Speaker 1Okay, up to this point in this course, we've been focused on patients who have what we call standard diversions, meaning that the rectum or the bladder has been removed or bypassed, the patient has an abdominal wall stoma, and our whole focus is on containment of stool or urine, protection of peristomal skin, educating the patient regarding complication prevention, and supporting them in adapting to this change in body appearance and function. But the next group of classes is going to shift, and we're going to start talking about management. We're going to start with continent fecal diversions, and specifically with the ileal pouch anal anastomosis. We're going to talk about indications, construction, and management. So we'll talk about what IPAA even means. We'll talk about indications and criteria for the creation of an IPAA. We're going to spend a good bit of time talking about the IPAA, and we're going to talk about what it means to be an IPAA and what it means to be an IPAA, and we're going to talk about what it means to be an IPAA, and we're going to talk about what it means to be an IPAA, and we're going to talk about what it means to be an IPAA, and we're going to talk about what it means to be an IPAA, and we're going to talk about comparing and contrasting the surgical procedures involved in a one-stage, two-stage, and three-stage IPAA. So that'll be a huge focus in this class, and then we'll talk about management for each stage of an IPAA. So when we talk about a continent fecal diversion, and specifically when we talk about a continent fecal diversion, we're going to talk about the management of each stage of an IPAA. So when we talk about a continent fecal diversion, and specifically when we talk about a continent fecal diversion, and specifically when we talk about ileal pouch anal anastomosis, what's happening? What are we doing? What's the patient going to end up with? Well, to this point, we've talked about connecting the bowel to the abdominal wall, having stool or urine empty onto the abdominal wall, and managing it with an external pouch. But here we're talking something very different. We still have a situation where we need to remove the colon and most of the rectum, but instead of connecting the ileum to the abdominal wall and having the patient wear an external pouch, with the IPAA, we're going to create an internal reservoir that's connected to the anal canal. So ileal pouch, anal anastomosis. So we create a reservoir out of the end of the ileum and we connect it to the anal canal. So now the anal sphincters provide control of elimination. So the ileal pouch acts as a neorectum or a substitute rectum. Continence as we've said, is provided by the anal sphincters. That's their job. They're very good at that. This is indicated for selected patients who require removal of most of the rectum and all of the colon. Other terms that you will hear used to reference an ileal pouch, anal anastomosis, are restorative proctocolectomy, although that's not so accurate because it suggests that we're going to provide a substitute for the colon. We can't really do that. But J-pouch is a pretty accurate term because the pouch that's formed out of the end of the ileum typically is formed in the shape of a J, and that J-pouch is connected to the anal canal. So some people who undergo ileal pouch, anal anastomosis construction, refer to themselves as having an anastomosis. Sometimes you'll hear, oh, we have a support group for people with a J-pouch. So J-pouch, ileal pouch, anal anastomosis, commonly used interchangeably. So what's the advantage? Well, there's a major benefit as compared to proctocolectomy with an end ileostomy in that there's no stoma and no external pouch. But there are also some potential problems when you compare an ileal pouch, anal anastomosis to a proctocolectomy with an ileostomy, and that is people who have ileal pouch connected to the anal canal, they're still missing the colon. So they're going to have increased stool frequency, some of them report fecal urgency, and a small percentage. Sometimes they experience fecal leakage. So what are the indications, what are the criteria that would result in a patient being considered for an ileal pouch, anal anastomosis? First of all, it's a patient with a benign disease process, like inflammatory bowel disease, who requires removal of the anastomosis. of the colon, removal of the rectum. So most commonly is a patient with ulcerative colitis. It could also be a patient with familial adenomatous polyposis. Critically important for the sphincters to be intact and innervated with normal function, the patient has to have excellent control. If you have a patient with frequent episodes of fecal incontinence, if there's some question as to sphincter damage or denervation, no, they would not be a good candidate for an ileal pouch anal anastomosis because they're going to have mushy stool that they have to control with the anal sphincters. In general, ileal pouch anal anastomosis is a good candidate for an ileal pouch anal anastomosis. Ileal anastomosis is considered contraindicated for a patient with Crohn's disease. First of all, remember that Crohn's disease can occur anywhere in the GI tract, all the way from the mouth to the anus. If we created an ileal pouch, connected it to the anal canal, there's the risk that Crohn's would recur in the pouch, and that would just result in yet another surgical procedure. Having said that ileal pouch anal anastomosis is typically considered contraindicated for patients with Crohn's disease, there is a subset of patients with Crohn's disease. If they had Crohn's colitis, if they've never had small bowel disease, never had perianal disease, then some surgeons will consider them a viable candidate for an ileal pouch anal anastomosis. So long as they realize that there is the possibility that the Crohn's could recur in that ileal pouch, and that they might have to undergo ileal pouch takedown and a standard ileostomy. Now look at the bottom bullet point. This is really important. They found this makes a huge difference in patient outcomes long term. And especially in terms of patient adaptation. And that is the patient should be the one making the decision. They should be given all data about pros and cons of ileal pouch anal anastomosis, pros and cons about proctocolectomy with standard ileostomy. And it should be their choice to proceed with this procedure. Now we're going to talk a little bit about surgical construction. There are a number of approaches. In general, ileal pouch anal anastomosis is performed in stages. And whether they do a two-stage or a three-stage is determined by patient status and other factors impacting on surgical options. So we're going to talk our way through that. There are a few patients who do not undergo a staged procedure. They have everything done at once. And that's considered a one-stage procedure. That is appropriate only for patients who are slender. So the mesentery is going to be mobile. The surgeon will be able to construct the pouch, pull the pouch down into the pelvis, connect it to the bone marrow, connect it to the anal canal. So they have to be slender. And they should have no risk factors for impaired healing. So in other words, a one-stage procedure is not a good option for a patient on steroids. It's not a good option for a patient who has any issues with malnutrition or other conditions that would result in delayed healing or prolonged healing times. So if you do this as a one-stage procedure, you have to have the ideal candidate, not on steroids, in good nutritional condition, slender so that you'll have a mobile mesentery. And most patients who have ulcerative colitis resulting in surgical proctocolectomy or on steroids may have nutritional compromise and are not good candidates for a one-stage procedure. But that can be done. So if you look at the slide on top, that shows a patient who's undergone a one-stage procedure. So the patient went into the operating room with a colon and a rectum. They come out, the colon's been removed, the rectum's been removed all the way down to the anorectal junction. A reservoir has been created out of the end of the ilium. That reservoir has been anastomosed to the anal canal. And now stool is going to go right into that ilial reservoir. Continence is dependent on the anal sphincters. So that is a huge procedure to be done in one stage. But there are some surgeons who will do a one-stage procedure for selected patients. Two stages the most common, and that's what you see middle of the screen. In a two-stage procedure, they will first remove the colon and the rectum. They will go ahead and create the ilial pouch reservoir. They'll connect the pouch to the anal canal. But as you can see in the diagram on the left, they also do a temporary loop ileostomy. So that loop ileostomy is done to allow plenty of time. For that ileal pouch to heal, for the anastomosis between the ileal pouch and the anal canal to heal. And then once you have good healing of the reservoir, good healing of the anastomosis, then they close the ileostomy. And you now have everything going through to the reservoir with continence being controlled by the sphincters. So the big difference in a one-stage procedure and a two-stage procedure is that with the two-stage procedure, you have temporary protection of the reservoir, temporary protection of the anastomosis, because you've done that diverting loop ileostomy. And the ileostomy is closed only when healing is complete. So when would a two-stage procedure be done? So the big difference in a one-stage procedure and a two-stage procedure is that with the two-stage procedure, you have temporary protection of the anastomosis, because you've done that diverting loop ileostomy. procedure be indicated anytime there's any risk for delayed healing. And then with a three-stage procedure, this is appropriate for a patient who's critically ill at the time of the original surgery. Or maybe you have a patient who's been on steroids for a long time and they've had associated weight gain. And as a result, the mesentery is not mobile enough to be able to heal. So you have to be careful. And then with a three-stage procedure, you have temporary protection of the anastomosis, because you've done that diverting loop ileostomy. So with a three-stage procedure, stage one simply involves removal of the colon, partial removal of the rectum. They leave most of the rectum in place as a Hartman's pouch, and they do an end ileostomy. So they do an end ileostomy. You take out the very diseased colon, possibly part of the rectum, do the Hartman's pouch, do the ileostomy. Now you have time to get the patient well. Get them off steroids. Correct any nutritional deficiencies. Allow them to lose weight if they need to do so. And then stage two, you take down the end ileostomy. You use the end of the ileum to create the reservoir. You connect the reservoir to the anal canal. But you come back and do a diverting loop ileostomy. So again, you have protection for the reservoir, protection for the anastomotic line until healing is complete. And then stage three is takedown of the ileostomy. So that's one stage, two stage, three stage approach to ileal pouch anal anastomosis in a summary slide. Now we'll talk about the anastomosis, and we'll back up and talk about one stage, two stage, three stage in a little more detail. So when they make the reservoir, they turn the ileum back on itself, sew it onto itself to create a reservoir. And then they're going to connect that reservoir to the anal canal. There are two approaches. They can do a hand-sewn anastomosis or a stapled anastomosis. And there are implications. So when they anastomose the ileal pouch to the anal canal, they do it right at the anal transition zone. Now that's the junction between the anal canal and the rectum. That's where you have all of the receptors that signal rectal distension and also the receptors that differentiate between gas, liquid, and solid. So that anal transition zone, critical to continence, signals rectal distension and differentiates type of rectal contents. Now when they do a hand-sewn anastomosis, they will take the time to strip out the mucosal layer. And when they strip out the mucosal layer from the anal transition zone, that eliminates any risk of dysplasia, any risk of cancer in that zone, which is particularly important among patients with familial adenomatous polyposis. So that is considered the best approach if the patient has familial adenomatous polyposis. And if there's any dysplasia at the time of surgery. Remember that patients with ulcerative colitis might also have dysplastic changes. And there might be patients with ulcerative colitis who would also benefit from that hand-sewn approach. Now if they do a stapled approach, they allow the mucosa to remain intact. And they just staple the reservoir to the anal canal. And that's considered appropriate and very safe if there are no dysplastic premalignant changes at the time of surgery. It's a faster approach. Also, there's less risk of any temporary disruption in the patient's ability to sense rectal distension and to differentiate between gas, liquid, and solid. But some clinicians believe that they require more frequent follow-up because there is still the potential, even though it's just a rim of mucosal tissue left, still, at least technically, there's the potential for dysplastic changes. So some surgeons recommend at least annual anoscopy to inspect that band of mucosal tissue. To date, there's no evidence that there's any. There have been no issues with dysplastic changes with malignant development in that little rim of mucosa among patients who have undergone a stapled anastomosis. So some surgeons do hand-sewn, some do stapled. Hand-sewn routinely recommended for the patient with any level of dysplastic changes. But hand-sewn can result in some temporary issues. no ostomy. So you might not even be involved with these patients. Here's the criteria for a single stage procedure. The patient has to be slender with a mobile mesentery so that the surgeon is able to construct the pouch, pull it down into the pelvis and anastomose it to the anal canal with no tension. The patient cannot be on steroids, cannot be on other anti-inflammatory or immunomodulator medication because that will interfere with healing times. And the patient has to be well nourished with no impediments to healing. So you can see this is not commonly done. Now there are also some potential issues early post-op because if you go into the operating room with a colon and a rectum and you come out with neither, just an ileal pouch and anastomose to your anal canal, then you're going to go through a period of time where you have high volume output all going through this baby pouch and controlled by your anal sphincter. So you're going to have a period where you have fecal frequency, urgency and significant risk of leakage. Especially at night, when you're asleep and when your muscle tone diminishes. Many of these patients have issues with leakage at night for the first few weeks to months. Also because of that, they're at high risk for perianal skin break dip. Now here are things that we can provide for these patients if we're involved in their care. We can counsel them in regards to dietary modification and other modifications to thicken the stool. So it's that BRAT diet, foods high in soluble fiber like bananas, rice, apples, peeled apples or applesauce, peanut butter, toast, anything that thickens the stool. Also we teach these patients it's best if you drink fluids at mealtime. So there's something to balance the fluid intake. If you drink large amounts of fluids in between meals, then that can increase your risk of diarrhea. On the other hand, it's critically important to maintain sufficient fluid intake. So drinking fluids at meals might not be enough. So they might have to either eat frequent meals throughout the day with significant fluid intake at each small meal. Or they might have to supplement their fluid intake at meals. So it's really important to maintain sufficient fluid intake at meals with fluid intake in between, even if it does cause some diarrhea. Early post-op, we want them to avoid insoluble fiber. Insoluble fiber increases peristalsis. It would increase diarrhea. And they may need to avoid citrus foods because sometimes citrus foods cause burning in the perianal area. When they eat oranges or grapefruit or drink orange juice or grapefruit juice or tomato juice, then they need to avoid those foods initially. We also want to teach them strategies to reduce fecal urgency and frequency and leakage that involve medications and also involves some behavioral strategies. So we've already talked about dietary medications. High intake of soluble fiber. Minimal intake of insoluble fiber. Think about when you time fluid intake. So now let's look at medications. Psyllium products can be very helpful. Adding two teaspoons of psyllium to four ounces of water three to four times a day can thicken the stool. It can help take it from thick liquid to mush. Psyllium and diphenoxylate, the two major anti-diarrheal medications. So the surgical team will be titrating doses of these anti-diarrheal agents to try to control stool frequency to a manageable level. Also you want to tell the patient when you feel that intense urge to go, it's instinctive to get up and run. But what I want you to do is I want you to tighten your sphincter, do deep breathing, try to push through and buy a little bit of time. Because when you resist the urge to go, you force that pouch to expand in volume a little bit. That pouch starts out low volume, but it can increase in volume to 400 milliliters or even more. So we want to stretch out your ileal pouch. And the only way to stretch it out is to delay defecation. Some people find it too anxiety-producing to delay going to the bathroom. So they'll come out better walking to the bathroom, tightening their sphincter, using deep breathing, getting to the bathroom, maybe even sitting on the toilet. But then using deep breathing and sphincter contraction to delay defecation for as long as possible. So that they're gradually stretching out the reservoir. So if you think about the fact that the reservoir starts out being somewhere between 50 and 100 milliliters, you can see that if you take it from 50 to 100, you have doubled capacity and you've cut stool frequency in half. And given that average output is going to be about 800 milliliters a day, if you do that, you're going to have to go to the bathroom every time you have 50 milliliters in the reservoir, that's 16 trips. If you can make it to 100, that's 8 trips. If you can increase your reservoir to 200, now you've cut it down to 4 trips. So obviously, resisting the urge to go, increasing the size of the reservoir, critically important in long-term quality of life. So if you go to the bathroom every time you have 50 milliliters in the reservoir, that's 16 trips. And of course doing anal sphincter exercises because you want your sphincter muscles to be as strong as possible. So contract as hard as you can like you're trying to hold in gas. Hold as long as you can. Relax for 10 seconds. Yes, you want them doing those throughout the day. We also want to teach them perianal skin care because essentially they've gone from having an intact colon to having an ileostomy that empties through their anal sphincter. So we've got to take care of that perianal skin. We want them to use very gentle skin care. So moistened wipes, either baby wipes or water-based wipes. We want them to routinely. We want them to routinely use an absorptive pad between the buttocks so they make some anorectal dressings that are butterfly shaped that are great because they provide absorption at the point of contact. And then having them routinely use a moisture barrier product like Desitin or any of the moisture barrier products you use in practice every day. Okay. So having talked our way through a lot. Okay. Well, one stage procedure, you can probably immediately see the advantage of a two stage procedure. So let's just review what that involves. So in stage one, they will remove the colon and the rectum down to the anorectal junction. They will use the end of the ileum to construct the ileal pouch, that J pouch. They will go ahead and connect the ileal pouch to the anorectal junction. The ileal pouch to the anal canal. But then they also do a diverting loop ileostomy. And then stage two is a very simple procedure. It's just takedown of the loop ileostomy. So what are the criteria here? Well, they're going to do a two stage procedure with that diverting loop ileostomy. And then they're going to do a two stage procedure with that anorectal junction. to normal rapid healing. If they have any nutritional compromise, if they're on steroids, if they're on other anti-inflammatory medications or immunomodulators, then the surgeon is almost always going to do a two-stage procedure because he or she realizes that it's going to take a little bit longer for this ileal reservoir to heal, a little bit longer for this anastomosis to heal, and you don't want any stool going through the reservoir through the anastomosis until it's very well healed. So do a two-stage. By time, protect your reservoir, protect your anastomosis. The takedown procedure for the ostomy is very simple. So you think about managing a patient with a two-stage ileal pouch anal anastomosis procedure, you realize that stage one is all about managing the ileostomy. So you are going to be working to establish an effective pouching system and to teach that patient how to manage the pouch, how to empty, how to change, how to manage minor skin irritation. Realize also that when you have a diverting loop ileostomy, many times the functional os empties very close to skin level, even though the surgeon tries his or her dead level best to create a centrally located os, many times the os ends up being very close to skin level. So it is not at all uncommon for us to have to use convexity to create a centrally located os, many times the os ends up being very close to skin level. So it is not at all uncommon for us to have to use convexity when we're dealing with a diverting loop ileostomy in this situation. So first it's all about create a stable, secure pouching system and teach the patient. Also, we want to prevent dehydration. If you look at the illustration on top, so you see the end of the ileum is down in the pelvis. It's been turned into a reservoir connected to the anal canal. So this diverting loop ileostomy is higher in the ileum. That means you're going to have higher volume output, higher risk for dehydration. So we're right back to everything we can do to thicken the spine. And to prevent dehydration, we're going to recommend dietary modifications like a BRAT diet, high in soluble fiber, very low in insoluble fiber. We're probably going to recommend frequent small meals throughout the day, frequent fluid intake throughout the day. We're going to recommend anti-diarrheal agents. So that includes. Psyllium products, two teaspoons of psyllium mixed in four ounces of water to thicken the stool. It also includes loperamide and diphenoxalate, the two major anti-diarrheal, anti-motility agents. Those doses will be titrated by the surgical team to try to get ileostomy output down under 1,100 to 1,200 milligrams per day. And keep it there. And then we've got to assure adequate fluid replacement. So for most patients, that involves baseline intake of two liters a day. And then we recommend either replacing ileostomy output, one-half milliliter of replacement for each milliliter of ileostomy output, or in addition to that, two liters a day. An easier thing for patients, as we mentioned before, is to have them drink a glass of replacement fluid every time they empty their pouch. Don't gulp it down, but go get a glass of replacement fluid and drink that glass of replacement fluid over the next 30 minutes to an hour. So a lot of emphasis on dehydration prevention, adequate fluid intake. Then we're going to teach them dietary modifications to prevent food blockage. So we're going to identify foods high in insoluble fiber. We're going to explain that if they eat a lot of insoluble fiber, it could create an indigestible bolus of fiber that gets stuck just proximal to the stoma. We're going to recommend that they avoid insoluble fiber until their stoma remains the same size for two weeks, meaning edema has resolved. We're going to recommend that they add insoluble fiber to the diet, one food at a time, small amounts, chew thoroughly. So basic ileostomy management. Strategies to maintain hydration. Strategies to prevent food blockage. How to pouch. How to manage minor skin breakdown. But we also want to remember that this patient will be undergoing stage 2 within probably two to three months. So they've got to start doing some preparation. Stage 2 is ileostomy closure, ileostomy takedown. And once they undergo stage 2, everything will be going through that pelvic reservoir. All of their control will be up to the anal sphincters. So we want them to do sphincter strengthening exercises. Just like we talked about earlier, contract as if you're trying to hold in gas. Hold it for as long as you can. Do 15 of those three times a day. Because when we close your ileostomy, we want your sphincters to be in peak form, like Olympic-style strong. So you've got to gear them up. Teach that patient sphincter exercises. The other thing that's really helpful is if you have them keep a chart, what they eat, what they drink, and what happens with their output. Because when they undergo stage 2, when we close the ileostomy, and everything starts going through their pelvic reservoir, they need to be very clear about which foods and which fluids thicken their stool and reduce stool volume, and which foods and fluids increase stool volume and make their stool thinner. So keeping those records can be tremendously beneficial for them following stage 2. Okay, so let's talk about stage 2. So stage 2, their ileostomy's gone. Now, everything is going through the small bowel into that pelvic reservoir. Output is controlled by their sphincters. So again, they need to continue dietary modifications to thicken the stool. Even more importantly, they need to continue to exercise. So again, they need to continue to exercise. with a small reservoir, typically 50 to 100 milliliters capacity, if they can consciously delay every time they have the urge to go. then they'll constantly stretch the reservoir a little bit more, a little bit more, a little bit more, until pretty soon, instead of having a 50-milliliter reservoir, they have a 100-milliliter reservoir, and now their stool frequency is cut in half, so we've got to help them understand that. We want them to understand the importance of conscious delay, and we want to take care of the perianal skin, so again, we're saying to them, okay, we've closed the ileostomy. Everything's going through the reservoir. It's going to take time for the reservoir to stretch until the reservoir capacity increases, until the stool consistency is reliably thick. You're going to want to use some kind of moisture barrier ointment for protection of the perianal skin. You're probably going to want to use those anorectal dressings, those little butterfly dressings that wick any moisture right at the anal opening, right at the point of contact. So now let's talk about a three-stage procedure. If I haven't scrambled your brains already, this should do it. So this is typically required when a patient's critically ill at the time of original surgery. It's also sometimes done when the patient is in a hospital that does not do continent diversions. There's no surgeon there who has experience with the ileal pouch anal anastomosis. So in that situation, the three-stage procedure is done to keep that patient's options open. So stage one is simply take out the colon, maybe the proximal portion of the rectum, but the primary focus, get the colon out. Typically that's where most of the pathology is, where most of the symptom symptomatology is coming from. So do the colectomy, do a Hartman's pouch. So close the rectum, leave it in place, in the pelvis, and do an end ileostomy. Stage two, take down the end ileostomy, create the ileal reservoir, attach the ileal reservoir to the anal canal, but then do a diverting ileostomy to protect the healing reservoir, to protect the anastomotic line. And then stage three is simply take down of the ileostomy. So again, we've mentioned, why would you do this? Maybe the patient was pregnant, the patient was obese, the patient was acutely ill at the time of surgery, the patient had major risk for impaired healing, or there was no surgeon who was qualified to do the ileal pouch anal anastomosis. So they did instead a Hartman's pouch end ileostomy, which keeps that patient's options open. So we'll walk through stage one, stage two, stage three. So in stage one, the colon is gone, the rectum is sitting in the pelvis as a Hartman's pouch, no care required, and they have an end ileostomy. So our whole focus is management of that end ileostomy, establishing effective pouching system, teaching the patient how to empty, how to change the pouch, heavy focus on fluid management to prevent dehydration, and dietary modifications to prevent food blockage. All of the things we talked about when we talked about ileostomy management, and the things we just talked about when we talked about stage one of a two-stage procedure. Then you want to get them ready for stage two. So, stage three, stage four, stage five, and stage six. So stage two is what? Stage two is when you take down the end ileostomy, create the reservoir, and attach it to the anal canal. So readiness for that means we need to wean them off steroids, wean them off any anti-inflammatory medications. If they've been on steroids and they've gained weight, then we need them to lose weight. Once we wean them off steroids, we need to put them on a weight reduction plan so that we restore the mobility of the mesentery and the ability to stretch that reservoir down into the pelvis. And we want to make sure we optimize nutritional status before we take them back to surgery for stage two. Stage two, what's happened? Okay, now you see you have the reservoir. You have created the reservoir. It's attached to the anal canal, and you have a diverting loop ileostomy. The diverting loop ileostomy is there to protect the healing reservoir and the anastomotic line. So now we're focused on establishing an effective pouching system for this diverting loop ileostomy. We're going to have to tell the patient, "I know you had an ileostomy before, and you had a pouching system that worked great for you before, and this ileostomy is in the same spot as your previous ileostomy, but this one's different. Your first one was an end ileostomy. You told me you had no problems with pouching. Your pouch stayed on for a long time, and now you have an end ileostomy. You're going to have to put it on four or five days routinely." This is what we call a loop ileostomy. Those tend to empty closer to skin level, so many times we need to use a different pouching system. So I know with your first ileostomy, you used a two-piece pouch, or you used a one-piece pouch. It was flat. You didn't have to use convexity. But with this ileostomy, because it's emptying closer to skin level, we're going to be using a different pouching system. It's going to have a backward curve. It's going to provide more support right around the ileostomy. So I just wanted to review those differences with you and why. We're going to reinforce self-care. We're going to reinforce fluid management to prevent dehydration. We're going to reinforce diet modification to prevent food blockage. They already know these things, but we're going to reinforce those things because they're critically important. And then we're going to get them ready for stage three. So remember, with stage three, we have ileostomy closure, and everything will go into and through the reservoir. So now we want them doing their anal sphincter exercises, 15 reps, three times a day, three times a day. We also remind them that it's very helpful if they keep a record of what they eat, what they drink, when they have diarrhea, when they have increased gas, when their stool is thicker, so that they know what to eat and what to avoid after stage three. In stage three, the ileostomy is closed. Everything is going through the reservoir. All output is controlled by the anal sphincters. So it's just the same things that you've heard before. Dietary modifications to thicken the stool. They've probably been doing some of these with the ileostomy, but now critically important because everything's going through the reservoir. So now it's critical for them to increase their intake of soluble fiber. Strictly limit their intake of insoluble fiber. We remind them in general if you can eat at least small amounts of food when you're drinking fluids, that helps to avoid very, very liquid output. Again, we tell them if you're having burning with citrus foods or fluids, avoid those foods and fluids. If you're having burning with citrus foods, avoid those foods and fluids until you get to a different point where your stool is consistently mushy to soft. And then you can resume your intake of citrus foods, citrus fluids. Bulking agents, again, typically very helpful. They're usually the last thing to be eliminated. So throughout this post-op period, we keep them on psyllium, two teaspoons, and three to four ounces of water, three to four times a day. We will gradually be weaning them off their antidiarrheal medications, their loperamide, their diphenoxalate, in conjunction with the surgical team. Once again, we tell them the same thing as our other patients: you have a baby reservoir. At baseline, it probably holds about 50 milliliters, a little less than two ounces, maybe a little bit more than two ounces. We want to increase its capacity. The way to increase its capacity is to make it stretch, make it hold more, make it work harder. The way you do that is by delaying defecation. Every time you get the urge, hang on as long as you can so your reservoir begins to stretch. And again, we talk to them about skin care and prevention of skin damage. So, we want you to be very clear on this. We know it'll take some review, but it's very important for you to understand the basic concept of the ileal pouch anal anastomosis, creation of a pelvic reservoir out of the end of the ileum, the reservoirs connected to the anal canal, eliminations controlled by the sphincters. It is an alternative to ileostomy for a patient who requires removal of the colon and removal of most of the rectum. Common issues. Long term, fecal urgency and frequency and possible leakage. Now, for most patients, long term, they get down to about four to six stools a day. Long term, most patients have very few, if any, issues with leakage. And most patients have minimal issues with urgency. So long term, outcomes are generally good. But short term, frequency, urgency, leakage, all possible. They need to know that. As we have said, to the point of distraction, probably, it can be done as a one stage, a two stage, or a three stage procedure. So hopefully you can just about quote this with me, a one stage. They take out the colon. They take out most of the rectum. They create a reservoir out of the end of the ileum. They connect it to the anal canal, and that's it. Now, everything goes through that pelvic reservoir, elimination controlled by the sphincters. A huge adjustment for that patient post-operatively. And only appropriate for a patient who's in great physical condition, who is going to heal normally, who is slender and has a mobile mesentery. Two stage, by far the most common. So stage one, all the hard work is done, colon is removed, most of the rectum is removed, the reservoir is created out of the end of the ileum, the reservoir is connected to the anal canal. Then they also do a diverting loop ileostomy to protect the healing reservoir and the anastomotic line. Stage two is simply closure of that loop ileostomy. So now everything is going through the reservoir. Stage three breaks it up. This is done for a patient who is not a good candidate for the reservoir at the time of the initial surgery, they're too sick, their weight doesn't permit construction of a pelvic reservoir, or there's no one qualified to do it. In this case, they take out the colon, they leave the rectum or most of the rectum as a Hartman's pouch. Then they do an end ileostomy. That gets the patient well, gets them off steroids, off all the anti-inflammatories. Stage two, they disconnect the end ileostomy, they turn the end of the ileum into a reservoir, they connect the reservoir to the anal canal, and then they do a diverting loop ileostomy to protect the healing reservoir and to protect the anastomotic line. Then stage three is takedown of the ileostomy. In another class, we will talk in a little more detail about some of the specifics of management. Thank you.
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