Continent Fecal Diversion

Question 1

Criteria & contraindications for fecal diversions

Answer 1

Criteria:
1. Pt is motivated and reliable
2. Disease limited to colon (not for crohn’s patient d/t preserving bowel, prevention of short gut syndrome r/t flare up of disease)
3. APR w/ end ileostomy (UC or FAP) - covert to Koch Pouch
PP: nipple value dysfunction

Question 2

Basic postopcare & longterm care for pt w/ Koch Pouch/BCIR; usual interval for intubation longterm; signs/symptoms & management of pt w/ pouchitis, as well as preventative strategies; importance of medical alert bracelet

Answer 2

Continent Ileostomy:
Koch Fecal pouch 45-50 cm of distal ileum (does not require Vit B12 replacement)
Postop: prevention of pouch distension
intubated 1-2hr then advance to QID & pen
expand pouch capacity 50-500cc

thick drainage: thin via increased fluids (prune/grape juice), instill air/water, leave for 24-48 hours then retry, chronic issue (Miralax)
Longterm intubation QID + prn

Pouchitis: itching, tenderness, cramping, malaise frequency & fullness, inflammation to fecal reservoir, increased mucosal discharge, can be related to sclerosis cholangitis

Prevention: irrigation, hydration, probiotics (VSL-3)
Treatment: Clear fluids, 1-2x/daily irrigation (controversial), antibiotics (Flagyl or Cipro), increased fluid intake, avoid insoluble fibers, NO pericardia XL (wax shells)

Medical alert bracelet IMPORTANT (eg. decreased LOC), sepsis can occur if bladder not emptied, carry #28-34 FR catheter at all time

Question 3

Surgical Procedures involved in Stage 1 and Stage 1 or two-stage ileal-anal reservoir procedure; major issues in mgmt of patients following Stage 1 and Stage 2 of a two-stage procedure; guidelines for perianal skin care following ostomy takedown

Answer 3

Reservoir from terminal ileum, anastomosed to anorectal junction (NEORECTUM); continence from anal sphincter
Stool thick & mushy like ileostomy r/t enzymes
freq BM 4-6x/day
Pt: motivated, slender, good anorectal function

One Stage: Pts NOT on steroid/good health (eg. FAP) colectomy, subtotal proctectomy, stripping mucosa from rectal stump (creating reservoir, direct anastomosis to rectal stump; better outcomes

Two Stage:
Stage I - colectomy, subtotal protectomy, stripped mucosa from rectal stump, PROXIMAL diverting ileostomy (usually loop)
Stage II - Ileostomy takedown

Three Stage: For very ill pts, obese/can’t loose weight, steroid dependency, can be done later by surgeon qualified for continent procedures.
Stage I - subtotal colectomy, Hartman’s pouch, Brook ileostomy
Stage II - subtotal protectomy, stripping mucosa from rectal stump, creation of reservoir, anastomosis of reservoir to rectal stump
Stage III - Ileostomy takedown

Perianal skin care: potential diarrhea & leakage x 6 months after ileostomy takedown, no anal intercourse
sphincter exercises once ileal-anal suture line healed

Prevention skin breakdown:
1. dimethicone
2. perianal absorptive pads (anorectal drsg)
3. white cotton underwear
4. unscented white toilet paper
Perianal skin breakdown: thicken stool/prevent leakage
skin protective paste (Criticaid)

Diarrhea:
low roughage (insoluble fiber), low fat - soluble fibers wick up H20
1. Bulking agents (Metamucil 1-2 tsp/each meal)
2. Antimotility agent (loperamide - enhances sphincter tone)
3. Sphincter exercises & relaxation/deep breathing to delay defactation (increase reservoir from 50 to 500 cc)
Improved within 6 months r/t:
increase reservoir capacity
bowel adapts/increased sphincter tone
meds
dietary modifications

LONGTERM 3-6 stools/day

Pouchitis:
Flagyl
Steroid enemas
Cipro
Probiotic VSL-3
dietary fiber