Practical strategies for treating postsurgical bowel dysfunction.

Postsurgical bowel dysfunction is a potential complication for patients undergoing ileoanal anastomosis, restorative proctocolectomy, and low anterior anastomosis. In our setting, these patients are referred to the Anorectal Physiology Clinic at the Townsville Hospital, Queensland, for comprehensive behavioral therapy. The goals of the therapy are as follows: improve stool consistency, improve control over stool elimination, decrease fecal frequency and rectal urgency, fecal continence without excessive restrictions on food and fluid intake, and increase quality of life. This article outlines our holistic approach and specific treatment strategies, including assessment, education, support and assistance with coping, individualized dietary and fluid modifications, medications, and exercise. Biofeedback is used to help patients improve anal sphincter and pelvic floor muscle function and bowel elimination habits. Information on the biofeedback component of the treatment program will be described in a subsequent article.

A phenomenological study of the postoperative experiences of patients undergoing surgery for colorectal cancer.

PURPOSE: This study was designed to investigate patients' experience during the postoperative phase of recovery following colorectal resection with end-to-end anastomosis. METHOD AND SAMPLE: This was a descriptive phenomenological study reliant upon individual interviews. The sample was purposefully drawn from those admitted for surgery. Interviews continued until no new data could be identified from the transcripts. KEY RESULTS: After initial relief that surgery was over, the experience was dominated by 'tubes and drains', the consequences of epidural anaesthesia and ongoing pain relief. Themes encompassed loss of dignity and control, inability to eat and drink and lack of sleep. Some found it embarrassing discussing and coping with intimate bowel issues in a communal environment, particularly in mixed sex wards. Patients' emotional state initially reflected their physical condition rather than their disease; as independence was regained, awareness that they were suffering from cancer recurred and was associated with fear and anxiety. Variations in requirements for information were evident indicating that communication does not always equate with understanding. Participants passed through a stage of complete dependence to a degree of renewed independence at discharge, which was itself associated with mixed emotions. For some, there was relief while others were anxious about leaving the 'safety' of the hospital environment. CONCLUSIONS: These findings provide considerable insight into the experience of colorectal surgery and so can make a significant contribution to the planning and delivery of care; they have the potential to impact on the care received by those with colorectal cancer.

Ileoanal pouch dysfunction and the use of a Medena catheter following hospital discharge.

With the advent of new surgical techniques to manage colorectal disease, the number of ileoanal pouch operations has amplified and therefore increased numbers of pouch patients are being discharged into the community setting. Community nurses will now encounter the ileoanal pouch patient and may be required to manage related complications. Restorative proctocolectomy with ileoanal pouch anastomosis (RPC) has become established as the gold standard operation for patients with ulcerative colitis (UC) and selected patients with familial adenomatous polyposis (FAP). Using a reservoir constructed from small bowel as a substitute rectum is a medical triumph which in the majority of cases improves the quality of life for patients, not only by eradicating disease and preserving anal sphincter function but also by avoiding a permanent ileostomy. Recent investigation into the use of Medena catheterization for pouch dysfunction has found that it is tolerated in the long-term and is associated with satisfactory quality of life in pouch patients with outflow obstruction.

Recommended follow-up for ileo-anal pouch patient.

One of the greatest advances in colorectal surgery over the past 30-years has been the development of restorative proctocolectomy with ileal pouch-anal anastomosis for patients suffering with ulcerative colitis and selected patients with familial adenomatous polyposis. This has coincided with a proliferation of new and exciting advanced clinical roles for nurses in the United Kingdom and subsequently has led to an increase in the responsibilities and professional status of nurses. Staff development is necessary to maintain the unique contribution that nurses make to health care in the terms of practice, education and research. Nurse specialists in gastroenterology are taking their place alongside medical specialists, and more importantly establishing themselves as the principle carer in many diverse roles. However, as these nursing roles expand, a recognized framework needs to be designed, which takes into account the educational, ethical and legal issues related to accountability of running nurse-led clinics, offering support, advice and follow-up for patients. This article provides nursing staff with research-based recommendations and practical guidance on running a successful nurse-led pouch clinic and follow-up service in collaboration with the consultant surgeon, gastroenterology teams and nursing staff involved specifically with the ileo-anal pouch patient.

Creating the evidence base: the journey from practice to research.

The ability to deliver accurate, evidence-based information when helping patients make decisions about their care is fundamental to the role of the clinical nurse specialist. For patients with ulcerative colitis who are considering surgery to form an ileo-anal pouch, it is essential to give them information about the psychosocial, as well as the physical, effects of such surgery. As many of these patients are of working age, understanding the likely consequences for paid employment is a priority. However, very little evidence is available on this subject. The authors therefore decided to develop a research study aimed at filling this gap. A proposal to conduct a phenomenological study into the subsequent employment experiences of patients who have undergone ileo-anal pouch formation has been developed. This article seeks to explore how the research idea and its methodology stemmed from practice and highlights the importance of seeing research and practice as complementary components of good nursing care.

Robotic-assisted laparoscopic cystectomy with ileal conduit for urinary diversion.

This case demonstrates the need for flexibility when approaching major abdominal surgery through a robotic approach. While the case was initiated with robotic technology, it ultimately had to be converted to an open procedure for reasons of patient safety and to ensure a good surgical outcome.

Preparing for loop ileostomy surgery: women's accounts from a qualitative study.

Restorative proctocolectomy has become increasingly the surgical treatment of choice for ulcerative colitis and familial adenomatous polyposis since its inception in 1978 [Parks and Nicholls, 1978. British Medical Journal 2(6130), 85-88]. As Keighley, Grobler and Bain [1993. Gut 34(6), 680-684] point out it not only eradicates disease, it preserves the anal sphincter, so enabling patients to void normally. However, for many patients surgery takes place in stages, with the formation of a loop ileostomy as the first stage. As its use increases, so more nurses (both specialist and general trained) will be involved in providing ongoing care and support both pre and post operatively. Although research is available regarding surgery, ileo-anal pouch formation and function together with possible complications, little is known about the immediate post operative period. This paper reports a study of female patients' accounts of their preparation for, and experiences of such surgery. It was part of a larger study into the quality of life of women following restorative proctocolectomy [Notter, 2002. The Quality of Life of Women Following Restorative Proctocolectomy]. A total of 50 women participated in this study, which used descriptive phenomenology to explore their lived experiences. The surgery proved to be a pivotal period in their lives, with surgery the dream of full recovery had gone. The findings reveal a traumatic time with memories dominated by the issues of pain, the changes to their body and in most cases problems with the loop ileostomy. Most were left with a determination to maintain the pouch at all costs. This study identifies major implications for nurse education and training, regarding all aspects of care during this critical time. Findings show the immense and long lasting impact this type of surgery can have on quality of life.

Development of a nurse-led ileo-anal pouch clinic.

The ileo-anal pouch procedure is now seen as the operation of choice for individuals suffering with ulcerative colitis or familial adenomatous polyposis (Fazio, 1999); however, patient follow-up after this surgery remains variable. This article highlights the effectiveness of running a nurse-led follow-up service. A patient satisfaction survey has shown that having a familiar face at each follow-up visit is hugely beneficial, providing continuity and reassurance for patients and their relatives. This nurse-led clinic provides adequate time for patients to discuss a variety of issues including management of sore perianal skin and pouch dysfunction. The growth and development in clinical skills, knowledge and nursing autonomy has seen the emergence of many nurse-led clinics, where nurses are utilizing their advanced skills. Within the nurse-led ileo-anal pouch clinic in Oxford, physical and/or internal examination, and investigations, such as rigid or flexible pouchoscopy, are performed. Such procedures were positively evaluated by patients.

Continent diversions: the new gold standards of ileoanal reservoir and neobladder.

In recent decades, surgical treatment of familial adenomatous polyposis, chronic ulcerative colitis, and muscle-invasive bladder cancer has undergone a revolution. Specifically, ileoanal reservoir and neobladder have become the new "gold standard" of definitive surgical therapy for these disorders. This article discusses issues in surgical construction, indications, contraindications, perioperative care concepts, and nursing and health professional implications related to these two procedures. These interventions include screening candidates for ileoanal reservoir or neobladder to rule out Crohn's disease or metastatic cancer and educating candidates for continent diversions about the proposed procedure(s) and associated events, potential complications, postoperative exercise, sexual health and function issues, and the benefits of support group participation so they can gain a realistic understanding of ultimate functional outcomes. Questions for future research are addressed.

Ulcerative colitis--diagnosis and surgical treatment.

Ulcerative colitis is a serious illness affecting the colon. Extracolonic manifestations include sclerosing cholangitis, arthritis, eye diseases, ankylosing spondylitis, and sacroiliitis. Ulcerative colitis may increase a patient's risk of cancer, depending on the duration and extent of the disease. Surgery is the only definitive way to remove the disease in its entirety. It may be possible for patients who do not wish to have a permanent stoma to undergo a restorative proctocolectomy with ileal pouch-anal anastomosis. Normal bowel physiology, pathophysiology of ulcerative colitis, medical and surgical treatments, and postoperative complications are discussed.

The ileal pouch anal anastomosis: past, present, and future.

The modern era of ileal pouch anal anastomosis began just over 20 years ago. Several areas remain controversial, including patient selection, surgical technique, use of a temporary diverting ileostomy, aging sphincters, complications, and postoperative management. This article reviews current controversies concerning ileal pouch anal anastomoses and our approach to managing patients who undergo this complicated procedure.

Caring for patients with coloanal reservoirs for rectal cancer.

Advances in surgical techniques enable select patients with rectal cancer to have sphincter-saving procedures that restore the continuity of the GI tract, eliminating the need for a permanent colostomy. One of the preferred surgical options is the construction of a coloanal reservoir or colonic J-pouch. This procedure is usually performed in two stages (two surgeries) and involves creating a temporary ileostomy. Patients undergoing treatment for rectal cancer frequently require adjunctive therapy for the disease before and after surgery. They require extensive education and support during the course of treatment and through rehabilitation.

The lived experience of having an ileoanal reservoir: a phenomenologic study.

OBJECTIVE: Ileoanal reservoir (IAR) surgery or ileal pouch anal anastomosis is a relatively new surgical technique for people with ulcerative colitis or familial adenomatous polyposis. Little attention has been given to the experiences of people undergoing the procedure. The purpose of this qualitative study was to understand the lived experience of persons who have had construction of an IAR. DESIGN: The study was grounded in the phenomenologic approach of Van Manen to capture the lived experience of having an IAR as perceived by those persons in their everyday world. SETTING AND SUBJECTS: A purposive sample of 10 individuals with direct and personal knowledge of the experience were interviewed in detail. Subjects were recruited by contact with an IAR support group and a local WOCN group. All interviews were conducted in a private setting in a health care facility, school, or the participant's home. METHODS: Data collection involved face-to-face interviews lasting from 1 to 2 hours. Interviews were audiotaped and transcribed. MAIN OUTCOME MEASURES: Demographic data from the interviews were tabulated. Analyses of transcripts revealed 10 essential thematic categories with multiple theme clusters of the IAR experience related to lived body, time, space, and relationships. Analyses were completed by the researcher and a faculty mentor. RESULTS: The particular thematic categories that evolved from the data were (1) restricted life world, (2) living with uncertainty and fear, (3) seeking control, (4) vicious cycles: crisis and normalcy, (5) seeking and giving support, (6) alienation from the body, (7) living with bodily alterations, (8) the gift of time, (9) role and relationship changes, and (10) the end of the tunnel but relative results. All 10 theme categories were correlated with a literature review and other sources. CONCLUSION: The study provides a portrait of courage and survival for individuals experiencing major surgical interventions and bodily invasion associated with IAR after years of living with UC. Implications for nurses and health care personnel and questions for future research are presented.

Ileoanal procedures: acute and long-term management issues.

The pelvic pouch procedure has become the preferred surgical treatment for patients with ulcerative colitis and familial adenomatous polyposis. Even though this operation removes the diseased colon and allows defecation through the anus, the outcome is not "perfect." Rather, ongoing management issues occur that require attention. This article reviews acute and chronic management issues related to the creation and management of the pelvic pouch.