12. Ileostomy in Adults - Indications and Surgical Construction

In this class, we're going to discuss Iliastomy and adults with a focus on indications and surgical construction. We'll talk about surgical indications for the creation of a temporary or permanent Iliastomy. We'll also talk about disease processes that may result in an Iliastomy. And we will have a particular focus on inflammatory bowel disease and the implications for Iliostomy creation. So we're going to start by talking about surgical indications. We have mentioned in previous classes that an Iliostomy, a temporary Iliostomy, may be required to protect a distal inastomosis when there are concerns about delayed healing. And we've specifically mentioned the fact that patients with comorbid conditions, like poorly controlled diabetes, in stage renal disease, in stage liver disease, are high risk for impaired healing, as are individuals on steroids at the time of surgery. So patients who require intestinal resection and anastomosis in situations where there are concerns about delayed healing frequently benefit from a temporary diverting Iliostomy to provide a detour and protection of that distal inastomosis until healing is complete. Temporarily, Iliostomy may also be done when the surgeon has concerns about tension on the anastomosis if they had to really work to pull the two ends of the bowel together. They know that that anastomosis is going to require more time to heal. That that anastomosis is at higher risk for breakdown. They will protect that anastomosis with a proximal diverting Iliostomy. And finally, anytime you are doing bowel resection and anastomosis in the presence of significant intra-abdominal infection, that anastomotic line is high risk for delayed healing and for anastomotic breakdown. Almost always when an anastomosis is done in the presence of significant intra-abdominal contamination, a proximal diverting Iliostomy will be done as well to protect that anastomosis. To summarize, anytime you have an intestinal anastomosis that is going to require more time to heal and that is at risk for breakdown, the standard is to protect that anastomosis with a proximal diverting Iliostomy. So look at the slide on bottom, the illustration on bottom. This is what is typically done, a diverting loop Iliostomy. So typically the Ilium is just pulled out in a loop construction. The anterior wall is opened, this provides temporary diversion as we frequently explain to patients it acts like a detour. It detours the stool until that distal anastomosis is healed and then it can be taken down. Take down is typically three to six months following the original surgery. Another reason for temporary Iliostomy is to protect a pelvic reservoir. Now I'm going to go over this very briefly. You need to know that we'll discuss this in great detail in a future class. But in selected patients who require removal of the colon and removal of the rectum, a decision is made to create a pelvic reservoir. A pelvic reservoir can be constructed by looping the small bowel back on itself to form a reservoir and connecting that reservoir to the anal canal. In most situations where this might be done is a very complex procedure. Many times the patient is on steroids when this process is initiated. And as a result, a temporary Iliostomy is typically done during the initial stages of pelvic reservoir construction to provide a temporary detour to protect that pelvic reservoir until it is well healed and ready for business. During stage one of a three stage procedure we usually see an end Iliostomy as you see in the illustration to the left. During stage two of a three stage procedure we typically see a loop Iliostomy. Again, we don't want you to spend too much time on this. We just want you to realize that a temporary Iliostomy may be indicated when you have a newly constructed reservoir in the pelvis. Just to divert the stool away from that reservoir until it has time to heal. All the rest will cover in a later class. There are also a number of disease processes that may result in Iliostomy. The first few that we're going to discuss are pretty rare, so you may or may not see patients with this. The first one is familial adenomitus polyposis, FAP. This is a genetic disorder, it's autosomal dominant, which means that each pregnancy carries a 50% risk of transmission. And what is happening is you get mutation of the tumor suppressor gene. As a result, typically beginning and adolescence or early adulthood, individuals develop thousands of polyps in the colon and rectum. You'll see in a later slide that the colon and the rectum can be literally carpeted with polyps. Now you know that any individual polyp can deteriorate into a malignancy. And when you have hundreds to thousands of polyps, just the sheer number, means that some of those polyps are going to progress to a malignancy. As a result, individuals with familial adenomitus polyposis carry essentially a 100% risk or guarantee that they will develop colorectal cancer if the colon and the rectum are left in place. The main age of development is 39 years. But some people develop colorectal cancer in their late teens or their 20s. So 39's median, but remember some people develop it at a much earlier point. So when we think about familial adenomitus polyposis, as ostomy nurses, we tend to think primarily about what's happening at the level of the colon, what's happening at the level of the rectum. And that's very important because that's where we get the colorectal cancer. But people with FAP are also at risk for extra intestinal malignancies. They can get megaloblastomas, so CNS malignancies, they can get thyroid cancer, they can develop duodenal malignancies. In addition, they can develop nonmalignant lesions. We know they have polyps, but they can also develop desmoid tumors. Now, you may or may not be familiar with desmoid tumors. They are not malignant in that they do not metastasize. But they can be very difficult to treat because these tumors are almost like scar tissue. They're fibromatous lesions that can cause significant interference with local structures, with local organ function. So even though they're nonmalignant, they can have very significant pathologic effects. So familial and nomadous polyposis, a very difficult condition to treat. Now, known carrier should undergo sigmoidoscopy or colonoscopy beginning at 10 to 12 years of age. Typically, the recommendation is that they undergo sigmoidoscopy or colonoscopy every two to three years until polyps begin to develop. Once polyps are seen, they should undergo colonoscopy every year. Now, I want you to focus on the illustration on the top right. This is a specimen remodeling. moved from someone with familial adenomitus polyposis and opened up so that we can see the inside. And I want you to appreciate the fact that literally this colon is carpeted with polyps. So a lot of patients will say, well, can't you just take out the polyps or can't you take out any polyps that looks suspicious? But when you look at that illustration, you're like, no. There's-- we're talking thousands. There's too many, it's too high risk. So back to screening. Upper GI screening, thyroid screening should be completed as well. So individuals with FAP should have not only colonoscopy, but upper GI endoscopy and thyroid screening. Genetic counseling is critical because these individuals are all of child-bearing age. And they need to know that every single pregnancy, there's a 50% risk that this infant will be born with the FAPG and will develop all of these polyps. So how do we manage? Well, there's no medication that's going to eradicate all of those polyps. So management is essentially surgical. It's procto-collectomy, remove the colon, remove the rectum. Most individuals at this point undergo a continent-fegal diversion. So what they do is remove the colon, remove the rectum, use the end of the LEM, the end of the small bowel to create a reservoir. It's usually known as a J-pouch. That J-pouch is anastomose to the anal canal. So they have semi-liquid mushy stool that stored in that J-pouch. Elimination is controlled by the anal sphincter. The alternative is to take out the colon and the rectum and do a permanent ilostomy. But the vast majority of patients elect the continent diversion with the iliopouch, anal anastomosis, which we'll discuss in much greater detail later. Now, there are some additional disease processes. One is gardener syndrome. Gardener syndrome used to be considered its own disease process. Now it's considered to be a variation of familial adenomitus polyposis. It's associated with mutation of the APCG. And the APCG is the adenomitus polyposis collagen. It's proto-oncagine. So what's different about gardeners is compared to familial adenomitus polyposis? Well, again, you get the adenomitus polyps in the colon rectum. That's not different. But gardeners is also associated with development of multiple osteomas, so bony tumors. In the mandible and skull, especially, they develop epidermoid cysts. They develop soft tissue tumors. They develop those fibromas and desmoid tumors that can cause a lot of damage in terms of normal organ structure. So when you look at gardeners, it's like, well, you've got all of these lesions in the colon and rectum, but you've also got all of these tumors and growths that are outside the colon and rectum. So would surgery be indicated? Actually, medical management is usually first line. And what they've found is that insides, given along with GI protection, may be helpful in preventing progression to malignancy. Obviously, these patients will require endoscopic screening as well as dental x-rays because the tumors that grow in the mandible and the skull. Surgical management is not first line. It's not curative. It's not recommended unless there's something that cannot be managed non-surgically. So if you have an obstructing lesion, yes, then you proceed with surgery. But only with an obstructing lesion that cannot be managed otherwise. What about Putes Jaguar Syndrome? It's another rare genetic disorder, again, just like familial polyposis. It's autosomal dominant. So the polyposis syndrome is the primary finding. You have a different kind of polyps, those. These are hammer-tomatos polyps. And as you see at the bottom of the slide, these are large, pedunculated polyps. They have a central core of smooth muscle. So you can see one in the illustration on top. So where do these occur throughout the GI tract? Most commonly in the small bowel, the jigenum, but they can also occur in the stomach and they can occur in the colon. In addition, you can develop polyps in other organ systems in the bladder, in the lungs, in the nose, in the uterus, in the gallblath. One unique finding with Putes Jaguars is you get this mucocutaneous pigmentation. So look at the illustration on bottom. You see these freckles on the oral mucusa, the lips. You can see it in the eyes. You can see it in the perianal area and in the genitalia. That's not pathologically significant, but it's diagnostically significant. Because if you see this, it should be an alert to do a workup. So we should be screening these individuals beginning at about AJ, that's awfully young, but these kids should be screened every one to three years. Screening includes both upper GI and Doscopy. Remember, lesions can occur in the stomach and the jigenum, as well as colonoscopy. And we have to screen for extra intestinal malignancies and be very alert to any symptom development. In terms of management, we don't have good medical management. Surgical management is not curative. You can't take out the colon and cure them because lesions can show up in the stomach and the jigenum. We can't take out the entire GI tract without making this person TP independent, which has its own set of issues. So these patients are managed essentially symptomatically. Surgical resection is reserved for individuals who develop colorectal cancer or obstructive lesions. A pretty uncommon reason for Iliostomy is colonic inertia. And it's exactly what it says. It's a functional disorder that's characterized by a marked reduction in parasitic activity. The etiologies unclear. And some patients, it seems to be low levels of neurotransmitters. And some patients, it seems to be damaged to the ganglion cells within the bowel wall. And others, we just don't know. But we do know the end result, which is severe constipation, that does not respond well to standard therapy. Because standard therapy is all aimed at increasing parasitic activity, either through mechanical distinction of the bowel, animals, or more commonly through medications that activate parasitic pathways. But when you have low levels of neurotransmitters, when you have damage to the nerve cells within the bowel wall, then standard therapies do not work. So patients who fail to respond to pharmacologic therapy may require, collect me and Iliostomy. Sometimes they'll begin with a temporary Iliostomy to see, OK, we're going to temporarily bypass the colon, see if we get a positive result, and kind of buy some time while we hope that additional therapies come onto market. But many individuals end up with permanent Iliostomy. Now, a common question is, well, why don't you just take out the colon, since the colon is the source of the functional blockage? Why don't you take out the colon and connect the Ilium to the rectum, and then the individual doesn't have to have an estimate, but it hasn't worked well. People have done better with Iliostomy than they have done with Iliorectal inastomosis. You get still to the rectum. You've still got to get it through the anal canal, and that has continued to be a problem. So for patients with colonic inertia that does not respond to medication therapy. If they get to the point of surgery, it's usually an iliostomy. By far, the most common disease process that results in iliostomy is inflammatory bowel disease. To the extent that most of us is ostomy nurses, if we see a person with a long-term iliostomy, we tend to assume that they had inflammatory bowel disease. Of course, we should never do that. We should always go back and look. But that just tells you that inflammatory bowel disease is by far the most common disease process resulting in iliostomy. So what is it? It's a chronic inflammatory process involving the GI tract. It is characterized by a cyclic pattern of remission and recurrence. Remission and recurrence. So I'm better now I'm sick again. I'm better now I'm sick again. There are two major types of IBD. I'm sure a lot of you are aware of this. There's chronic ulcerative colitis, also known as UC and Crohn's disease. From an epidemiologic perspective, inflammatory bowel disease most commonly develops during the 10 years, 20s and 30s. So it affects young people. Now you see there's a second peak during the 40s and 50s that's frequently associated with smoking cessation and we'll get back to that. Smoking seems to be protective for patients with UC and tends to make people with Crohn's disease worse. But bottom line inflammatory bowel disease across the board primarily affects teens and young adults with a second peak involving those in their 40s and 50s. For reasons not totally understood it's much more common in industrialized countries though it does occur throughout the world. In the US, UC is slightly more prevalent than Crohn's disease. So the prevalence of UC is 214 per 100,000 Crohn's disease 174. What causes it? That's what everyone wants to know. That's certainly what the patient wants to know. What causes this? What did I do? What did I not do? What can I do to fix it? That's also the question that researchers have been trying to answer for many years. Current thinking is that etiology is probably multifactorial. We know there's a genetic predisposition and research has identified a number of genes that are involved. That genetic predisposition seems to result in an abnormal immune response to one or more environmental insults. What do we mean by environmental insults? It could be an acute gastroenteritis, an acute infection in the gut. Well, when you have an infection you get an immune response. And then if I have this genetic abnormality, my immune response may be prolonged, it may be excessive, it may not shut down. Anabotic use. Well, we know that anabotic use alters the microbiome in the gut. And if we alter the microbiome, if we alter that bacterial balance in the gut, we can trigger an immune response that is, again, excessive or prolonged. Tobacco use seems to be a trigger for individuals with Crohn's disease. But interestingly, smoking cessation, tobacco cessation, seems to be a risk factor for those with ulcerative colitis. So you see there's so many things we do not understand. And finally, there's some evidence that hygienic factors can play a role. And not in the way you would probably think. So you probably think, oh, well, people who aren't very clean and who are exposed to more bacteria, actually it seems that kids who grow up with a normal response to dirt and bacteria develop a healthier immune response than those whose environment is essentially kept fairly sterile. It just tells you how much we don't understand. But what I want you to remember is that current evidence suggests that some kind of genetic predisposition underlies inflammatory bowel disease and causes an abnormal immune response to GI tract infection, to use of antibiotics, to tobacco use or tobacco cessation, and possibly to hygienic factors. Well, how do we diagnose inflammatory bowel disease? We start with history. So how long have you had symptoms? The average individual whose diagnosed with inflammatory bowel disease has had symptoms for years that have been attributed to something else. Oh, you had a GI bug. Oh, it was something you ate. Oh, you were under a lot of stress. So how long have you been having symptoms? What has your symptom pattern been? Has it been relapsing recurring? That's a classic symptom pattern for somebody with inflammatory bowel disease. And what are your symptoms? Abdominal pain, food intolerance, nausea and vomiting, blooding your stools. Do you have symptoms at night? That's one of the things that helps to differentiate between inflammatory bowel disease and irritable bowel syndrome. People with irritable bowel syndrome do not typically have nocturnal symptoms. Nocturnal symptoms are very common within inflammatory bowel disease. Weight loss also very common among individuals with inflammatory bowel disease because if every time you eat you have pain or you have diarrhea or you have nausea with the risk of vomiting, pretty soon you don't want to eat very much. And so you get into food avoidance. In addition, some individuals with inflammatory bowel disease have malabsorption syndromes that further contribute to unplanned weight loss. You start with history. Tell me how long this has been going on. Tell me what the patterns fit. Tell me what your specific symptoms are. Tell me about nighttime and tell me about your weight. Then they'll do lab studies. CBC to help rule out blood loss inemia. So is your H&H normal? Are their indicators of infection? Is your white count elevated? They might also do a sad rate to look for chronic inflammation. Always though do stool tests to rule out other pathogens. C. dev, guiardia and to rule out parasites. We don't want to mess something else that could be causing these symptoms. Then a physical exam and imaging studies, imaging studies are very important to identify fistulas and abscesses. So typically CT or MRI of the abdomen. And finally colonoscopy and biopsy because there are some very distinctive findings. When you visualize the colon wall, when you biopsy the colon wall that helps to make a definitive diagnosis and helps differentiate between Crohn's disease and ulcerative colitis. Do we have to differentiate? If I've got all these symptoms, I know I've got IBD. I'm pretty sure I have IBD. Does it matter? Well, which one it is? Yes. Because it impacts on prognosis. It impacts on treatment. It has a very specific impact on surgical options. And that differentiation is based on symptoms and on diagnostic findings specific specifically endoscopic findings. Okay, so let's differentiate between ulcerative colitis and Crohn's disease. We're going to look at anatomic involvement. We're going to look at pattern. We're going to look at bowel layers involved. We're going to look at common symptoms. So with ulcerative colitis, the rectum is always involved. That's where it starts. With ulcerative colitis, the inflammatory process starts distally and proceeds approximately. Always involves the rectum, can involve variable links of the colon. Occasionally in patients who have involvement of the entire colon, you'll Yet a little bit of distal Iliol involvement, they consider that to be backwash Iliitis. The pattern is very unique. With ulcerative colitis is continuous and circumferential. There are no skip areas you go from distal to proximal. Rectums always involved. And the sigmoid, then the descending colon, then the transverse colon, then the ascending colon. So you would never see with ulcerative colitis where you had lesions in the rectum. The sigmoid looked normal and then you had lesions in the descending colon. It's always continuous and progresses from distal to proximal, very different from crums. Which bowel layers are involved with ulcerative colitis is just the mucosa, and sometimes a little bit of the submucosa. The deeper layers are involved only with formative complications like toxic mega colon. But routinely it's the mucosa. So then it makes sense that the clinical presentation would be frequent bloody stools because you've got mucosal involvement, and the mucosa is extremely well vascularized. So if you have acute mucosal inflammation and the rectum is always involved, then you're going to have a lot of fecal urgency and frequency, and you're going to have bleeding into the stool. Some patients have crampy pain. A lot of patients have weight loss because symptoms are much worse after eating people start to avoid food. The tea gets common because a lot of these individuals develop a blood loss anemia. Some people have fever and night sweats. You do not get perienal disease. You do not get fishers and fistulas because this is not a transmural process. The inflammation is confined to the mucosal layer. Own endoscopy, what do you see? You see a lot of mucosal ulcerations. You see a lot of bleeding. There are no granulomas. There are no strictures. There typically are no fishulas. What about Crohn's disease? Very different. Crohn's disease can literally occur anywhere in the GI tract. On the mouth to the anus, now the most commonly affected area is the distal small bowel, the ilium. In fact, originally Crohn's disease was known as terminal iliitis because that was the section of bowel most commonly involved. Obviously, they quit using the term terminal iliitis because people thought it meant they were about to die, so now we call it Crohn's disease. But that is the most common sight of involvement, the distal small bowel. But there are many different patterns. 20% of individuals with Crohn's disease have disease limited to the colon. They essentially have Crohn's colitis. That's actually the subset that frequently does the best once they have surgical intervention. It can occur anywhere. The pattern, again, totally different than ulcerative colitis because you commonly see skip areas. So you might have a patient whose rectum looks fine. They have a lot of disease in the sigmoid. And then the descending might be fine and they might have lesions in the transverse colon. But you can have normal sections of bowel interspersed with disease sections of bowel. One of the most damaging issues with Crohn's disease is that it's transmural. All layers of the bowel wall are involved. That means that patients typically have severe pain. That means they're much higher risk for fistula formation, for abscess formation. So the clinical presentation, abdominal pain is usually the hallmark of Crohn's disease. Many of them will report frequent loose stools if there's significant small bowel involvement. Again, weight loss is common both with Crohn's disease and ulcerative colitis. With Crohn's disease, there's multiple factors. It can be food avoidance because of symptoms. But it can also be that you have small bowel involvement and interference with nutrient absorption. Some individuals with small bowel involvement have a lot of issues with nausea and vomiting. If the mouth and the esophagus are involved, you can see oral ulcers. You can have a patient who has trouble swallowing, you can have a patient who has trouble chewing. They have pain with chewing, pain with swallowing. Most patients do not have mouth and esophageal involvement, but some do. Frequent bloody stools are common if the colon's involved and there's a subset of patients with Crohn's disease who have peri-anal disease. They have a lot of fishers and fishulas from the anal canal out into the surrounding tissue, from the rectum out into the surrounding tissue, that those lesions are typically very painful. On endoscopy, what do you see that might be different? You see granulomas. So these fibrotic lesions, you get a cobblestone effect, which you can see from the illustration in the middle of the slide. Also very common to see strictures with long standing disease, because you've got inflammation resolution, inflammation resolution, and it's transmural. So every time you go through an acute transmural inflammatory process, you develop a little more scar tissue, and eventually you end up with stretchers. Let me see if I got. So I'm going to summarize, I thought I had another slide, but I don't. It's in the next class, sorry. So in summary, I'm looking at indications for Iliostomy. There are some surgical indications. You will see a patient undergo diverting loop Iliostomy, when there's a need to protect a distal inastomosis, the Iliostomy is serving as a detour. You'll also see patients undergo an Iliostomy when they have a newly constructed pelvic reservoir. Again, a detour to protect that inastomosis, protect that newly constructed reservoir until healing is complete. There are several distinct disease processes that would result in Iliostomy, familial adenomitis polyposis, because you have multiple adenomas polyps throughout the colon and rectum. You have essentially a 100% risk of developing colorectal cancer unless the colon and the rectum are removed. Colonic inertia, you have a colon that does not work, does not propel stool to the rectum. You have a patient with a functional obstruction. If they do not respond to pharmacologic therapy, the only thing that can be done is to bypass the colon with Iliostomy. Then the most common disease process, resulting in Iliostomy, is inflammatory bowel disease, Crohn's or ulcerative colitis. Temporary Iliostomies are almost always done as loops, permanent Iliostomies are always done as an end stomach. We'll talk more about medical management of inflammatory bowel disease in a later class. Thank you. [BLANK_AUDIO]