pose a risk for ongoing inflammation or possibly cancer formation in ulcerative colitis patients, and is a risk for new polyps and cancer formation in polyposis patients after surgery. However, the anal muscle dilation necessary for the mucosectomy has the disadvantage of lengthening the operation and may weaken the anal sphincter, which in turn may predispose to difficulty with control of bowel movements. Fortunately, as we have learned more about the operation, it has become clear that the sensation of fullness that means the pouch must be emptied is retained even without leaving a muscular cuff of the rectum. In an individual patient, the decision to perform a mucosectomy or not must be individualized based on patient build, sex, and technical factors during the operation. Ileal pouches that are taken into the pelvis have been devised to avoid a permanent ileostomy. As a practical matter, J pouches are the easiest to make, the most reliable, can be made with stapling surgical instruments that make the procedure much faster and more secure, and J pouches function about the same as S and W pouches after one year. For these reasons, 98% of pouches made in our hospital (and nationally) are J pouches. The major indication for an S pouch at the present time is that greater length can be gained from the spout or outlet of the S pouch, allowing bowel that might otherwise be too short to reach into the deep pelvis in a J to actually reach down deep. Another indication for an S pouch is that a narrow pelvis may not admit a J pouch, but will allow the S pouch where the wider part of the pouch is positioned up higher in the pelvis. On very rare occasions (less than 1%), the surgical team cannot get bowel (in any kind of pouch) to reach the pelvis. In these cases, the only option is a permanent ileostomy for technical reasons.

3 Page 3 Ileostomy/Colostomy An ileostomy is an end or loop of ileum, part of the small bowel, that is brought out through the abdominal wall, sewn to the abdominal wall on the inside, and then opened so that the bowel contents empty into a bag. This bag is secured around the ileostomy to the patient s abdomen and must be emptied several times a day. A colostomy is essentially the same thing but is made out of colon rather than small bowel. Ileostomy contents are more watery and more irritating to skin than stool, so ileostomies are generally created with more projection above the skin so that the bowel contents empty into the bag more reliably. Continent Ileostomy A continent ileostomy (i.e. Koch or Barnett pouch) is an ileostomy that does not require the patient to wear a bag. This is achieved by creating a pouch made out of small bowel inside the abdomen in which intestinal contents are stored. A valved outlet to the pouch, surgically created, prevents leakage until the pouch is drained by a tube passed through the ileostomy. This must be done several times a day. There are a number of different techniques described for forming such ileostomies. Although this is the best option for some patients, especially those who have poor anal sphincter muscle function, such pouches are prone to scarring and breakdown that in many patients require surgical correction or construction of a new pouch, sacrificing additional small bowel. Regionally and nationally, few patients receive continent ileostomies. Ulcerative Colitis (UC) The most common indication for pouch surgery is ulcerative colitis. This is a type of inflammatory bowel disease that affects the innermost lining (mucosa) of the colon and rectum, often visibly at colonoscopy and always microscopically evident on biopsies of the bowel. We do not know why this disease occurs though there is a great deal of work being done to answer this question. Not all patients with ulcerative colitis require surgery. Many either have mild symptoms or a course of disease that flares up occasionally, requiring treatment, then subsides. These patients are often best managed with medical treatment. Patients with a more severe form of the disease that leads to bloody stools, severe cramps and pain that requires repeated admissions to the hospital for treatment or prolonged use of toxic drugs such as Prednisone (a steroid medication) with potentially severe side effects. These patients are often referred for surgical treatment to eliminate the colon and rectum that are so severely inflamed. On occasion, ulcerative colitis progresses

4 Page 4 so rapidly that the bowel is at risk for rupturing internally. This is termed toxic colitis and is a life-threatening disorder, often requiring emergency surgery. Other patients have active ulcerative colitis for years that never flares as seriously, but over time they develop an increasing risk of cancer. Patients with active ulcerative colitis for over 10 years need to be concerned about this cancer risk and should be screened with periodic colonoscopy. Biopsies at the time of colonoscopy are screened for cancer and dysplasia. Dysplasia in such biopsies, a microscopic diagnosis of abnormal cells, is a strong predictor of increasing cancer risk and is often an indication to have the rectum and colon removed before a cancer can develop or get out of control. Crohn s Disease and Indeterminate Colitis Ulcerative colitis is one kind of inflammatory bowel disorder. The other kind is Crohn s disease. Ulcerative colitis involves the colon and rectum and never affects the small bowel, stomach, esophagus or other parts of the gastrointestinal tract. This distinguishes it from Crohn s disease where all parts of the gastrointestinal tract from the mouth to the anus might be affected, and where the disease usually involves the full thickness of the bowel wall not just the mucosa. The pattern of the disease, areas of intense involvement side by side with completely uninvolved areas (skip pattern) and the microscopic appearance of bowel biopsies are the most useful studies to distinguish Crohn s disease from ulcerative colitis. This is very important because patients with ulcerative colitis are candidates for IPAA operations while those with Crohn s disease are generally NOT offered IPAA. In Crohn s patients, healing tends to be slow and may not be complete. Intestinal pouches in Crohn s patients tend to break down and leak, and tend to develop fistulas or connections from the pouch to the other bowel, to the skin, or to other organs like the bladder or vagina. Unfortunately, in some patients, Crohn s disease of the colon cannot be reliably distinguished from ulcerative colitis. These patients are given the diagnosis of indeterminate colitis. Since 90% of these patients actually have ulcerative colitis, we usually offer otherwise suitable patients who need to have the colon and rectum removed, a pouch operation. Most will do well. About 50% of Crohn s patients who receive a pouch will have to have it removed, usually because of early or late complications that prevent full healing.

5 Page 5 Familial Polyposis (also known as Adenomatous Polyposis Coli APC) Familial polyposis is a genetic disorder that is either inherited or, occasionally, occurs because of a new genetic mutation. The effect of this disorder is patients of either gender develop polyps or growths in the colon and rectum that eventually, untreated, will inevitably result in the development of cancer. These polyps can develop as early as late childhood. Patients with such polyps may have normal bowel function and be without symptoms, or may have occasional bleeding into the stool. Cancers that develop in patients with untreated familial polyposis do so on average by age 35 and can be very aggressive, often proving incurable by the time they cause symptoms and are discovered. With this risk, patients with familial polyposis are usually advised to have the organs at risk, the colon and rectum, removed. Ileal pouch reconstruction is often offered to avoid a permanent ileostomy. Unfortunately, patients with familial polyposis are at risk for other disorders also. They may also develop polyps in the upper part of the gastrointestinal tract that, if present, often require surgical treatment. They are also prone (5-15%) to develop tumors called desmoids after bowel surgery that, when present, often develop in the abdominal wall or mesentery of the small bowel surrounding the blood vessels that nourish the bowel. These tumors can be, depending on their location, a very difficult management problem. After removal of the colon and rectum (termed total proctocolectomy), patients with familial polyposis need to be followed in the long term for these problems with serial endoscopic exams of the stomach and first part of the small bowel, and careful physical examination. Once detected, closely related family members of a patient with familial polyposis should also be evaluated for the genetic abnormality. Surgical Therapy Surgical treatment for UC and APC has two goals. The first is to remove the diseased organs, the colon and rectum. The second is to reconstruct the gastrointestinal tract in the most functional form, taking into account what is best for an individual. For most patients, this means replacing the rectum with an intestinal pouch placed into the pelvis and emptying through the anus with the muscles of the anus acting as the valve mechanism. For some patients with poor anal muscle function who are over 60 years of age, have poor general health, or insufficient intestinal length, a permanent ileostomy may be required. While both goals may be accomplished during a single operation, some patients require two and occasionally, three planned operations to safely accomplish both goals. Each option for surgery has benefits and risks. The best option for an individual patient is the one that minimizes risk while giving that patient the best chance for a healthy life after surgery.

6 Page 6 Indications for Surgery The three indications for surgery are: 1. Ulcerative Colitis not controlled by medical treatment controlled with medical therapy, but unacceptable complications or side-effects have developed from the medications with bleeding, recurrent hospitalizations, or a life-threatening risk of perforation with associated dysplasia or cancer 2. Indeterminate Colitis (usually ulcerative colitis) 3. Familial Polyposis Patients considered for surgery must also be fit enough to tolerate the stress of a general anesthetic and a major surgical procedure, and after all that still be able to heal! This is an important consideration in patients who are very severely ill from ulcerative colitis or who have suffered severe side effects from drug therapy (with Prednisone and/or Imuran) which, while effective at controlling the disease in some patients, also increases the risk of poor healing and surgical complications including infection, pouch leakage, and disruption of the abdominal wound. Options for Surgery Options for surgery are: 1. Removal of rectum and colon and immediate IPAA reconstruction without ileostomy, with or without mucosectomy (One Stage IPAA) 2. Removal of rectum and colon and immediate IPAA reconstruction with a temporary ileostomy, with or without mucosectomy, followed by later closure of the ileostomy at a second operation (Two Stage IPAA) 3. Removal of the rectum and colon with permanent ileostomy (One Stage Permanent Ileostomy) 4. Removal of colon leaving the rectum with temporary ileostomy, later removal of the rectum and IPAA with or without mucosectomy, possibly followed by another temporary ileostomy (Two or Three Stage IPAA)

7 Page 7 Factors that determine which of these is best for an individual patient include: patient age, weight, sex and general health type of disease: ulcerative colitis vs. familial polyposis type, duration, and side effects of medications patient continency (ability to control bowels) prior abdominal and especially, bowel surgery nutritional status technical factors during the actual operation, anastomoses and integrity of the tissues (Usual values of these factors that suggest one or another option) Option Age (yrs) General Health Longterm steroids Continency Abd Surgery Nutritional Status Technical Problems 1 < 60 Good No Good Minimal Good None 2 < 60 Fair Possibly Good Minimal Fair Possible 3 > 60 Fair to Possibly Poor Common Poor to fair Possible poor 4 < 60 Poor Often Good Minimal Poor to fair Possible Option 1: One Stage IPAA The one-stage IPAA treatment is reserved for patients aged less than 60 with good continency, good general health, and no long-term steroid treatment, in whom the technical steps of the operation are presumed to go well. Most patients with familial polyposis and well-controlled, stable ulcerative colitis should be considered for a one-stage procedure. With rare exceptions, these are all elective operations rather than emergency operations. Patients having a one-stage operation complete the entire procedure of proctocolectomy and pouch reconstruction during a single operation. The obvious advantage of doing the entire operation in one stage is that when everything heals well, patients do not need further surgery. However, there are several disadvantages. First, right after surgery, many patients have some incontinence due to stretching of the anal sphincter during the surgery. Add to that the caustic nature of the stool that must be evacuated from the pouch on average times a day initially (until the pouch stretches and adapts to absorb more) and you can understand that many patients develop, predictably, a sore and tender bottom (like a diaper rash). The other disadvantage of Option 1, the one-stage procedure, is that the pouch must work immediately. If there is a leak or other technical problem, patients can get peritonitis, which makes them very ill, and requires emergency surgery to drain the pouch and create a diverting

8 Page 8 ileostomy. Although this is a rare problem, ileostomies created under these circumstances must be kept for months while the abdomen heals. The resulting scarring from healing of the leak may weaken or constrict the pouch so that long-term function is compromised, may lead to an increased risk of bowel obstruction over time and may also lead to infertility for women of child-bearing age, due to scarring of the fallopian tubes. For these reasons, if there is any significant question about the patient s capability to heal, about the strength of the tissues or the integrity of the pouch, a temporary diverting ileostomy may be the safest course. Often, the decision to omit an ileostomy is one that can only be made during the last hour of the operation. Option 2: Two Stage IPAA The two-stage IPAA procedure, pouch and temporary DIVERTING ileostomy, is generally offered to patients with poor nutrition or long-term steroid use where their illness, nutrition status or medications pose a risk for good wound healing. Often patients are considered for a two-stage procedure because the activity of their disease increases the risk of complications from pouch leak or failure. An ileostomy diverts the bowel contents away from the pouch allowing it to heal, making any leak a much more manageable problem. Ileostomies in IPAA patients are often constructed from a loop of bowel and may not have much projection above the skin because the pelvic attachment of the pouch restricts some of the bowel mobility on the abdominal wall. Once healing of the pouch and the pouch-anal anastomosis has been proven by X-ray studies, the temporary ileostomy is closed in a 1-2 hour operation and rather brief, 3-4 day hospital stay. Option 3: One Stage Permanent Ileostomy Patients over the age of 60, those with significant anal incontinence or poor anal sphincter function, and those with other medical problems that would restrict their ability to heal well and develop a functional pelvic pouch should consider a permanent ileostomy. This is the simplest of the options with the least difficult recovery, in general. However, it does commit the patient to a permanent stoma. Usually, once the anal sphincter mechanism has been removed, there is no option to consider later pelvic pouch creation since the valve mechanism has been removed. Option 4: Two or Three Stage IPAA Patients, usually only those suffering with ulcerative colitis, who are severely ill from their disease, are often considered for a two or three stage procedure. Malnutrition, severe colonic bleeding and anemia, high dose steroids, multiple or prolonged hospital stays for colitis are the usual reasons to consider this option. The goal of the first stage operation is to

9 Page 9 remove the majority of the disease, removing the colon and leaving the closed off rectum in place while creating a temporary ileostomy. With the majority of the diseased bowel removed and the rectum no longer functioning to passage stool, the patient s disease is usually much easier to control. Medications, including steroids, can be tapered down and often stopped completely (though over a gradual process). Bleeding from colitis is stopped and the patient s nutrition can be improved because they can again eat without bleeding and activating colitis. Once the patient has healed up and regained his or her health, usually off any steroids (except occasional use of steroid enemas to control rectal disease), the second stage of surgery is to remove the rectum and create an ileal pouch as previously described, placing this into the pelvis. Depending on how this operation goes and how well the patient has healed, another diverting ileostomy may be created to allow the pouch to heal. Alternatively, if appropriate, no ileostomy is made and the pouch is allowed to start functioning. The same advantages and disadvantages discussed in Options 1 and 2 pertain to forming or avoiding a temporary ileostomy in these patients. Preoperative Preparation Preoperative preparation differs for the different patient groups. 1. Medications. In patients on steroid medications such as Prednisone, attempts at reducing the dose of Prednisone may help reduce the risks of surgery, but should not be reduced so far that the patient becomes more acutely ill with malnutrition, bleeding, profuse diarrhea, and a more severely inflamed bowel. Under these conditions, the patient s condition is actually a greater risk than a higher dose of Prednisone for surgical complications. If they have been on Prednisone prior to surgery, it is very important for patients to continue taking some Prednisone (even if the dose is lower) since suddenly stopping this drug may lead to life-threatening complications. Imuran should be stopped at least 1 week before surgery to prevent problems with wound healing. Management of other medications will be handled on an individual basis. In general, patients on medications for hypertension and diabetes should continue taking these right up to the time of surgery, and will be advised by the surgical team or presurgical clinic about any modifications for the day of surgery. Endoscopy. All patients should have had a colonoscopy within 6 months to reduce the risk of an unsuspected cancer in the colon or rectum. Familial polyposis patients should undergo upper endoscopy to screen for stomach or duodenal adenomas as previously discussed. 2. Preoperative Studies. In some patients, measurement of the anal sphincter pressure using anorectal manometry may be of value in predicting postoperative continency. This will be decided during the

10 Page 10 preoperative evaluation. Chest X-ray, cardiogram, and blood tests help us during the management of an anesthetic and to avoid the risk of clotting problems that might lead to unexpected surgical bleeding. In anemic patients, we prepare blood for possible transfusion during or after an operation, though significant blood loss (over 500 cc's) is rare with these operations. Patients who wish to avoid transfusion under any circumstances should indicate this at the time of signing the surgical consent form. 3. Consultations. Often, patients are evaluated by our Medical Consultation Team, a team of physicians who assist the surgical services with the management of complex medical conditions such as diabetes, hypertension, heart and lung diseases, during the surgical treatment and recovery periods. All patients will also be evaluated and counseled by the Preanesthesia Clinic. Those who are likely to require an ileostomy will also see the nurse enterostomal therapists, who will provide further information and help with stoma management. 5. Bowel preparation. Just prior to surgery, all patients will be asked to complete a mechanical bowel preparation, a cathartic such as Fleet s phosphosoda or Colyte, and to take some oral antibiotics. Written instructions for these are provided in the clinic. These two steps are extremely important since the quality of the prepared bowel is a critical determinant of complications after surgery. The more stool and fluid left in the colon and rectum, the more likely the patient will be to have infectious complications, and the more likely the patient is to end up with a temporary ileostomy due to spillage or other intraoperative difficulties. After midnight on the day before surgery, nothing should be taken by mouth, other than selected medications with a sip of water. 6. Informed consent. By reading this document and discussing the management of the bowel problems under consideration, we hope that you will become better informed about the complications and potential outcomes of this type of surgery. It is very important that the patient understand what the surgical plan is, how it may change, and what potential complications can be anticipated. Not all complications can be avoided; however, our job is to detect them as soon as possible and to take corrective measures quickly to minimize the risk of further difficulties. 5. Arrival on the day of surgery. Most patients having one of these operations, unless acutely ill from severe colitis, will be arriving at the hospital on the day of surgery. All work-up and preparation for the surgery is commonly done prior to the day of surgery. The schedule for the surgery day is not determined until the evening before surgery, due to the importance of looking at the entire schedule and order of operations so that critical personnel and equipment are available for

11 Page 11 the operation. The Presurgery Clinic will call you before your operation to confirm the time of arrival. Unfortunately, unforeseen delays, longer operations, and emergencies may change the schedule even on the day of surgery. We try to minimize these delays but some are inevitable. In the event of a delay, we will advise you and your family as soon as possible and keep you informed. Technical Aspects of Surgery Technical stages of the operation depend on which option is being followed. The following description deals with the basic parts of the operation. On average, such operations take 4-7 hours to complete, depending on the exact procedure and the nature of the patient. A. Resident and Student Participation in Your Care The University of Washington is a teaching institution with nurses, medical students, and resident or trainee surgeons all acting as critical members of the team. However, your surgeon has responsibility for all aspects of your care, and all significant decisions about that care will be made by you and your family with the attending surgeon. In the operating room, as on the ward, the attending surgeon conducts the operation that you and he or she have discussed, but every operation is assisted by several nurses, at least one medical student, and at least one resident surgeon. Having a team caring for you means that many members of the team are constantly reviewing your status and helping you and the attending keep fully aware of all vital signs and laboratory results that bear on your status and recovery. This is to everyone s, especially the patient s, advantage! It also helps train the next generation of physicians in as realistic a setting as possible. B. Anesthesia and Preparation The anesthetic is administered in the operating room (OR). However, many patients receive a mild sedative prior to entering the OR. Some patients are candidates for an epidural anesthetic, a tube placed beside the spinal roots that carry pain signals. This is a very safe and commonly used adjunct to drugs administered by vein for anesthesia. When placed successfully, epidural catheters are useful for anesthetic management during the operation, and in 9 out of 10 patients, work well for postoperative pain control. Once in the OR, monitors are connected and the patient is put off to sleep. A variety of medications are used for the anesthetic. As necessary, details of this management will be discussed with each patient during the preanesthesia visit, and immediately prior to surgery. Once asleep, a ventilator breathes for the patient. Many

12 Page 12 patients will have a tube inserted through the nose into the stomach, and all will have a catheter inserted into the bladder to monitor urine flow. This urinary catheter is generally left in place for 4-5 days, or until the epidural catheter is removed. Additional IVs are also inserted on occasion depending on the judgement of the anesthesia team. Depending on the plans for the surgery, the patient may be positioned lying flat and carefully padded and secured, or the legs may be placed into secure holders that allow the surgical team access to the bottom for removal of the rectum and attachment of the pouch inside the anus. A heating blanket is also used to maintain the patient s temperature in the normal range during the operation, since this seems to be important for minimizing postoperative complications, including infections. C. Incision For most patients, the abdominal incision is down the midline of the abdomen, extending from the pubic bone to above the belly button. How far above the belly button this incision is extended depends on the mobility of the colon and small bowel that must be manipulated. D. Colectomy (removal of the colon) Removal of the colon is accomplished by dividing attachments of the right and left colon to the lateral walls of the abdominal cavity, dividing any adhesions (scars) to other organs such as the liver, gallbladder, or small bowel, dividing the attachment of the omentum (a sheet of fatty tissue that extends from the stomach to the colon) to the colon, and finally dividing the blood vessels to the colon. These are tied with surgical suture or controlled with clips. In patients who are gravely ill with a very inflamed colon, the bowel may be paper thin and very fragile, so great care is taken to minimize the risk of a tear in the bowel that might lead to spillage of bowel contents inside the abdomen. Often, surgical stapling devices are used for parts of this procedure. E. Proctectomy (removal of the rectum) Removal of the rectum requires special care. The tubes carrying the urine from the kidneys to the bladder, the ureters, are identified and protected. In the male, the nerves that support potency, normal erectile function of the penis, are protected. The blood vessels of the rectum are progressively dissected from the upper rectum to the lower rectum, controlling the vessels with sutures or clips. Special retractors are necessary to allow surgery in the deep pelvis. Part of the procedure may be done from below, through the anus. When this maneuver is carried out as part of Options 1, 2 or 4, the purpose is to strip the

13 Page 13 mucosa or inner lining of the bowel off the very last part of the rectum (termed mucosectomy) leaving the muscles of the rectal wall. This is done to help preserve sensation in the pouch that is brought in to replace the rectum, but this same function is present in the muscles of the pelvic floor that remain, even if the entire rectum is removed. Recently, mucosectomy has been less commonly used to minimize the risk of incontinence with stretching of the anal muscles. When proctectomy is carried out as part of Option 3, the anal muscles are also removed and the wound where they used to be is sewn closed to heal. F. J pouch (pouch to replace the rectum) The most common pouch, the J pouch, is usually constructed using a special surgical stapler. This device lays down four rows of staples and cuts between the middle two. The staples secure the two loops of bowel together, and the cut makes the two lumens into one big cavity, forming the pouch. The J is measured at 15 cm or 6 inches. Another stapler is commonly used to attach the pouch just inside the anus, though this anastomosis may also be sewn by hand. G. Ileostomy (creation of a stoma) In patients who require an ileostomy because of weak tissues, a poor bowel preparation, an incomplete staple line, or those having Option 3 (permanent ileostomy), either the end of the bowel or a loop of small bowel is brought through a small hole made in the abdominal wall, usually in the right lower abdomen. The bowel is then secured internally and externally with sutures. A stoma appliance, a plastic bag with a special adhesive rim, is then affixed to the skin around the stoma and the stoma is allowed to heal. Many different sizes and styles of appliances are available to allow the best fit to be made. Some are one-piece, others come in two pieces (bag and skin adhesive patch). The enterostomal therapists will work with each patient who requires a stoma to make sure that they understand how to fit, change and manage their appliance. Some fine-tuning may be required at first, and as the stoma heals and swelling recedes, a smaller size or shape may be necessary. Remember, like all other aspects of the healing process, patients with stomas must learn how they work and must be patient during the inevitable early frustrations of living with a stoma. Eventually, they will become part of you, incorporated into your life and lifestyle.

14 Page 14 H. Closure of the Incision Prior to abdominal closure, one or two drains may be placed into the pelvis, depending on the requirements of the procedure. These will usually be brought out through small stab incisions in the lower abdomen and secured with a suture. The incision is then closed in several layers. An inner layer closes the fascia or strength layer of the abdomen. Skin staples are usually used to close the skin layer and the incision is covered with a dressing that is left in place for about three days. I. Postoperative Recovery and Length of Stay (LOS) Patients should be able to cough, deep breathe, move around in bed and, within 24 hours, get out of bed to sit up. We ask them to try to walk in the hall by the second day postoperatively. Most patients are in the hospital for 5-8 days, depending on age, extent of operation and pace of recovery. To leave the hospital, patients must be able to care for themselves, be walking and dressing themselves, be eating adequately and having bowel function. They must have adequate pain relief with oral pain medications and have no evidence of infection, bleeding, or any other complications of the operation. Patients who have had an epidural catheter for pain management often have difficulty with urination until the epidural is stopped. Indeed, surgical manipulation in the pelvis, even without the epidural catheter, may cause difficulty with urination for 4-7 days. For this reason, we leave the urinary catheter in at least 4 days or longer if the epidural catheter is still being used for pain. J. Pain Management Postoperative patients who received an epidural catheter may use it for pain. Sometimes, this is not feasible or does not work, in which case most patients will use a PCA (patient controlled analgesia) pump to give themselves small shots of pain medication when they are uncomfortable. This provides better control of the pain than waiting for the nurse or other caregiver to administer pain medications. It is not uncommon for the pain management to require some adjustment. They may still have some discomfort or pain, but the level of this pain should not prevent breathing exercises and getting out of bed. Conversely, excessive pain medication may slow breathing and put the patient at risk of aspiration, or make the patient so sleepy that they are unable to assist with their recovery. We will do everything we can to identify those with too little or too much pain medication and change the dose, route, or drug to gain better control of postoperative discomfort. Prior to discharge, patients will be changed to an oral pain

15 Page 15 medication, usually oxycodone or Percocet (a mixture of oxycodone and Tylenol). Patients with allergies to these drugs or intolerance due to nausea may be given Vicodin or another replacement. Stool softeners are rarely necessary for patients having this operation due to the absence of the colon. Recovery Early Recovery Patients with an ileostomy may expect to empty the pouch 4 or 5 times a day, depending on diet and fluids consumed. They may suffer burns to the skin around the stoma due to a leak or poor appliance fit. This eventually gets better as the patient learns how to manage the pouch and the ileostomy function stabilizes. Patients who had ulcerative colitis as the indication for surgery often feel immediately better after surgery. They have had a source of chronic illness and inflammation removed, and feel an immediate improvement. Their bowel function is often poor with frequent bloody bowel movements and the recovery after surgery is a definite improvement. Patients who have the surgery for familial polyposis often have few symptoms prior to surgery and the recovery may be harder since they approach it from a different perspective. The function of any of the ileal pouches is good, but for most patients it will never replace or function as well as a normally functioning rectum. Over time, however, it usually gets progressively better and for most patients is a better alternative than a permanent end ileostomy. Continency The ability to control bowel function is good but not perfect after formation of an ileal pouch. Most patients are continent during the day but may have minor incontinence during the night, requiring use of a pad. Continency improves over time as the sphincter muscles heal from surgery and strengthen, and as the consistency of the BMs gets less liquid. Both before and certainly after surgery, patients are urged to do Kegel exercises (muscle strengthening exercises to tighten the anal sphincter muscle). Squeezing down and holding the squeeze for 15 to 20 seconds, 10 to 30 times a day, works the muscle and over time will also increase its strength. Patients with a functioning J pouch can initially expect BMs per day. These will be loose, watery and may be caustic on the skin around the anus. Many patients find that use of zinc oxide ointment or bag balm on the skin around the anus helps protect it. Most patients initially use dietary modification, antidiarrheal agents and supplementary dietary fiber to help control their stool frequency. Some experimentation is necessary but as

16 Page 16 healing and adaptation of the pouch progress, the diet can often be liberalized, antidiarrheal agents tapered and the use of fiber reduced. Dietary modification Patients should start off with a rather bland diet after surgery. Avoid things that caused diarrhea before the surgery. Liquids should be consumed separately from solids, rather than washing down a meal with a large volume of liquid. In patients with frequent loose stools or a high ileostomy output, dehydration and salt losses may become significant. In these situations, patients should drink juice or salt-containing liquids, like Gatorade or Powerburst. Increasing fatigue, dizziness, thirst or low blood pressure may be signs of dehydration and should be evaluated immediately in the clinic or emergency room. Often a quick IV and modification of medications is all that is necessary. Occasionally, patients must be readmitted for several days of IVs and further treatment. Antidiarrheal agents Most patients with a functioning J pouch start off on antidiarrheal agents, most commonly Imodium. This is available as a prescription or over-thecounter, but the former is cheaper. One or two tablets, or one or two teaspoons of the Imodium elixir BEFORE meals and BEFORE bedtime often slow bowel transit, improving absorption and reducing stool volume and frequency. After several months, many patients taper off this medication or only use it episodically. Since patients with a J pouch are always more prone to diarrhea (for example, with a cold) due to the loss of the colon, having some Imodium around is often a good idea, especially on trips and special occasions. For patients intolerant of Imodium or not sufficiently controlled by it, we may try stronger medications such as Paregoric (Tincture of Opium), but these latter medication may have side effects and are only used when needed. Dietary fiber For some patients, increased fiber in the diet firms up the stool and makes it easier to evacuate. For others, it increases volume. Those who will benefit from it are hard to distinguish from those who will not. Thus, we often try some fiber such as Metamucil or Fibercon, to see if it will help. Addition of fiber should be done when no other changes in medications or diet are going on, so that the effect of the fiber is clearly distinguishable from the effects of the other treatment changes. Activity, Weight Restriction, and Work Recovery from surgery also requires healing of the abdominal incision. Patients are asked to refrain from heavy lifting (<15 lb. max) or vigorous physical activity for 6 weeks. Those receiving steroids prior to surgery are asked to be cautious for 8-10 weeks, to avoid hernia formation from wound disruption. Most patients are off narcotic pain medication by 3

17 Page 17 weeks and most are able to return to work after 4-6 weeks, assuming their recovery has been otherwise uncomplicated. Driving is not allowed until the patient is off all narcotic pain medications. Late Recovery Eventually, stool frequency subsides to 6-8 BMs in a 24-hour period, averaging 1 every other night, but this may take up to a year to occur. Some patients have a higher rate; some average only 2-3 per day. Younger patients seem to have better adaptive capabilities. Some adaptation has even been documented to occur after 1 year. Clinical Follow-Up Patients are asked to return at 1 week and 1 month after completion of the J pouch, with additional appointments to the clinic as necessary and convenient. Many patients traveling to Seattle from a distance achieve follow-up with their referring local physician. After the initial follow-up period, patients usually return at 3, 6 and 12 months to make sure that they are doing well, progressing as expected and modifying medications appropriately. Yearly follow-up thereafter is appropriate. In all patients, yearly sigmoidoscopic evaluation of the pouch has been added to the routine digital anal examination for stricture formation and pouch healing. This is because of recent reports of dysplastic or precancerous changes found on long-term follow-up of pouches, though no cancers have been reported to date in pouches. Complications of Surgery Early Cardiopulmonary In any operation, there are some risks associated with the heart and lungs related to the anesthesia. The anesthesia is extremely carefully managed and such complications are rare but when they occur, can be lifethreatening. Aspiration pneumonia, cardiac arrhythmia or myocardial infarction all fall into this category. Older patients are at greater risk for these complications. Patients unable to perform lung exercises in the postoperative period are at risk for postoperative pneumonia, because of uncleared secretions. Deep venous thrombosis and pulmonary embolism All patients are at risk for developing clots in their legs during a long operation. Those with a prior history for deep vein thrombosis and especially those who have had pulmonary emboli (clots breaking off from the legs going to the lungs) are at very high risk. For average risk patients, we place pressure stockings on the legs and squeeze the calves and thighs

18 Page 18 to promote blood flow during the operation. Unusual calf swelling or pain, mysterious fever or shortness of breath in the postoperative period may be signs of a deep vein thrombosis or pulmonary embolus. For high risk patients, blood thinners are often used before and after the operation to minimize risks or recurrence. Infection The nature of this surgery requires that the bowel be opened. Despite optimal bowel preparation (oral and IV antibiotics that are routinely administered), contamination from the open bowel still increases the risk of infection somewhat. Infections occur in the wound most often, but can also occur in the abdomen and pelvis. In the pelvis, often the first concern is for a leak from a functioning J pouch. The management of the infection includes identifying the extent of the problem either by CT or by reoperation, diverting the bowel with a stoma when the infection is associated with an anastomotic or staple line leak, and draining the infection with surgical or radiologically placed drains. All patients also receive antibiotic drugs. Infections can also occur in the urinary tract with the catheters that are placed during surgery, and in the lung (pneumonia). Bleeding Bleeding during or after surgery is rare in these operations, unless the patient has a disorder of coagulation that prevents normal clot formation. However, every postoperative patient is closely monitored for signs of bleeding in the first 24 to 48 hours after surgery. Bleeding that is detected very early might require reoperation. Others will require observation and replacement of the lost blood with transfusion. Anastomotic leak In patients who undergo surgery according to Option 1 or have an interval closure of an ileostomy, leakage of the pouch is a possibility. The incidence of this complication is about 3-5%. It is more common in brand new pouches, rather than those protected and allowed to heal with an ileostomy. When it occurs, anastomotic leak usually becomes evident within 2-5 days of surgery and is marked by abdominal and/or pelvic pain, fever, rapid heart rate and laboratory changes indicating new onset infection or inflammation. In some patients, the pattern is so unmistakably clear that an immediate operation to divert the bowel and drain the infection is indicated. In others, a more subtle presentation may require CT scan or contrast study of the pouch to identify the area of leak. Following treatment of the leak and recovery, patients often are asked to wait for 3 to 6 months before further surgery to close the stoma. Prior to any such surgery, extensive studies are necessary to make sure the leak has healed. Unfortunately, such leaks may compromise pouch function so that it never works as well, and may lead to infertility in some female patients due to scarring of the fallopian tubes.

19 Page 19 Early small bowel obstruction Patients who regain bowel function then have the sudden onset of nausea, vomiting, abdominal distension and decreased bowel function, may be developing an early bowel obstruction. It may be difficult to distinguish this from a postoperative ileus (paralysis of the bowel), hence studies of the bowel with CT and barium are often undertaken. All patients with ileus and most with a postoperative bowel obstruction will resolve with bowel rest, occasionally with another NG tube, IV fluids and time. Some patients will require surgery to repair an early obstruction. Late Pouchitis Pouchitis is a condition of inflammation in the pouch that mimics ulcerative colitis, and seems to occur more often in patients with a history of severe ulcerative colitis. Symptoms of pouchitis are a sudden increase in the frequency of bowel movements, small frequent stools often with blood, pelvic pain, urgency, incontinence and fever. The incidence in patients undergoing pouch surgery is 20-40%. Some patients have a single bout, others have recurrent bouts. Stricture or narrowing of the pouch-anal anastomosis may predispose to this problem. Treatment includes evaluation and treatment of pouch-anal strictures with an endoscopic exam of the pouch, followed by a course of metronidazole (Flagyl), and antibiotic. Some patients need additional antibiotic treatment such as ciprofloxacin (Cipro) and very rarely, aggressive inpatient treatment becomes necessary. Few require full bowel rest and steroid enemas. In patients with recurrent bouts of pouchitis, a supply of Flagyl is kept on hand at home or on trips, to be used at the first sign of recurrent disease. Rarely, patients have such a severe pattern of pouchitis, unresponsive to all treatment, that the pouch must be removed. The incidence of this is 1%. Pouch-anal anastomotic stricture formation Pouch-anal anastomotic stricture is a narrowing of the anastomosis between the pouch and the inside of the anus. Such narrowing may predispose to pouchitis, and may make it difficult to evacuate the pouch completely, leading to incontinence. Reasons for stricture formation include a small leak at the anastomosis, poor blood flow to the anastomosis, or may be due to genetic characteristics that lead an individual patient to heal in that fashion. Some of the worst strictures, especially those that are recurrent or very dense, may be associated with Crohn s disease, mistaken for ulcerative colitis. Treatment for patients with an anastomotic stricture includes dilation (which may need to be done in the operating room under anesthesia), inspection of the pouch, and then use by the patient of an anal dilator twice a day for 3-6 months until the scarring process has stabilized, to prevent recurrent strictures. The incidence of this complication is 5-10%.

20 Page 20 Small bowel obstruction Due to the removal of the colon, all the surgical options described above are associated with a 16% lifetime risk of small bowel obstruction. Symptoms of bowel obstruction have been described above, but include nausea, vomiting, abdominal distension (variable), crampy abdominal pain, and decreased bowel function (gas and stool). Patients with these symptoms should seek medical attention quickly. In many cases, early aggressive treatment with IVs, resting the bowel by stopping all eating and drinking, and use of a nasogastric tube (tube from nose to stomach) to suck out the stomach contents, is associated with a 50% success rate in resolving the obstruction. The other 50% will generally require surgery to repair the obstruction. Unfortunately, recurrent obstruction can occur. Impotence Impotence is the inability for a male to achieve an erection during sexual activity. This can occur for a number of medical or psychological reasons. In male patients having this kind of surgery, the nerves that control erection run close to the surgical site for removal of the lower part of the colon and rectum, and can be stretched, injured by heat from cautery apparatus, or cut. These are often hard to see or detect, especially if the patient has had prior surgery or has intense inflammation. The risk of impotence after surgery to remove the colon and rectum, regardless of whether a pouch or ileostomy is used for later reconstruction, is about 1-5%. Hernia formation In some patients, especially those requiring multiple operations or on high doses of steroid medication at the time of their first operation, thinning and tearing of the abdominal wall may occur leading to a hernia. This can present up to years after the operation as a lump or mass or sore area, especially after vigorous physical activity. Usually, the lump pushes out when the patient strains or stands, and returns to the abdomen when the patient relaxes and lies down. Such hernias occur under the midline or ileostomy (if present) wounds. Such wound hernias are rare (under 5%), but when they occur, they often require another operation to correct the problem. Laparoscopic techniques may reduce the recovery time after surgery for such hernias.