Ileal Pouch-Anal Anastomosis Periprocedural Care

Updated: Dec 03, 2015
  • Author: Michael B Brewer, MD; Chief Editor: Kurt E Roberts, MD  more...
  • Print
Periprocedural Care

Patient Education and Consent

Written patient education materials are available at most colorectal surgery offices and inflammatory bowel disease centers. Additionally, nutritionists provide valuable education regarding dietary modifications recommended following ileal pouch–anal anastomosis (IPAA). Nurses with specialized training in ostomy care play a key role in helping patients become comfortable with and care for their stomas. Finally, online material is available, such as that provided by the American Society of Colon & Rectal Surgeons and the Crohn’s & Colitis Foundation of America.

Next:

Equipment

A variety of devices and surgical equipment are used in the creation of an IPAA. The proctocolectomy can often be performed wholly or partially by using a laparoscopic technique. In these cases, laparoscopy equipment such as the laparoscope, insufflator, and laparoscopic instruments are used. If a hand-assisted approach is used, a hand port device is employed. Energy devices are frequently used to mobilize the colon and rectum for removal and to divide the blood supply to these organs.

The ileum is typically divided with a gastrointestinal anastomosis (GIA) stapler, and the rectum is divided with a thoracoabdominal (TA) stapler or a curved TA stapler. For the IPAA portion of the procedure, the pouch is most frequently created with several firings of the GIA stapler. The pouch is then connected to the anal canal by using the end-to-end anastomosis stapler; alternatively, they may be sewn together by hand.

Previous
Next:

Patient Preparation

Before the IPAA procedure, patients are typically asked to perform a bowel preparation to potentially reduce infectious complications and to allow for easier handling of the colon and rectum. A bowel preparation clears the colon of fecal material, thereby decreasing the bacterial load. This is usually accomplished the day before surgery with 4 L of a polyethylene glycol electrolyte solution or 300 mL of a magnesium citrate solution. The patient is asked to maintain a clear liquid diet the day before surgery and to fast after midnight the day of surgery.

Anesthesia

The IPAA procedure is usually done with the patient under general endotracheal anesthesia. This means that the patient is completely asleep, with the airway protected by means of a breathing tube.

Positioning

The patient is positioned in the low lithotomy position on his or her back with the legs in stirrups (the “frog-leg position”).

Previous
Next:

Monitoring & Follow-up

Postoperatively, patients are monitored on a regular basis to ensure that their surgical wounds heal appropriately and that they are able to maintain adequate hydration despite sometimes copious fluid losses. Once bowel movements have slowed, follow-up visits occur less frequently. It is important to endoscopically survey the rectal cuff regularly in patients who have undergone IPAA to assess for precancerous or cancerous changes. [2]

After restorative proctocolectomy, bowel habits and stool character are significantly different. Initially, patients will pass liquid stool as often as 15 times daily and frequently experience urgency. In time, this frequency will decrease, and stool will become more formed as the body adapts to the new anatomy. Because the ileal pouch does not accommodate to the same degree as a healthy rectum and the colon normally absorbs 90% of the 1-2 L of water it is presented with daily, bowel movements will never be as infrequent or formed as what is considered normal.

Patients should expect between three and eight bowel movements daily that resemble toothpaste in consistency. If necessary, antimotility agents and bulking agents can be used to help slow the passage of stool.

In response to the changes in the body’s physiology, patients must adhere to several dietary modifications to stay healthy. [3, 4] High fluid losses in liquid stool can lead to dehydration and electrolyte disturbances. For this reason, patients are encouraged to drink copious amounts of fluids. Salt losses are replaced with supplemental dietary salt or electrolyte drinks.

Meals high in carbohydrates can help thicken stool output. Patients often eat frequent small meals throughout the day to avoid large small bowel loads and subsequent urgency. Avoiding late meals may decrease nighttime awakenings for bowel movements. Finally, metabolic complications, such as B12 deficiency and iron deficiency, can occur after IPAA. These can be prevented by means of regular vitamin and mineral supplementation. [5]

Previous