Saumil Mahendra Chudgar, MD

• Associate Professor of Medicine

https://medicine.duke.edu/faculty/saumil-mahendra-chudgar-md

Patients commonly are on psychiatric medications medications ranitidine discount oxytrol 2.5mg with amex, have longstanding constipation issues treatment 7 february buy 2.5 mg oxytrol with amex, history of laxative abuse symptoms carbon monoxide poisoning order 2.5mg oxytrol with amex, diabetes or have had previous abdominal surgery medications starting with p cheap 2.5 mg oxytrol overnight delivery. Early volvulus may be associated with minimal distension that dramatically increases over time treatment resistant schizophrenia buy oxytrol pills in toronto. Patients may describe previous episodes of abdominal pain that spontaneously resolved medicine in ancient egypt generic 2.5 mg oxytrol otc, or previous episodes that were treated non-operatively. Diagnostic Tests Diagnosis of volvulus is suspected given the history of presentation, clinical exam and imaging. Plain abdominal X-ray may be enough to diagnose a volvulus, as classic radiographic findings may be present. Transverse colon volvulus can be seen on plain films as well with several findings consistent with the diagnosis: a dilated, air-filled colon with abrupt termination at the 1339 1340 Chapter 72 Non-Malignant Large Bowel Obstruction 72. By following the lumen and the area where it disappears (arrow), volvulus can be better localised. In order to enhance the diagnostic yield of a plain X-ray, a water-soluble contrast enema may be obtained. In some cases, such as sigmoid volvulus, a water-soluble contrast enema can be used to potentially reduce a volvulus. Due to the risk of perforation and extravasation of contrast into the peritoneal cavity, water-soluble contrast is recommended over barium for the contrast enema. By following the lumen and the area where it disappears, volvulus can be better localised. If the patient has signs or symptoms of systemic illness such as fever, leucocytosis, peritonitis, systemic sepsis or haemodynamic instability, immediate resuscitation and emergency surgical intervention is warranted, along with the initiation of broad-spectrum intravenous antibiotics. In the absence of such findings, patients can be resuscitated and then undergo semi-urgent operative or nonoperative interventions. If non-operative management fails, or if surgery is indicated and the patient has been Volvulus 1341 Patient diagnosed with sigmoid volvulus Clinically unstable Clinically stable 72 - Emergent surgical intervention - Unsuccessful detorsion - - Resuscitation Endoscopic decompression with rigid protoscopy or flexible sigmoidoscopy Rectal tube insertion Successful detorsion Development of peritoneal signs, recurrent volvulus - Serial abdominal exams - Repeat abdominal xray - Continued colonic decompression Clinically stable - Completion colonoscopy to rule out other malignancy - Elective open resection 72. Resuscitation should include optimisation of electrolytes, cardiopulmonary stabilisation and clearance, fluid repletion with isotonic fluids and then discussion for potential surgical intervention. A nasogastric tube should be inserted with intravenous replacement of gastrointestinal losses. The patients should be monitored closely during the resuscitation period and reevaluated for any evidence of worsening abdominal exam or decompensation. The advantage of using a rigid proctoscope is that it can be more quickly obtained for use at the bedside. However, the visualisation is less than ideal and the procedure is limited by the length of the scope which may be inadequate for detorsion. With flexible sigmoidoscopy, one may be able to directly visualise the area much better and can cover a greater distance. The endoscopist may also be able to view the lumen more thoroughly to detect any sign of mucosal ischaemia or necrosis of the bowel, which might necessitate the need for emergent operative intervention. With successful detorsion, there will usually be a forceful evacuation of flatus and stool. After detorsion, a rectal tube should be inserted and fixed in place to prevent recurrence and to help decompress the colon. The tube should be inserted at least 20 cm proximal to the anus and ideally be placed proximal to the site of the volvulus. It is possible that nonviable bowel is detorsed, which may not be immediately recognised, leading to the peritonitis. If detorsion is not successful, then operative intervention is recommended urgently. With successful detorsion and decompression of the colon, elective or semi-elective sigmoid resection is recommended as recurrence is common. Recurrence rates of sigmoid volvulus after detorsion are reported from 25% to 50%, to 80% to 90% within three months of initial presentation. Open sigmoid can be performed through a small incision, since the sigmoid is already very mobile, and the dissection component of a sigmoid resection is minimal. If megacolon is present, then subtotal 1342 Chapter 72 Non-Malignant Large Bowel Obstruction colectomy with ileorectal anastomosis is recommended, as recurrence rates are high. A primary anastomosis saves the patient from having a colostomy or a second procedure. The risks of a single-stage resection procedure include potential anastomotic leak or other anastomotic complications, especially in the setting of a megacolon, long-operative time and a procedure that may be more technically demanding. Tube caecostomy with colonic lavage followed by sigmoid resection and primary anastomosis may also be performed. Risks of caecostomy include longer operative times and an increased wound infection rate. Sigmoidopexy involves fixing the colon to the abdominal wall or surrounding structures either with the use of tubes or sutures and can be performed laparoscopically. Risk of recurrence is high with surgical procedures that do not include the removal of the sigmoid colon (>25%). The benefits, however, include no risk related to the anastomosis or stoma and a shorter operative time. Emergency operations for sigmoid volvulus have a higher morbidity and mortality than elective surgery. The recurrence rate after simple detorsion was 36%, and no recurrences were observed in those undergoing sigmoid resection. For sigmoid volvulus, the authors recommend sigmoid resection with primary anastomosis whenever safe. In pregnancy, the enlarging uterus may push the mobile caecum out of its position, producing torsion. Nonoperative treatment is usually ineffective given its location on the right side, with reports of success of conservative treatment being low as 30%. If gangrenous bowel is encountered during laparotomy, detorsion should not be performed so as to prevent septic shock from release of toxins in the gangrenous loop. End ileostomy should be considered when the patient is at increased risk for anastomotic complications (malnutrition, immunosuppressed, haemodynamically unstable or perforation with contamination). If viable bowel is found at the time of laparotomy, detorsion can be performed, and resection is recommended. Benefits of resection in this setting include low recurrence rates and removal of any ischaemic or potentially injured bowel. Risks include longer operative time and risks associated with an anastomosis or ileostomy. Viable bowel can also be detorsed without resection and fixed by caecopexy or caeocostomy, but these procedures, however, have high risks of recurrence (25% to 70%) and higher mortality rates than resection. Vascular compromise is less likely and tends to occur more commonly in young, female patients. Caecal bascule is treated as a caecal volvulus with resection and primary anastomosis as the preferred surgical option. The terminal ileum, caecum and proximal right colon rotate, usually clockwise, around its mesentery. Endoscopic decompression may be feasible but is generally difficult to detorse effectively. Risks of perforation, incomplete detorsion and recurrence make endoscopic attempts a potentially dangerous treatment option. Similar to sigmoid or caecal volvulus, gangrenous bowel should not be detorsed and should be resected with a primary anastomosis or a diverting stoma. Viable bowel can potentially be detorsed and pexied, but previous studies have shown a high rate of mortality and complications with simple detorsion. Primary anastomosis or creation of a stoma should be dictated by patient-related factors, feasibility of anastomosis and concern for risks of an anastomosis versus a stoma. Ileosigmoid Knotting Ileosigmoid knotting is a condition also known as compound volvulus, involving volvulus and obstruction of the small intestine and the sigmoid colon. With peristalsis, the loop containing the heavy meal rotates and squeezes, forming a knot and closed loop obstruction in the sigmoid colon and the small bowel. Pre-operative diagnosis is difficult, with only about 20% being diagnosed pre-operatively. The endoscope will not be able to be advanced in ileosigmoid knotting, due to the complete obstruction of the sigmoid colon. Timely surgical intervention is the treatment of choice after appropriate resuscitation. If the bowel is viable, resection is still recommended due to unknown risks of recurrence. The small bowel is typically anastomosed, whilst the colonic segment may or may not be due to potential damage to the distal blood supply from the volvulus. The inferior mesenteric artery or superior rectal Strictures 1345 72 (a) (b) (c) (d) 72. Configurations with ileosigmoid knotting include the ileum wrapping around the sigmoid colon (a and b) or the sigmoid colon wrapping around a loop of ileum (c and d). Some authors have advocated that coloproctostomy can be safely performed, depending on the judgment of the surgeon. If the stricture is in the proximal colon, there may be distended loops of small bowel, giving the appearance and presentation of a distal small bowel obstruction. Causes include inflammatory conditions, such as diverticular disease or inflammatory bowel disease, radiation, infectious or mechanical strictures from previous surgery. The process typically develops over a longer time period, with symptoms of increasing abdominal distension, constipation, early satiety, straining with stools, change in calibre stool and crampy abdominal pain. With worsening obstruction, the patient may present with faeculent vomiting (in the 25% where the ileocecal valve is incompetent), although patients may present without vomiting despite a marked distension. Endoluminal colonic lavage has been proposed but appears to offer no benefit and increases risks associated with a longer operative time and a higher rate of wound infection. The benefits of this procedure include the ability to decompress the colon prior to surgical intervention. With diverticular strictures, however, there may be a higher incidence of complications with stent placement, and stent placement should be used sparingly. Ischaemic Strictures Colonic strictures can develop from non-occlusive ischaemic disease, arterial occlusive or venous occlusive disease and are a rare cause of large bowel obstruction. Presentation of symptoms are similar to other types of stricturing disease, but will be preceded by a course of ischaemic colitis or a severe vascular ischaemic insult. These types of strictures are more typical in patients over 70 years of age, with a previous history of cardiovascular disease. The typical areas affected are in the watershed distribution such as the splenic flexure or the rectosigmoid artery distribution. They should be suspected in patients with risk factors for ischaemia or previous episodes of ischaemic colitis, and their presence in the typical watershed areas. Patients with ischaemic strictures may be at an increased risk for invasive surgical intervention or at an increased risk of anastomotic complications given their medical co-morbidities. Successful non-operative management with either stenting or balloon dilatation has also been described. In a large review of patients undergoing colorectal stent placement for colonic strictures, there was a higher incidence of perforation when these were placed for benign strictures as compared to malignant strictures, whilst dilation was not associated with an increased risk of perforation. Initial treatment should include nasogastric decompression, resuscitation and conservative management unless there are signs or symptoms of bowel ischaemia, which is rare. After resuscitation, elective resection is recommended during the same hospital admission. If active inflammation is present, then a course of antibiotics is recommended prior to resection. These individuals may be more advanced in age or have risk factors for development of certain colonic infections. Persistent stricture after treatment of the infectious process should be treated with either resection or with dilatation and stenting. Treatment is usually non-operative with dilatation, which can be performed with endoscopic or transanal techniques, depending upon the location. Radiation-Related Strictures External radiation or brachytherapy can lead to obliterative endarteritis, ischaemia and fibrosis. The rectum is typically the most common site of injury at the rectosigmoid junction, followed by the terminal ileum as a result of pelvic radiotherapy. Patients may have rectal bleeding, obstructed defaecation, tenesmus, diarrhoea or a change in stool calibre. There may be signs of subacute inflammation and chronic fibrotic changes on imaging. Treatment options for radiation strictures include operative and non-operative techniques. Non-resectional techniques have been described including rectal pullthrough, myotomy or stricturoplasty, but these are associated with high complication and mortality rates. Risks of anastomatic complications are also increased due to radiation injury in the remaining bowel. Stoma formation also has its risks, such as herniation, prolapse, ischaemia or necrosis. Non-operative techniques have been described for strictures associated with radiation therapy with balloon dilatation and triamcinolone injection. Symptoms typically correlate with the menstrual cycle, which may aid in diagnosis. Macafee and Greer reviewed 7,177 cases of endometriosis and found intestinal implants in 12% of patients, most frequently in the rectosigmoid area (72%), small intestine (7%), caecum (3. Surgical resection should be used as treatment for patients with endometriosis causing bowel obstruction.

Prompt evacuation of flatus or stool with reduction of abdominal distention on physical examination was observed in 10 out of 11 patients (91%) randomly assigned to neostigmine treatment compared to none of the 10 individuals in the placebo group (p < 0 treatment ear infection 5mg oxytrol with visa. Treatment was considered to have ultimately failed in three of 11 patients receiving neostigmine compared with eight of 10 patients receiving placebo (27% vs symptoms 2 days after ovulation discount 5mg oxytrol amex. In particular treatment room oxytrol 2.5mg for sale, two patients who had initially responded to neostigmine required colonoscopic decompression due to recurrent colonic distention medications bad for your liver buy oxytrol 5mg fast delivery, one of whom eventually proceeded to subtotal colectomy due to failure of colonoscopic decompression medications that raise blood sugar generic oxytrol 5 mg with amex. The dose can be repeated if necessary although the exact time interval from the initial dose remains controversial (see below) symptoms qt prolongation order oxytrol australia. Intravenously administered neostigmine generally has a rapid onset (<20 min) and a short duration of action (<2 hours). Reported initial response rates range from 45% to 95%, whilst the overall response rates are between 56% and 100% (see Table 73. Contraindications to the use of neostigmine are a heart rate of less than 60 beats per minute, a systolic blood pressure less than 90 mm Hg, bronchospasms requiring medication, a serum creatinine exceeding 3 mg/dL, use of beta-blockers, acidosis, recent myocardial infarction, any clinical or radiological signs of bowel perforation, any suspicion of mechanical bowel obstruction, active gastrointestinal bleeding and pregnancy. The most common, generally self-limiting side effect is crampy abdominal pain, followed by hypersalivation (see Table 73. The rate of symptomatic bradycardia, requiring in most cases treatment with atropine injection, was 6% based upon nine studies. Due to its effect on the cardiovascular system, patients receiving neostigmine should be monitored at least in a telemetry unit and sometimes require transfer to the Intensive Care Unit. It has been suggested that premedication with glycopyrrolate can reduce both the incidence and the magnitude of the adverse effects associated with neostigmine. After 24 hours, the non-responders crossed over to the alternative management arm. Eleven out of 13 patients randomised to neostigmine infusion passed stools after a median time of six hours versus none in the placebo group. Following crossover management, eight out of the 11 additional patients receiving neostigmine also passed stools after a median time of 12 hours versus none amongst the crossover placebo recipients. One patient initially randomised to placebo failed to respond to crossover treatment with neostigmine and eventually developed caecal perforation requiring right haemicolectomy, which he survived. Another patient who had responded to neostigmine experienced ischaemic colitis, detected colonoscopically 10 days after neostigmine infusion, which was successfully treated with supportive treatment alone. A third patient also responded to crossover neostigmine, but died from intestinal necrosis seven days following initial study enrolment. Few studies have attempted to define factors associated with response to neostigmine. The initial response rates based on 11 studies range between 71% and 100%, whilst the recurrence rates range between 4% and 29% and the overall success rate between 73% and 92%, respectively. The reported iatrogenic colonoscopic perforation rates range from 0% to 2% (see Table 73. It is inevitable that colonoscopy to decompress the dilated colon is performed without bowel preparation. Air insufflation should be kept to a minimum and air should actually be suctioned out, as the colonoscope is advanced to reduce the calibre of the colon, without collapsing it entirely whilst maintaining adequate visualisation. Unlike colonoscopy performed for other, elective indications, the endoscopist should not insist in attempting caecal intubation, as this might increase the risk of bowel perforation without demonstrable added benefits. Passage of the endoscope proximal to the hepatic flexure is generally sufficient to achieve effective colonic decompression. It is generally advisable to leave a decompression tube in place as there is evidence suggesting that this is associated with an increased success rate. The decompressing tube was left in place between two and 13 days following initial colonic decompression. The overall clinical success of colonoscopic decompression was 88% (44 out of 50). Only two of the eight procedures not associated with decompression tube placement were followed by clinical success (25%). A decompression tube positioned in the right colon or in the transverse colon was associated with statistically similar clinical success rates. Whilst the individual circumstances probably played a significant role in the decision to selectively leave a decompression tube in situ as well as its specific location within the colon, the authors concluded that decompression proximal to the splenic flexure should usually be sufficient. In general, a tube left in place is particularly useful for patients whose underlying conditions are likely to be accompanied by a long hospital stay, such as in the case of sepsis or other conditions requiring prolonged mechanical ventilation. In this respect, the management of patients having areas of mucosal ischaemia visualised at the time of colonoscopic decompression is controversial. Five patients (33%) in the placebo group, who had initially responded to neostigmine, developed recurrent caecal dilatation compared to none in the polyethylene glycol group (p = 0. It is a possible option for patients who have failed non-operative management but are associated with excessive perioperative risk. Percutaneous endoscopic cecostomy: a new approach to nonobstructive colonic dilation. Complications of percutaneous caecostomy are stool leakage along the catheter, which in the worst case scenario can result in intraperitoneal spillage, pressure necrosis from the tubing system and peristomal infection, which generally responds well to broad-spectrum antibiotics, although at least one case of cellulitis resulting in sepsis and death has been reported. The authors emphasise that delay in effective intervention whilst awaiting response to neostigmine infusion, possibly resulting in repeat neostigmine administration, could allow the development of colonic ischaemia and perforation. A number of cases of 73 Acute colonic distention Surgery Yes Ischaemia or perforation or cecal volvulus The Role of Endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction. Even more recently, a number of authors do not consider neostigmine as the inevitable treatment option after failure of supportive management and have successfully used colonoscopy instead. However, there are no clear guidelines on the timing of repeat neostigmine administration, particularly on a safe interval whilst awaiting clinical response, before pursuing alternative treatments. In at least three studies, the exact time interval between first and repeat neostigmine administration was not specified. The overall prognosis associated with such concurrent conditions should also be taken into consideration in the decision to operate. Historically, the most commonly reported procedure has been caecostomy, which remains a controversial procedure. References 1361 mortality rates in the order of 30% and were even higher amongst patients undergoing surgery with an ischaemic or perforated bowel. Patients were divided according to the treatment received into those undergoing medical management alone, colonoscopic decompression alone, surgery alone and a combination of surgery and colonoscopy. A more specific subgroup analysis on those patients who underwent surgery after unsuccessful colonoscopy was also carried out. It was reassuring to note that the proportion of patients undergoing surgery significantly decreased over the study period, from 7. The overall morbidity following surgery was approximately 37%, and the mean length of stay was 18. Amongst the remaining procedures, approximately 50% of the surgical patients were associated with a partial colectomy code, and approximately the same percentage had been coded as undergoing a colostomy creation. An ileostomy was coded in about 20% of the patients and a total colectomy in approximately 3% to 4%. Patients undergoing both colonoscopy and surgery were more likely to have a colostomy. The subset of 261 patients who underwent surgery after unsuccessful colonoscopy was associated with a significantly increased mortality when compared with colonoscopic treatment alone (15. For example, the lack of details on many patients who underwent both colonoscopy and surgery as well as the combination of the various surgical procedural codes, which were not mutually exclusive. Although supportive measure and neostigmine infusion have played an important part in conservative treatment in the past, colonoscopic decompression by an experienced endoscopist avoiding air insufflation and flatus tube insertion is generally recommended to assess mucosal ischaemia and to exclude any possible mechanical cause. If the condition recurs despite these measures and there is no evidence of ischaemia or perforation, then colonoscopic caecostomy provides a reversible method of decompression when caecal dilatation is present. Assessment of predictors of response to neostigmine for acute colonic pseudoobstruction. The acute contrast enema in suspected large bowel obstruction: Value and technique. Acute colonic pseudo-obstruction: Treatment by endoscopic decompression and proximal colonic tube placement. Pseudoobstruction associated with colonic ischemia: Successful management with colonoscopic decompression. Percutaneous endoscopic cecostomy: A new approach to nonobstructive colonic dilation. Retrospective study of neostigmine for the treatment of acute colonic pseudo-obstruction/Discussion. Neostigmine for the treatment of acute colonic pseudo-obstruction in patients with abdominal surgery. Acute pseudo-obstruction of the colon as a postoperative complication of hip arthroplasty. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudoobstruction. Factors predicting successful outcome following neostigmine therapy in acute colonic pseudo-obstruction: A prospective study. The use of neostigmine to treat postoperative ileus in orthopedic spinal patients. Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: A prospective, randomised, placebo controlled trial. During the American Civil War, such injuries were considered expectant, as most injured presumably succumbed to secondary infection and sepsis. Continued improvements in aggressive resuscitation techniques, improved use of antibiotics and faster evacuation from point of injury to definitive surgical care have lowered mortality from penetrating wounds of the colon to less than 5%. It accounts for more deaths and more years of life lost than cancer, diabetes and heart disease combined. In recent military operations Enduring Freedom and Iraqi Freedom, up to 95% of colorectal specific trauma are penetrating wounds (gunshot, blast, fragmentation) whilst a small minority are due to blunt trauma. Examples include gunshot wounds, both low velocity civilian gunshot wounds and high velocity injuries seen in military conflict as well as stab wounds. Of blunt colon trauma injuries, 75% to 90% are due to motor vehicle collisions resulting in the transfer of high energy to gas-filled, more mobile organs. These are often associated with injuries to the liver, spleen, small intestine, thorax and head. Devascularisation injuries secondary to avulsion of supporting mesenteric blood supply are also common, usually due to motor vehicle collisions with associated deceleration injury. Other causes of colon trauma include injuries due to colonoscopy and concomitant biopsies, polypectomies, excessive use of electrocautery or barotrauma due to over-insufflation. Advanced Trauma Life Support teaching mandates that the airway of the injured patient be obtained and secured. Adequate oxygenation and ventilation need to be maintained and necessary adjuncts including intubation or placement of a tube thoracostomy performed if necessary. Adequate circulation is measured by sufficient blood pressure, palpable distal pulses, brisk capillary refill and end organ perfusion. In neurologically intact patients, obtaining a personal history and the understanding the mechanism of injury may assist in diagnosis and management of injuries to the colon and rectum. Understanding the type of weapon used, length of knife involved or mechanism of iatrogenic injuries may direct further management. After establishing airway, breathing, and adequate circulation, a complete head to toe physical examination should be conducted in a thorough manner. Special focus should be placed on examination of the abdomen and perineum and performing a digital rectal exam. Inspection of the abdomen should note any penetrating injuries as well as abdominal distention, peritoneal findings of palpation and significant bruising. Significant pelvic trauma, manifest by obvious pelvic fractures or haematoma, should raise the index of suspicion for rectal trauma. Blood on digital rectal exam or visible at the urethral meatus suggests intra-pelvic injury until ruled out by further evaluation. Initial evaluation of abdominal trauma following stabilisation of the injured patient may include multiple modalities, depending on the stability of the patient. An acute abdominal series of radiographs (upright and supine abdominal films as well as a left lateral decubitus film) may detect the presence of free intra-peritoneal air. The technique is operator-dependent, but, with practice, it has been shown to accurately identify the presence of fluid inn the sub-hepatic space, the sub-splenic space, the Colon Injury Grades 1365 S F K 74. Free intra-abdominal air, extravasation of oral contrast, free intra-abdominal fluid or thickening of the colonic wall with mesenteric stranding are all indication for operative exploration. Of note, oral contrast has not been shown to increase the diagnostic accuracy of identifying colon injuries, and administering oral contrast and waiting for transit through the intestines may cause delay in diagnosis and treatment. Tangential but non-penetrating wounds may be admitted for observation with serial exams to evaluate for the delayed development of peritonitis. Wounds that do not penetrate fascia may be discharged home from the emergency department. Diagnostic peritoneal lavage is a technique largely falling out of favour in current management of abdominal injuries. The procedure, used most commonly in unconscious patients, involves using a sterile technique and local anaesthesia to make a 2-cm incision infra-umbilically and aspirate peritoneal fluid from the injured patient. Aspiration of gross blood suggests significant intra-abdominal haemorrhage and mandates laparotomy. If the aspirate is non-bloody, one litre of saline is instilled into the pelvis via intravenous tubing.

The occurrence of non-adenoma-like raised lesions and of flat high-grade of dysplasia in the pouch should be considered as indications for pouch excision medicine you can give dogs buy discount oxytrol. However treatment 3rd metatarsal stress fracture discount oxytrol generic, in case of high-grade dysplasia symptoms high blood pressure oxytrol 5mg amex, some investigators recommend pouch excision symptoms colon cancer generic oxytrol 5 mg online. The disconnection medicine you can order online purchase oxytrol mastercard, pouch revision and reconnection of the ileal pouch-anal anastomosis with or without an anorectal or pouch resection involve dissection both from the anus and the abdomen treatment 6th feb cardiff cheap oxytrol 2.5 mg amex. The mesentery of the entire small bowel should be followed up to its origin, and the whole of the small bowel mobilised. The small bowel is packed up into the upper abdomen, leaving only the bowel leading down to the pouch. The strategy, as always, is to do the easy parts first and when stuck turn to another site. Usually, it is possible to reach all the way down to the pelvic floor, but if this is judged too risky, the surgeon may have to decide not to go ahead and abandon the original intention of the procedure. If on the other hand the dissection proves possible, the abdominal operation stops when the pelvic floor or corresponding fibrosis is reached. This can be facilitated by injecting adrenaline diluted in saline under the mucosa. Finding the right plane in case of excessive fibrosis from sepsis can be difficult. The best strategy is to have an agreement that the surgeon should do what appears to be most sensible procedure at the time whilst avoiding risk, as this is a matter of improving function and not a lifesaving operation. If it is not possible to do a redo pouch, one should have an agreement on the alternatives, which might include a continent reservoir ileostomy or a conventional permanent ileostomy (see Chapter 69 on continent ileostomy). The specific risks involve those of dissecting in a frozen pelvis where it may not be possible c 68. The majority of authors report that most of the original pouch can be reused after trimming off any friable and damaged tissue at the site of the anastomosis. Sometimes, preservation of the pouch is not possible, in which case another new pouch can be constructed taking into account any possible difficulty with distal reach. Another option is to preserve as much of the original pouch as possible and then do an enteroplasty at the inlet by adding a new segment of small bowel on a well-vascularised pedicle so as to add more bowel to the pouch. The Lone Star retractor is very helpful in facilitating the new pouch anal anastomosis. After placement of all the sutures, the pouch is gently pulled down and the anastomosis is completed under direct vision. When distal reach of the pouch is a concern, the Parks anal retractor with detachable blades may be preferred by some over the Lone Star retractor. The anal sutures are placed in the same manner taking great care to keep them long and separated on mosquitos. The pouch is then pulled down and all sutures are placed through the full thickness pouch wall. This method allows for an anastomosis that is rather high up in the anal canal, but this does not compromise subsequent anal function. The complication rates and functional outcome after redo procedures are generally acceptable, but it is essential to inform patients that the overall chance of a good function is less than that of an uncomplicated primary pouch operation. After five years, 74% of the pouches were still functioning and 61% reported good or excellent outcomes in terms of frequency and continence. In those without a stoma, the overall functional outcome, and QoL scores were reported to be acceptable in 80%. Incidence of and impact of medications on colectomy in newly diagnosed ulcerative colitis in the era of biologics. An assessment of inflammation in the reservoir after restorative proctocolectomy with ileoanal ileal reservoir. Diagnosing pouchitis: Comparative validation of two scoring systems in routine follow-up. Clinical Gastroenterology and Hepatology: the Official Clinical Practice Journal of the American Gastroenterological Association. Pouchitis after ileal pouch-anal anastomosis for ulcerative colitis occurs with increased frequency in patients with associated primary sclerosing cholangitis. Irritable pouch syndrome: A new category of diagnosis for symptomatic patients with ileal pouch-anal anastomosis. Endoscopic assessment of acute inflammation of the ileal reservoir after restorative ileo-anal anastomosis. Patterns of distribution of endoscopic and histological changes in the ileal reservoir after restorative proctocolectomy for ulcerative colitis. Incidence and short-term implications of prepouch ileitis following restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis. Incidence and Severity of Prepouch Ileitis: A Distinct Disease Entity or a Manifestation of Refractory Pouchitis Restorative proctocolectomy with ileal reservoir: Pathological and histochemical study of mucosal biopsy specimens. Misdiagnosis of specific cytomegalovirus infection of the ileoanal pouch as refractory idiopathic chronic pouchitis: Report of two cases. Faecal calprotectin for screening of patients with suspected inflammatory bowel disease: Diagnostic meta-analysis. Consecutive Monitoring of Fecal Calprotectin and Lactoferrin for the Early Diagnosis and Prediction of Pouchitis after Restorative Proctocolectomy for Ulcerative Colitis. Serial Fecal Calprotectin and Lactoferrin Measurements for Early Diagnosis of Pouchitis After Proctocolectomy for Ulcerative Colitis: Is Pouchoscopy No Longer Needed Long-term clinical outcome and anemia after restorative proctocolectomy for ulcerative colitis. Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy. Prophylaxis of pouchitis onset with probiotic therapy: A doubleblind, placebo-controlled trial. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: A double-blind, placebocontrolled trial. Rifaximin for the treatment of active pouchitis: A randomized, double-blind, placebo-controlled pilot study. Impact of budesonide on liver function tests and gut inflammation in patients with primary sclerosing cholangitis and ileal pouch anal anastomosis. Effect of withdrawal of nonsteroidal antiinflammatory drug use on ileal pouch disorders. Rifaximin-ciprofloxacin combination therapy is effective in chronic active refractory pouchitis. Antibiotic combination therapy in patients with chronic, treatment-resistant pouchitis. Four-week open-label trial of metronidazole and ciprofloxacin for the treatment of recurrent or refractory pouchitis. Combined ciprofloxacin and tinidazole therapy in the treatment of chronic refractory pouchitis. Barreiro-de Acosta M, Garcia-Bosch O, Souto R, Manosa M, Miranda J, GarciaSanchez V et al. Efficacy of infliximab rescue therapy in patients with chronic refractory pouchitis: A multicenter study. Barreiro-de Acosta M, Garcia-Bosch O, Gordillo J, Manosa M, Menchen L, Souto R et al. Efficacy of adalimumab rescue therapy in patients with chronic refractory pouchitis previously treated with infliximab: A case series. Expression of colonic antigens by goblet and columnar epithelial cells in ileal pouch mucosa: Their association with inflammatory change and faecal stasis. Low levels of vitamin D are common in patients with ileal pouches irrespective of pouch inflammation. Risk factors for low bone mass in patients with ulcerative colitis following ileal pouch-anal anastomosis. A unique variant of afferent limb syndrome after ileal pouch-anal anastomosis: A case series and review of the literature. Results and complications after ileal pouch anal anastomosis: A meta-analysis of 43 observational studies comprising 9,317 patients. Recurrent volvulus of an ileal pouch requiring repeat pouchopexy: A lesson learnt. Surgical correction of the efferent ileal limb for disordered defaecation following restorative proctocolectomy with the S ileal reservoir. Treatment of rectal cuff inflammation (cuffitis) in patients with ulcerative colitis following restorative proctocolectomy and ileal pouch-anal anastomosis. Clinical course of cuffitis in ulcerative colitis patients with restorative proctocolectomy and ileal pouch-anal anastomoses. Systematic review of cuff and pouch cancer in patients with ileal pelvic pouch for ulcerative colitis. Preoperative colorectal neoplasia increases risk for pouch neoplasia in patients with restorative proctocolectomy. Prior colorectal neoplasia is associated with increased risk of ileoanal pouch neoplasia in patients with inflammatory bowel disease. Histomorphologic and molecular features of pouch and peripouch adenocarcinoma: A comparison with ulcerative colitisassociated adenocarcinoma. Inflammatory bowel disease-associated colorectal cancer: Proctocolectomy and mucosectomy do not necessarily eliminate pouch-related cancer incidences. Banasiewicz T, Marciniak R, Paszkowski J, Krokowicz P, Kaczmarek E, Walkowiak J et al. Pouchitis may increase the risk of dysplasia after restorative proctocolectomy in patients with ulcerative colitis. Atrophy and neoplastic transformation of the ileal pouch mucosa in patients with ulcerative colitis and primary sclerosing cholangitis: A case control study. Risk of dysplasia and adenocarcinoma following restorative proctocolectomy for ulcerative colitis. Disconnection, pouch revision and reconnection of the ileal pouch-anal anastomosis. Reconstructive surgery for failed ileal pouch-anal anastomosis: A viable surgical option with acceptable results. Redo ileal pouch-anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy Transabdominal Redo Ileal Pouch Surgery for Failed Restorative Proctocolectomy: Lessons Learned Over 500 Patients. Salvage procedures after restorative proctocolectomy: A systematic review and meta-analysis. At that time, surgery for colitis had become safer, since we had learned to operate earlier on patients with acute colitis, and mortality was lowered and usually well below 10%. However, ileostomy appliances were not as refined as they are today, and living with an ileostomy was rather miserable. Appliances that were available, were mostly made of rubber and were bulky so that they could not be hidden under clothing. Leakage was a regular problem, and often allergies followed, giving severe skin problems. Kock was inspired by the urologists and had also himself constructed a double-folded ileal bladder substitute from bowel. It is told that he sat at his kitchen table with the inner rubber tubing of bicycle tyres experimenting with different pouch designs. At one time, he also experimented with a caecal pouch, but it was dismissed due to evacuation and leak problems. The initial idea was that the architecture of the ileal segments, included in the pouch, would go to all four corners, thus cancelling out each 1304 other which resulted in an atonic pouch able to adapt to volume loads without giving rise to pouch contractions. The first pouches constructed in humans had an outlet consisting of one of the pouch corners that was drawn obliquely through the rectus abdominis muscle to assure continence. In some patients, this worked well; but for most, continence was unpredictable and unreliable, perhaps due to the fact that the pouch was not as atonic as hoped. Therefore, the development continued with the addition of the nipple valve proximal to the stoma outlet. The nipple valve is an intussusception of the bowel protruding into the reservoir. The principle is that when pressure rises in the reservoir, the valve will be further compressed and thus maintain continence. When this construction is intact, the continent ileostomy is an almost miraculous improvement compared to the conventional ileostomy. When constructed below the belt line, this stoma is situated flush on the skin is simply covered with a small plastic dressed gauze and is very discrete. Unfortunately, it is prone to slippage and malfunction with incontinence and pouch intubation difficulties. Throughout the years, several attempts were made to improve the stability of the intussusception. Stiches through both bowel segments, peeling off the peritoneum of the intussuscepted bowel peritoneal surfaces, reinforcing the base of the intussusception with fascia lata or synthetic mesh, different suturing and stapling techniques have all been tried and evaluated. Although better than initially, problems with valve continence continued and was the reason behind the low acceptance of the continent ileostomy in a worldwide Indications 1305 69 (a) (b) 69. As for all complicated surgical procedures, they are best performed in the setting of a team with at least two to three surgeons and a dedicated nursing staff. There is a belief that the pouch must be kept continuously drained and empty during the first post-operative weeks so as to ensure optimal healing, with as little strain as possible on the newly constructed nipple valve. Protecting the continent ileostomy with a proximal diverting loop ileostomy has also been tried. Furthermore, the ileorectal anastomosis is in vogue again, at least in some countries, leaving the continent ileostomy at best as the third option for patients facing a colectomy for ulcerative colitis. In such situations, the continent ileostomy is a valid alternative to an incontinent conventional ileostomy.

Patients should be mobilised as soon as possible and offered oral fluid medicine rash purchase 2.5mg oxytrol fast delivery, which symptoms xxy purchase genuine oxytrol on line, if tolerated medicine net buy generic oxytrol 5 mg on line, can be followed by light diet as early as the first post-operative day medications containing sulfa generic 2.5 mg oxytrol fast delivery. The risk of thromboembolism is high in surgery for inflammatory bowel disease and low molecular weight heparin should be continued at least until patient is fully mobilised or even up to four weeks post-operatively medicine zebra order 2.5mg oxytrol with visa. Ileus is usually secondary to other complications symptoms in children discount oxytrol 5mg with visa, which need to be excluded, but can also be caused by electrolyte disturbances from severe disease or the operation. The most severe complications are anastomotic leak and infectious complications due to an infected haematoma, per-operative contamination, an anastomotic leak or peroperative bowel injury. An overt anastomotic leak should either be diverted, or more frequently, the anastomosis must be taken down and an ileostomy fashioned and the rectal stump closed. A deep-seated infection or an abscess can often be treated by radiologically guided drainage and antibiotics. Bleeding is rare and will usually settle without any surgical or endoscopic intervention. Ileorectal anastomosis is a lesser procedure compared with an ileal pouch anal anastomosis, involving a shorter operating time and less blood loss (see Table 67. After both procedures, there is a high risk of post-operative complications, being 23. About 36% to 70% of the failed ileorectal anastomosis in ulcerative colitis was managed by an ileal pouch anal anastomosis later on in life. In familial adenomatous polyposis, the functional outcome was no worse after a secondary ileal pouch anal anastomosis compared with a primary pouch without a previous ileorectal Cancer Risk and Surveillance 1283 anmastomosis. There is sometimes the possibility of performing a redo ileal pouch anal anastomosis, but so far the success rates are low, especially when performed for septic complications with an inferior function, compared with a primary ileal pouch anal anastomosis. A metaanalysis comparing ileal pouch anal anastomosis in ulcerative colitis and familial adenomatous polyposis showed the risk for pouchitis to be higher in ulcerative colitis as well as a small increased stool frequency, but with otherwise comparable outcomes in function and failure as amongst those with familial adenomatous polyposis. The rationale for treatment is both their anti-inflammatory effect and, possibly, cancer prevention (Table 67. In many units undertaking ileorectal anastomosis for ulcerative colitis, the algorithm so far has been proctectomy and ileal pouch anal anastomosis for those developing intractable proctitis despite the use of topical mesalazine. There are several reports of patients developing rectal cancer within 10 years of diagnosis,16,24,25,37,44 treated by ileorectal anastomosis in ulcerative colitis. Furthermore, cancer may also occur after ileal pouch anal anastomosis, although to a far lesser extent. These patients should not be offered an ileorectal anastomosis other than in highly selected cases, such as in patients with a short life expectancy. Nevertheless, the absolute risk of developing rectal cancer after an ileorectal anastomosis in patients with ulcerative colitis is still low, being 2. There is a particular high-risk situation in the patient who has had a subtotal colectomy and an over-sewn rectal stump in terms of cancer risk if the rectum is left in situ. This would be a suitable place to consider the cancer risk in the rectal stump, not only when in circuit but also when diverted from the faecal stream. In general, the risk of malignancy is related to the extent of disease and its duration before colectomy. Grundfest and colleagues47 estimated a 13% rectal cancer risk at >25 years of follow-up. If rectal cancer develops in the retained rectum, the prognosis is generally worse than de novo rectal cancer because of late presentation, especially if the rectum is out of circuit because of proximal stoma. If endoscopic surveillance is problematic due to poor bowel preparation, anal disease, stricture or patient discomfort, or if there is biopsy evidence of severe dysplasia, then rectal excision should 1284 Chapter 67 Ileo-Rectal Anastomosis and Alternative Strategies in Colitis beadvised especially if the rectum has been in situ for more than 10 years. When the rectum has been in place for more than 20 years, the risk of rectal cancer must be explained to patients even if they are well and symptomatic. There are no guidelines regarding surveillance, but annual flexible endoscopy with multiple biopsies is recommended. In patients developing dysplasia at endoscopic surveillance, counselling for a proctectomy and a possible ileal pouch anal anastomosis should be made as the risk of developing rectal cancer increases with duration of follow-up. One mechanism is the higher rate of occlusion of the fallopian tubes by pelvic scarring and adhesions58 after pelvic surgery. This could be one reason for the reduced fecundability in ulcerative colitis compared with familial adenomatous polyposis as a result of the inflammatory nature of the disease. Two small studies from five European centres compared complete laparoscopic and/or hand-assisted laparoscopic ileal pouch anal anastomosis with open pouch surgery. No differences were found regarding healthrelated quality of life or disability despite a significantly higher stool frequency and need of anti-diarrhoeal medication in patients with ileal pouch anal anastomosis. Despite this, no differences in quality of life was found between the groups, apart from some dietary and work restrictions in those with an ileorectal anastomosis. There is a low risk of sexual dysfunction when the pelvis is not entered and the rectum is preserved; thus, the risk of both male and female sexual function is largely unaltered in colitis treated by colectomy and ileorectal anastomosis. There is an argument in familial adenomatous polyposis for avoiding an initial ileal pouch anal anastomosis because of poor physical function in some instances as well as compromised fertility and sexual function. Consequently, some authors advocate ileorectal anastomosis as a firststep procedure, and postponing the ileal pouch anal anastomosis until they are in a long-term relationship. This is often expressed as the fecundability or the probability to conceive in a specific time period. In familial adenomatous polyposis, the fecundability is unchanged after an ileorectal anastomosis compared with that of the general population, whilst it drops to 0. The same findings were seen after ileal pouch anal anastomosis in ulcerative colitis females, where the fecundability dropped to 0. These factors will be influenced by any on-going inflammation in the rectum or pouch, the volume and compliance of the rectum or the pouch, the sphincter function, as well as the sensory function of the anal canal. In the case of ileorectal anastomoses, recurrent proctitis will cause a similar functional disturbance. In proctitis, refractory to medical therapy, patients are far better off with a diversionary stoma or proctectomy with ileal pouch anal anastomosis. Most of the comparative studies between ileorectal anastomosis and ileal pouch anal anastomoses are in familial adenomatous polyposis. These data on function are not comparable with those in ulcerative Summary 1285 colitis, because proctitis is effectively non-existent after ileorectal anastomosis in familial adenomatous polyposis. Despite this there is not a great difference for the two operations for the different pathologies. Apart from a lower frequency of bowel movements after ileorectal anastomosis compared to ileal pouch anal anastomosis, there was also a lower incidence of leakages, the need for a protective pad, the capability of distinguishing gas from stool as well as need for dietary restrictions in ileorectal anastomosis than after ileal pouch anal anastomosis. In patients with ulcerative colitis, there is less data, but in a report from Gothenburg, soiling or a need of protective pads was reported in 11% of patients with an ileorectal anastomosis compared with 28% to 34% if they had an ileal pouch anal anastomosis. On the other hand, urgency was more common amongst those with ileorectal anastomosis, being 33%, compared with only 16% in ileal pouch anal anastomosis patients from the same unit. The latest report from Sweden patients with ileorectal anastomosis (n = 89) reported significantly less bowel movements in comparison with patients with ileal pouch anal anastomosis (n = 108). By contrast, a lower frequency and soiling are the advantages of ileorectal anastomosis compared with restorative proctocolectomy with an ileal pouch anal anastomosis. As medications have different advantages and disadvantages, so have surgical reconstructive methods after a colectomy. Patients also have different expectations and demands as well as worries when counselled after a subtotal colectomy. A trial to compare ileorectal anastomosis with ileal pouch anal anastomosis as primary treatment failed to recruit, because patients had different expectations of each after appropriate counselling. In Sweden, ileorectal anastomosis is used almost as frequently as ileal pouch anal anastomosis in ulcerative colitis, but this would not be the case in most other countries where pouch surgery would be preferred. Sometimes, this is chosen as a temporary solution to preserve fecundity and sexual function before pouch surgery. Some patients with a late onset disease and/or a short history of colitis might also be suitable candidates for ileorectal anastomosis as a more permanent solution. The use of ileorectal anastomosis to complement ileal pouch anal anastomosis and continent ileostomy increase the choices for ulcerative colitis patients who wish an alternative to an end ileostomy after subtotal colectomy. Patients should be carefully counselled about the advantages as well as the limitations of the available options before a joint decision is made between the patient and the surgeon regarding the optimum reconstructive procedure. There is a clear short-term role for subtotal colectomy and ileorectal anastomosis in selected cases with inflammatory bowel disease. It is being promoted as an alternative to subtotal colectomy and ileostomy alone for ulcerative colitis when patients wish to avoid a stoma and in women who fear they may become infertile after pouch surgery. However, if this option is used, surveillance of the rectal stump, especially if for any reason the rectal stump is no longer in the faecal stream is mandatory. Hopefully, currently ongoing trials will answer part of these questions in the near future. Probability, rate and timing of reconstructive surgery following colectomy for inflammatory bowel disease in Sweden: A population-based cohort study. Appendicitis, mesenteric lymphadenitis, and subsequent risk of ulcerative colitis: Cohort studies in Sweden and Denmark. The effect of appendectomy on the course of ulcerative colitis: A systematic review. Decreasing colectomy rates for ulcerative colitis: A population-based time trend study. Increased experience and surgical technique lead to improved outcome after ileal pouch-anal anastomosis: A population-based study. Results and complications after ileal pouch anal anastomosis: A metaanalysis of 43 observational studies comprising 9,317 patients. The place for colectomy and ileorectal anastomosis: A valid surgical option for ulcerative colitis Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Use of topical rectal therapy to preserve the rectum in surgery of ulcerative colitis. Ileal pouch anal anastomosis: analysis of outcome and quality of life in 3707 patients. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Fate of the rectum after colectomy with ileorectal anastomosis in ulcerative colitis. The fate of reconstructive surgery following colectomy for inflammatory bowel disease in Sweden: A populationbased cohort study. Primary and secondary restorative proctocolectomy for familial adenomatous polyposis: Complications and long-term bowel function. A comparison of adverse events and functional outcomes after restorative proctocolectomy for familial adenomatous polyposis and ulcerative colitis. Risk factors for colorectal cancer in patients with ulcerative colitis: A casecontrol study. Cancer prevention in inflammatory bowel disease and the chemoprophylactic potential of 5-aminosalicylic acid. Cancer of the rectum following colectomy and ileorectal anastomosis for ulcerative colitis. The risk of cancer following colectomy and ileorectal anastomosis of extensive mucosal ulcerative colitis. Long-term results of ileorectal anastomosis in ulcerative colitis in Stockholm County. Impact of familial adenomatous polyposis on young adults: Quality of life outcomes. Long-term results after restorative proctocolectomy with ileal pouch-anal anastomosis at a young age. Sexual function, body image, and quality of life after laparoscopic and open ileal pouch-anal anastomosis. Sexual functions in adulthood after restorative proctocolectomy for paediatric onset ulcerative colitis. Sexuality in patients with ulcerative colitis before and after restorative proctocolectomy: A prospective study. Ulcerative colitis: Female fecundity before diagnosis, during disease, and after surgery compared with a population sample. Impact of ileal pouch-anal anastomosis on female fertility: Metaanalysis and systematic review. Gynaecological and sexual function related to anatomical changes in the female pelvis after restorative proctocolectomy. A total laparoscopic approach reduces the infertility rate after ileal pouch-anal anastomosis: A 2-center study. Pouch size: the important functional determinant after restorative proctocolectomy. Ileorectal anastomosis and proctocolectomy with end ileostomy for ulcerative colitis. Update of complications and functional outcome of the ileo-pouch anal anastomosis: Overview of evidence and meta-analysis of 96 observational studies. Comparative clinical results of ileal-pouch anal anastomosis and ileorectal anastomosis in ulcerative colitis.

It is also important to fix the catheter as central as possible in the stoma opening so that no undue pressure on the bowel wall medicine to help you sleep generic 5mg oxytrol overnight delivery. A gauze roll is placed under the catheter curve medicine evolution cheap 5mg oxytrol otc, and it is firmly fixed with additional strips of adhesive tape medicine dictionary purchase oxytrol 5mg without prescription. The patient symptoms 2 weeks after conception order generic oxytrol on-line, especially the nursing staff and the surgeon symptoms depression discount oxytrol 5 mg online, has to be aware that due to the intussusception of the bowel wall as well as the relative narrow stoma opening medicine for pink eye 2.5mg oxytrol otc, the mucosa of the bowel might show itself as deep purple as a result relative ischaemia and/or high venous pressure, which is normal. After some 20 years or more experience with pelvic pouch surgery, the authors see a failure rate approaching at least 15% in unselected cases. Also, when a pouch fails, there is the question as to whether the pouch needs to be excised or not. Pouch excision carries a morbidity; hence, leaving a disconnected pouch may be a valid alternative. If the patient is interested in a conversion, this implies that the pouch is dissected free in the pelvis and either a transanal mucosectomy is performed or the entire anus is removed including resection of the anastomosis. Surprisingly, often the pouch can be dissected free without damage even when the indication is for previous septic complications. If the lower part of the pouch is badly torn, this does not automatically necessitate pouch excision. The sutures are then drawn up through the stoma hole and stitched to the anterior abdominal wall fascia and/or rectal muscle. After the pouch outlet has been pulled through the abdominal wall, these sutures are tied. Alternatively, the two lateral sutures are tied before pulling through the outlet. On the inner medial side, another four to six interrupted stiches are placed from the pouch wall to the inside of the anterior abdominal wall. This is most important on the upper aspect since gravity will tend to exert the biggest strains on the 1310 Chapter 69 Continent Ileostomy in Colitis 69. However, this is not always mandatory, and in some reported pouch conversions, the original pouch is not used at all. When the nipple valve stapling is complete, the anterior pouch walls are sewn together. The difference is that the converted pelvic pouches may have a different geometry and appearance. The converted (or new constructed pouch) has the same complications as those reported for continent pouches in general. A summary of the experience with this operation from the literature shows a modest failure rate (Table 69. The patients who agree to conversion should be highly motivated and aware of the risk of reoperations due to nipple valve dysfunction and major pelvic surgery. Taking out a pouch from the pelvis carries a risk of sexual and urinary dysfunction due to nerve injuries during a difficult dissection. Furthermore, in females, the loss of posterior support to the vagina may result in dyspareunia and vaginal discharge. Adhesions might result in fertility problem due to occlusion of the fallopian tubes. On the other hand, a well-functioning continent ileostomy will provide a better quality of life compared to poorly functioning pelvic pouch. The draining system should be repeatedly flushed every four hours after surgery with 30 to 50 cc water (tap water is used) so the bowel contents should freely drain. The exceptions are patients with chronic or recurrent pouchitis and those operated for familial adenomatous polyposis. For this, a small diameter flexible endoscope has to be used, either a paediatric colonoscope or a gastroscope, since the stoma and nipple valve will usually be no wider than 10 to 11 mm. In a well-functioning pouch, it should be quite straightforward to pass the scope through the valve, but it is probably wise always to do this under visual inspection. When the endoscope is inserted through the valve of the continent ileostomy, air is insufflated by deflecting the scope as much as possible (180 degrees) and gently rotating it. The small bowel inlet to the pouch is situated 3 to 5 cm from the nipple base and can usually be entered from the pouch. It is wise to measure the distance from the apex of the nipple valve to the skin surface. Depending on the amount of subcutaneous fat, this distance is usually somewhere between 6 to 12 cm. In patients who experience nipple valve slippage, the distance will be shorter (see below). If endoscopy is difficult or does not fully define the anatomy of the pouch, a radiological investigation by retrograde barium double contrast through the pouch catheter may further elucidate the problem. To further minimise the risk of blockage, patients should be given a diet that does not contain items that are known to cause problems, such as vegetables, nuts, coco, corn, mushrooms, etc. The anchoring stiches to the catheter are removed on the post-operative day 4 to 6, and the catheter is now kept in place with tape. After two weeks of continuous pouch drainage, the routine of intermittent emptying is commenced whilst keeping the drainage catheter in the pouch. The catheter is then removed every two hours, and the pouch is gently flushed and emptied. Emptying is gradually increased to four-hour intervals and perhaps a bit longer during the night. Patients usually stay in the hospital for much less time now; consequently, outpatient supervision by the nursing staff is crucial. After two weeks, the catheter plug is removed, and the patient is taught to intubate. Gradually, over the next few weeks, they can extend the time between catheterisations, but they must empty at least every six hours. Some patients have rather solid or sticky bowel contents and will need to flush the pouch with tap water to ensure satisfactory emptying more frequently. If patients are properly cared for, as described above, complications after a continent ileostomy construction do not differ from those experienced after any major abdominal operation. Localised post-operative abscesses are usually resolved with radiologically assisted percutaneous drainage. As mentioned before, relative ischaemia of the nipple valve is frequent and is often seen during the operation, especially if one of the longitudinal stapler lines interferes with the mesentery. One should not be overly worried about this, because in the majority of cases, circulation will improve, and the ischaemic mucosa will recover. A well-functioning pouch with no leakage will give the patient an excellent health-related quality of life. A specially designed gauze pad with an adhesive cover is used between catheterisations. Follow-up with respect to malignancy in the pouch is not necessary since 1312 Chapter 69 Continent Ileostomy in Colitis even think there is an advantage because the intussuscepted bowel will give fibrosis and become more stable. Prolonged post-operative ileus is a common complication; usually, a watchful conservative plan should be followed. Peritonitis or other signs of a serious intra-abdominal event are an indication for a relaparotomy. However, one should be aware that reoperations at this early stage can be difficult due to aggressive adhesions, making it difficult to separate bowels without inflicting damage. Such reoperations are frequently the start of a spiral of trouble with further bowel injury, organ failure, critical illness, abdominal wall problems and other serious sequelae. Pouchitis can affect the continent ileostomy to the same extent as the ileal pouch anal anastomosis. Instead, the patient will note watery and even blood-stained ileostomy effluent, with increased volumes and need for more frequent emptying of the pouch. Furthermore, there may also be a feeling of general malaise and perhaps some fever. In recurrent or chronic pouchitis, biopsies will be indicated to monitor for dysplasia. The pathologist may have difficulty interpreting dysplasia in the presence of inflammation. The treatment of pouchitis is exactly as for pelvic pouches, the difference being that continent ileostomies lend themselves better to local therapies whilst oral administration is also an option. However, there is no evidence to support the efficacy of this after continent ileostomies. Malabsorption and mineral deficiencies due to the pouch are rarely a problem, with the exception that a few patients may develop vitamin-B12 deficiency. Patients who have had previous bowel resections or revisions should be carefully monitored for B12 and other deficiencies. Since the knowledge of the continent ileostomy is diminishing and as there is a growing population of elderly patients with a continent ileostomy, a patient may present to a hospital or another institution unable to communicate that their stoma is continent. As a result of this not recognised system, prolonged bowel obstruction with higher pressure on the pouch and nipple valve can occur. It is nearly always associated with pouchitis and should resolve with catheter drainage and metronidazole therapy. Occasionally, bleeding may be traumatic, caused by instrumentation, in which case it may be necessary to leave the catheter for a couple of days to allow any injury to heal. As a result of bad eating habits or insufficient information on intake, people can ingest fruits or food particles, which, apart from being a causative factor for obstruction, can impair emptying due to blockage of the catheter. Furthermore, if such particles are not drained from the pouch, they may form enteroliths, which may overtime become quite sizeable. Clear mucous fluid leakage has nothing to do with valve dysfunction since it arises from the exit conduit. Complications Requiring Surgical Intervention There are a number of complications requiring surgical intervention. Skin level stricture the most benign is a skin level stricture at the stoma, which can be dealt by excising the stricture and fashioning a wider skin opening whilst taking care to preserve as much bowel as possible. After having mobilised the bowel down towards the fascia, it can be re-sutured to the new wider skin opening. Bearing this possible complication in mind, when constructing the pouch, one should not put tension on the bowel outlet. It is better to have a bit of excess bowel, which will make an operation for a skin stricture much easier. Sometimes, this inflammation will not respond to pharmacological therapies and develop into a fibrostenotic segment. Resection is a good option in these cases provided the continent ileostomy is well functioning and there is absolutely no indication for pouch removal. Pouch perforation Pouch perforation following intubation is a rare but potentially fatal complication. Perforation usually Late Problems 1313 occurs when the patient is at home, so there may be considerable delay in seeking surgical advice. This is usually associated with the pouch becoming loose from the anterior abdominal wall. The patient will report that the stoma has become incontinent and there is difficulty intubating the pouch. The aetiology of this might be either a misplaced suture or trauma upon intubating the pouch. This is often the result of a too wide an opening or from forceful catheterisation. Nipple valve slippage can present as an emergency ward, because the patient is unable to intubate and empty the pouch. In this situation, the patient is best taken to the endoscopy suite, and a flexible scope is used to enter the pouch. Sometimes, one has to resort to very thin endoscopes to be able to enter the pouch. It has even happened that surgeons have resorted to an acute laparotomy, which, in our experience, is hardly ever necessary. It is necessary to take down the pouch and outlet from the abdominal wall preserving it as intact as possible. It is sometimes possible to do local procedures for a desuscepted nipple valve or for the floppy incontinent valves. For the desuscepted valve, an enterotomy can be made to gain access, the valve can be grasped with tissue forceps or sutures so as to desuscept it again and restaple the valve, avoiding the mesentery. For the floppy incontinent valve, the redundant antimesenteric component can be stapled against a valve catheter. In most instances, the slipped valve can be invaginated and reinforced with additional longitudinal stapler rows, followed by meticulous suturing at the outer circumference of the nipple base, and a good fixation to the anterior abdominal wall. Alternatively, when the quality or length of the slipped valve is insufficient, a new valve can be constructed using 15 cm of ileum entering the pouch. The inlet bowel is transected after division of the mesentery from the bowel attachment reaching about 7 to 10 cm towards the mesenteric root. As in primary nipple valve construction, the mesentery of the first 10 cm leading into the pouch is stripped of its peritoneum and excess fat. The pouch is then rotated 180 degrees, and the proximal bowel end is sutured to the pouch at the site of the original excised valve. In these operations, the proximal bowel used for construction of the new nipple valve is often quite wide, 69 69. The mesentery of the first 10 of 15 cm, leading into the pouch, is stripped of its peritoneum and excess fat. As a consequence, the new valve may be a bit floppy and not perfectly continent upon testing. However, this will usually have no influence on the final outcome, as the nipple valve will, with time, adapt to a normal size.

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