j-pouches and stomas
TRANSCRIPT
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J-Pouches and Stomas
Samuel Eisenstein, MD
Assistant Professor of Surgery
Section of Colon and Rectal Surgery
Rebecca and John Moores Cancer Center
University of California, San Diego Health System
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Financial Disclosures
• I have nothing to disclose
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• J-pouch Surgery for Ulcerative Colitis
• Colectomy
• Reconstruction
• Postoperative expectations
• Stomas
• Types
• Enterostomal therapy
• Pouching and supplies
• Expectations
Agenda
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J-pouch Surgery For Ulcerative Colitis
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UC – Goals of Surgery
• Prevent life threatening complications
• Get off of immunosuppression
• Minimize extra intestinal manifestations
• Peripheral Arthritis (15-25%)
• Skin lesions (1-5%)
• Pyoderma gangrenosum
• Erythema nodosum
• Blood clots
• Cure The Disease!
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UC – Surgical Indications
• Fulminant disease unresponsive to maximal medical therapy
• Toxic Colitis
• Perforation
• Hemorrhage
Emergency Situations Elective Situations
• Dysplasia/Neoplasia
• Complications or Intolerance to medical therapy
• Disease activity refractory to medical therapy
• Disabling extraintestinalmanifestations
• Growth retardation in children
Between 30%–40% of UC patients will eventually require surgery, with
the majority of patients requiring surgery within 10 years of initial
diagnosis
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UC – Surgical options
• Subtotal colectomy + End Ileostomy
• Restore the patient to health
• Recovery, withdrawal from medications
• Then - Proctectomy +/-Pouch +/- Diverting ileostomy
• Total proctocolectomy +/-Pouch +/- Diverting ileostomy
Emergency Situations Elective Situations
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Total Proctocolectomy + Brooke Ileostomy
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J-Pouch Reconstruction
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Types of Ileal Pouches
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UC – Staging the Surgery• Stages
• 3 Stage:
1. Subtotal Colectomy + End Ileostomy
2. Restorative Proctocolectomy + Loop Ileostomy
3. Loop Ileostomy closure +/- Stricture Dilation
• 2 Stage:
1. Total Proctocolectomy + J-pouch Creation + Loop Ileostomy
2. Loop Ileostomy Closure
Or
1. Subtotal Colectomy
2. Restorative Proctocolectomy (undiverted)
• 1 Stage:
• Total Proctocolectomy + Creation of J-Pouch (undiverted)
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Minimally Invasive Approaches
• Laparoscopy
• Small incisions between 0.5-3 cm in size for access
• Largest incision is smallest incision that the organ can be removed from
• First approach for most abdominal surgeries
• Definite benefit in pain, recovery, return to work
• Single incision laparoscopy (SILS)
• Robotic Surgery
• Laparoscopic Surgery but instruments held by robot
• Better articulation
• Better ergonomics
• Many consider better for low pelvic surgery
• Similar benefits as laparoscopy
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UC- Postoperative Expectations
• After subtotal colectomy or restorative proctocolectomy
• 3-7 days in the hospital
• Discharged criteria:
• Stoma functioning
• Eating
• Off IV medications and fluids
• Able to take care of self at home or accepted to rehab facility
• 2-4 weeks pain requiring narcotic pain medication
• 4-6 weeks decreased energy level
• 6 months before feel back to old self/better
• Somewhat less after ileostomy closure
• After STC goal is to get off of all UC meds
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• Pouch function
• Initially
• Many BMs, fairly liquid
• Minimal urgency
• With time
• Fewer BMs
• Thicken up
• Ultimate expectation – Can be up to 6 mos
• 4-8 BMs daily
• Toothpaste consistency
• No urgency
• Excellent to perfect continence
• ~5-10% night time seepage requiring a pad
UC- Postoperative Expectations
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UC – Surgical Complications
• Mortality: 0 – 1%
• Morbidity:
• Pouchitis – 50%
• Cuffitis
• Anastomotic Stricture – 5-40%
• Small bowel obstruction – 20%
• Pelvic sepsis (early and late) – 5-25%
• Anasotomotic separation – 10%
• Pouch vaginal fistula – 10%
• Incontinence
• Decreased fertility in women – 3 fold
• Pouch loss – 5-8%
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• J-pouch surgery is a good option for patients with poorly controlled UC
• Can be staged in a variety of ways
• The key to minimizing complications is seeing an experienced surgeon
• There are minimally invasive approaches
• Function is better than life with UC in most cases
• Most postoperative issues are manageable without more surgery
Conclusions
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Stomas
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What is an Ostomy?
• Surgically created opening utilizing intestinal or other tissue to divert body waste
• Usually the ostomy is named according to the tissue used or the drainage expected
• Ileostomy: made with ileum (small intestine)
• Colostomy: made with colon (large intestine)
• Urostomy: drains urine
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Stoma Stats
• First ostomy created in 1776 for bowel obstruction
• No one really knows how many ostomates are in the US or World Wide
• Estimates range from 450,000-800,000 in US
• Colostomy = ileostomy= urostomy
• Average age = 68.3
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Stoma Comparison
• Last part of small bowel
• More liquid effluent
• More difficult pouching
• More leakage
• More dehydration
• Less bacteria – minimal odor
• Must be raised (Brooked)
• Easier to reverse
• Better temporary stoma
Ileostomy Colostomy
• Colon
• More solid effluent the further along the colon
• Easier pouching
• Less leakage
• Less dehydration
• More bacteria – more odor
• Can be flat (flush)
• More difficult to reverse
• Better permanent stoma
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Stomas
Colostomy
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• Prior to making the stoma
• Counseling on expectations
• Evaluation for positioning
• Long term planning
• In the hospital immediately postoperatively
• Teaching for pouching
• Troubleshooting
• Ordering supplies
• Long term postoperatively
• Help with any changes in pouching
• Skin care
• New products
Enterostomal Therapists (Ostomy Nurses)
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• Good positioning is key to longterm quality of life
• The ideal stoma:
• Location Location Location: Visually/ physically accessible, away from:
• Belt line
• Body folds or creases
• Surgical scars
• Hernias
• Bony prominences
• Well Budded
• Centered OS
• Good blood supply
Positioning
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Stoma Site Marking
• Patient laying down
• Looks like a nice flat abdomen
• BUT…….
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Stoma Site Marking
This is what happens when the patient sits up
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Pouching
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Equipment
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• Can avoid wearing a bag altogether if you irrigate your colostomy
• Only works for left sided colostomies
• Enema every other day
• Can be time consuming
Colostomy Irrigation
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Complications
Irritant Dermatitis
Causes:
• Poorly fitting pouch
• Flush stoma
Treatment:
• Adjust Pouching
Technique
• Stoma Revision
Parastomal Hernia
Causes:
• Significant weight gain
• Emergency stoma
creation/malnutrition
• Bad luck
Treatment:
• Adjust Pouching
Technique
• Stoma repair/Resiting
(<10%)
Stoma Prolapse
Causes:
• Transverse
Colostomy
• Malnutrition
Treatment:
• Stoma Revision
Stoma Retraction
Causes:
• Weight gain
• Stoma made in
crease
Treatment:
• Adjust Pouching
Technique
• Stoma Revision
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• Can avoid wearing a bag altogether if you irrigate your colostomy
• Only works for left sided colostomies
• Enema every other day
• Can be time consuming
Colostomy Irrigation
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• What kind of stoma will it be?
• Expectations for location and quality of effluent?
• Will it be reversible?
• How involved will the subsequent surgery be?
• Can I meet with an enterostomal therapist?
• Who will mark the stoma site prior to surgery?
• When will this be done?
What to ask your surgeon prior to stoma creation
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Most Common Patient Concerns
• Leakage > may need a refit or modification
• Odor > pouches are odor proof, deodorants available
• Clothing > minimal modifications
• Sex> fine once ok by MD, don’t use stoma
• Dating/ Disclosure> no one needs to know
• Showering/Bathing> no problem
• Swimming/ Sports> have fun
• Travel> have pouch will travel
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Live your life normally!
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Conclusions
• Stomas are more common than you would think
• Not all stomas are the same
• Some are reversible, some are not
• Enterostomal therapists are a key member of the surgical team
• See them before surgery
• See them after surgery
• You can do whatever you want with your stoma
• Life with a stoma is likely better than living with the problem which led to stoma formation
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Thank You!