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Common Procedures and Treatments
There are many different types of bowel resections or abdominal operations. Those have many things in common as well; except for one big difference the recovery on laparoscopic procedures is faster. We'll address specific differences when we briefly discuss each procedure.
Major Abdominal Procedures
Total Procto colectomy with ileoanal J. pouch anastomosis and diverting loop ileostomy
This is the medical term used to describe the procedure that we are recommending you. The operation in simple terms means that the entire colon is removed, the small bowel is then used to create a new rectum "THE POUCH" and this is finally connected to the anus.In some instances to be able to protect the pouch from stool leakage and or infection we create a diverting, protective, temporary ileostomy. Known as "Diverting loop ileostomy". This segment of small intestine comes out through the abdominal wall in to a "bag" or appliance. This will give you time to heal. You may have it for approximately for 3 months, in some instances we perform this procedure as a single stage, in another words, without ileostomy. Most of the time, this decision is made at the time of operation.
In the past removing the entire colon and leaving the patient with a permanent ileostomy was the standard of care for patients with familial polyposis or ulcerative colitis.This was a very unpopular procedure because the patients were totally incontinent to gas and stool and would have to wear an external collecting bag permanently.
Currently ileoanal J. pouch anastomotic is now an accepted surgical procedure to treat these patients. This procedure eradicates the diseased mucosa allowing the patient to preserve bowel continuity and allow defecation per anus.
It is very important for you to understand that this is a major operation and you will have to go through an adjustment period.First of all, getting used to the stoma and appliance on your abdomen, increased frequency of bowel movements and finally some modifications in your diet initially.
Like any other major operations, this procedure carries potential risks and complications. We will list some of them with some percentages to have as complete information as possible to help you make a final decision.
Overall mortality rate is less than 1%, the overall morbidity is 4 to 70%. Surgery failure is 6%; these patients require a permanent ileostomy. Continence is achieved in 90% of patients during the day and 60% of patients during the night.
1. Bowel obstructions 4-25%, only half of the patients with bowel structures require surgery.Obstructions occur within the first 90 days after surgery, 11% of the obstructions seem to be related to the ileostomy.
2. Pouchitis: characterized by frequency, urgency, cramps, bloating and tenderness, dehydration and low-grade fever.Watery mucousy and bloody stools and occasionally malaise and joint pains.
3. Proctitis: a rare instance especially if a segment of rectum is left behind, this is typically treated a medically.
4. Anastomotic strictures: the area where the small bowel and the anus were attached can develop scar tissue and stricture. Rarely becomes a problem, is usually managed by simple dilation.
5. Fistulas occur in 7% or less of patients. Fistulas are abnormal communications between the small intestine and the vagina or perianal skin. Most fistulas appear within six months after the operation. This instance should alert the surgeon to the possibility of Crohn's disease. In the absence of Crohn's disease fecal diversion and drainage of the infection, the fistula may resolve. If the fistula persists after three to six months, surgery to repair it should be considered. Patients with pouch vaginal fistulas may require excision of the pouch and up to 20%. Another kind of fistula is a pouch vesicle fistula which is a communication of the pouch and a urinary bladder.
6. Pelvic sepsis, abscess: Typically present with abdominal pain, decreased ileostomy function, anorexia, nausea or vomiting. The abdomen gets distended and tender. The patient may require imaging studies to establish the diagnosis. Occasionally the abscess can be drained percutaneously; in some other ocations surgery is required. If the abscess is inadequately drained this will lead to prolonged inflammation and decreased pouch distensibility with loss of its reservoir function. Pouch resection rates are approximately 50% and patients may require a laparotomy. The overall incidence of pelvic sepsis is 5 to 7%.
7. Anastomotic leak: this is the most common reason for pelvic or perineal sepsis 2.9%. Two thirds of the time this occur within the first thirty days after the ileal pouch anastomosis, proximal diversion and adequate drainage are the hallmarks of treatment of this complication.
8. Wound infection: this occurs in 3% of all patients and is easily treated by opening the wound and occasional he using antibiotics.
9. Bleeding: this is seen in 3.5% of patients, most of the time this spontaneously resolves occasional he is may require additional interventions.
10. Fecal incontinence: 60% of the patient's are fully confident at all times, 36% have occasional fecal spotting, and 4% have gross incontinence. Nocturnal leakage decreases from 50% at six months to 20% at four years and fecal incontinence decreased from 4% to 0% during the same period time.
11. Pouch perforation these can occur after her blunt trauma to the lower abdomen especially if the pouch is full. Perforation can also be associated with Salmonella infection or associated to lack of blood supply.
12. Infarction or pouch necrosis this is a very rare complication and it occurs in 0.1% of patients, tension off the vascular medical, rotation of the mesentery, venous outflow obstruction could be responsible for these.
13. A neurologic injury or sexual dysfunction: sexual function is improved after Proctor colostomy in one-third of women. This is because of improved health, increased libido. Frequency of intercourse remained unchanged for the majority of man. Frequency of orgasm in women was unchanged. Anal pain, soilage, or fecal drainage during intercourse was not reported. Dyspareunia or painful intercourse is reported to increase from 5 to 15% after surgery. Infertility is reported in a 5% of patients. Impotence or retrograde ejaculation developed and 4% percent of man, but this number seems to decrease with the advent of new medication for erectile dysfunction. Urinary retention it's only transient in some patients and only 2% of patients require intermittent catheterization.
14. Ileostomy dysfunction skin breakdown irritation 15%, this only occurs transiently. Dehydration it's very common and frequently disregarded. These can be associated with electrolyte abnormalities, decreased renal function, kidney stones. This represents one of the most frequent or common causes for readmission to the hospital after this type of surgery. Therefore, the patient needs to be very aware of the number of bowel movements per day or the number of exchanges of the bag. In the absence of pouchitis, our recommendation is to increase fluid intake like Gatorade, Pedialyte, broth or electrolyte containing solutions not just plain water. Take an antidiarrheal medication 1 to 2 Lomotil or Imodium every six hours to achieve between 4 to 6 bowel movements per day. The patient will undergo a period of adjustment learning what kinds of meals increased the output from the ileostomy and what kind of foods will decrease it. Initially a high fiber diet is avoided; this will be gradually increased over time.
15. Adrenal insufficiency: the symptoms include nausea, vomiting abdominal pain, fever, abdominal distention. Electrolyte abnormalities. This is more commonly seen on patients that have been on long term steroid treatments.
16. Alopecia or hair loss is seen in 38% of patients who undergo pouch surgery. This typically improves overtime.
17. Superior mesenteric syndrome this typically is seen on patients that have lost a lot of weight and the artery occludes the duodenum. Also improves with adequate nutritional support.
18. Overall failure rate of ileoanal pouch anastomosis is 3.4% and causes include pouch vaginal fistulas, perianal sepsis, public sepsis, pouch infarction, recurrent pouchitis, incontinence, recurrent bowel obstructions.
19. Malignant transformation or dysplasia: the cumulative risk is estimated at 6% at 20 years and 15% at 30 years. Lifetime surveillance is recommended. Carcinoma in the ileal reservoir after surgery for ulcerative colitis is rare but has been reported in patients that have had a pouch for more than 20 years.
20. Crohn's disease occasionally ileoanal anastomosis are performed on patients which ultimately are found to have Crohn's disease. The rate of pouchitis and ileitis is up to 100%, they develop pouch vaginal fistulas up to 33% and 67% may require re-creation of a loop ileostomy.
21. Indeterminate colitis is not a contraindication for pouch creation; this is when inconclusive gross and microscopic features are found during surgery. These patients have worse results those seen in patients with ulcerative colitis. Pouch failure rate is slightly higher for patients with indeterminate colitis compared with patients with ulcerative colitis 19 vs. 9% respectively.
What to expect after surgery:
When the intestine is extruded through the abdominal wall to allow elimination of stool through that area, which is known as STOMA. The specific name indicates what segment of intestine is used. For the small bowel is called ileostomy and for the large intestine or colon is called colostomy.
LENGTH OF STAY:
You will be admitted to the hospital the day of your procedure. In special circumstances patients are admitted the day prior. Immediately after surgery you will stay in recovery waking up from anesthesia. Once you pass that phase you will be in a room with a family member. The hospital stay is between varies on the procedure done and the approach used. A safe range would be 7 to 10 days for an OPEN CASE, 2 to 5 days for a LAPAROSCOPIC CASE. Recovery at home is approximately four weeks for open cases and 1 ˝ weeks for laparoscopic cases. During this time strenuous activity should be avoided.
Regarding hospital course the patient may anticipate having a tube in the nose, Foley (bladder) catheter. For the most part these remain in place approximately only few days.The patient may also have an abdominal and/or rectal drain. In most instances, all these tubes, as well as the skin staples, should be removed prior to discharge.
Bowel function will be different (Constipation, diarrhea or increased gas). It becomes more regular as the patient recovers with time.
What is a bowel resection?
This is where the diseased segment of bowel is removed (cut out) and the two ends of the bowel are re-connected. This is done most commonly with stapling devices. In some instances re-connection is not feasible and this would require a stoma.
In general, the diet of the patient is not restricted except for the first 2 weeks. Initially it is recommended to follow a bland diet, low in residue after that, a good fiber diet is adequate. However, too much fiber is not better because of its potential of abdominal distention, and even constipating effects. To read information about diet and nutrition, including instructions for a high fiber as well as low residue diet, click here. As mentioned before, bowel function will be irregular; it may oscillate between constipation and diarrhea. This will normalize over time.
Common sense will be a good guide as to how much activity to should be doing during the first couple weeks after your procedure.It is important to be active, out of bed for short periods of time.You should also spend some time resting.Avoid heavy lifting or straining because this will cause the wound to be more painful. Avoid driving for several days until you feel well, especially if you're taking pain medications.
Your wound will heal gradually over a period of one to six weeks depending on the type of surgery performed.Some bleeding and drainage could expected.Staples are removed 7 to 10 days after surgery. There is no need for special ointments or dressings in normal healing circumstances.
You will need to be seen in seven to 14 days after surgery please call the office to set up a follow-up appointment of soon as possible.If you are experiencing significant problems please not hesitate to call the office.
As with any surgery bleeding and infection are the most common, both of which are easily controlled with minor consequences. Possibly the most feared is an anastomotic leak. That could cause infection, sepsis, fistulas, peritonitis, or an abscess, sometimes even death.Under elective surgery, this is happens roughly 3 to 7%. Anastomotic stricture.This in some instances may change bowel habits. Also, adhesions may form from any abdominal surgery; this can only give problems in about 4% of the cases.
There are other types of postoperative complications can occur. These complications are not directly related to the surgery itself, like we described.The most common complications are atelectasis (collapsed lung), pneumonia, DVT's, PE's, myocardial event, arrhythmias or ischemia. These complications are not exclusive but represent the most common. The outcome of these complications is directly related to co-morbid disease and the severity of the event.
Postoperative pain and its control.
We have several ways of achieve postoperative pain control. The decision would be based on the circumstances but we have Oral and IV medications, PCA Patient Controlled Anesthesia where the patient administers the medication on demand. We use Epidural catheters and catheters that go directly in the wound. We'll make an attempt to keep you as comfortable as possible, knowing that there is no such thing as painless operation.
If you have any of the following signs or symptoms you must call. In these scenarios it is recommended the patient go to the nearest ER to be seen.
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