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PubMedDate not supplied

Predicting outcome of procedures to slow intestinal transit.

Procedures designed to slow intestinal transit in patients with the short-bowel syndrome (SBS) have unpredictable outcomes. Our aim was to evaluate the outcome and predictive factors for this complication in SBS patients. Ten patients (37-61 years) underwent reversed segment (n = 9) or nipple valve creation (n = 1). All patients had remnant lengths over 90 cm and rapid intestinal transit times. All subjects had benign diseases, including Crohn's (n = 3). Six patients had a colon remnant. SBS had been present for 8 to 150 months. Nine (90%) required parental nutrition (PN) preoperatively. A procedure was performed either alone (n = 5) or concurrently with an ostomy closure (n = 3), an ostomy revision (n = 1), or a fundoplication (n = 1). There was one postoperative complication (urinary tract infection) and no deaths. Two patients developed bacterial overgrowth. One required repair of an ileocolonic stricture. One reversed segment was taken down 12 months later. Five (50%) patients improved (off PN), five remained on PN or had persistent diarrhea. Patients with a successful outcome were more likely to have had ostomy takedown (60% vs 0%). The duration of SBS; presence of Crohn's disease, a colon remnant, or type 1 anatomy; and the transit times were similar in both groups. Adjusted remnant length (small intestine +30 cm for type 2 anatomy and +60 cm for type 3) was similar (136 +/- 20 vs 154 +/- 25 cm). Procedures may benefit half of selected SBS patients with adequate remnant length and rapid transit. Successful patients are more likely to have an ostomy takedown, but the outcome is less determined by transit time or intestinal length if over 90 cm.

Adult↗
PubMed1996

Case management: a new practice model for ET nurses.

An examination of wound, ostomy, and continence nursing practice provides ideas for improving patient care and for role development of the ET nurse. During this period of rapid health care reform, opportunities to expand ET nursing practice must be explored. For many ET nurses, care of the patient with an ostomy remains a primary focus. The fitting of prosthetic equipment and patient education concerning ostomy care may not, however, be enough to demonstrate the impact of ET nursing care on the outcome of patients with an ostomy. Caring for the patient undergoing gastrointestinal surgery by means of a case management model is a new option for ET nurses. Nurse case managers focus on the patient and the impact of illness from admission until discharge. They are accountable for coordinating the multidisciplinary team who cares for the patient and for the evaluation of outcomes. ET nurses must evaluate the outcomes of their care to demonstrate the continued need for our specialty practice. This article describes the efforts of ET nurses at a tertiary care center in the Midwest to develop a case management system for patients undergoing gastrointestinal surgery within their practice. The process of developing a critical pathway, or care map, is also described.

Case Management↗
PubMed1999

A multidimensional modeling of predictors influencing the adjustment to a colostomy.

PURPOSE: Factors contributing to the postoperative adjustment of patients who had undergone permanent colostomy surgery were studied. DESIGN: Cross-sectional study. SETTING AND SUBJECTS: Sixty patients who underwent colostomy surgery at 5 hospitals in Santiago, Chile, between 1987 and 1995 were evaluated. Subjects were between the ages of 27 and 89 and underwent colostomy surgery from 4 months to 19 years before data collection. METHODS AND INSTRUMENTS: A demographic questionnaire and a semistructured interview were used to elicit information concerning psychosocial reactions to a colostomy and perceptions about the changes in lifestyle created by the ostomy. Medical records were reviewed for information about disease-related characteristics and an ostomy self-care scale measured coping skills. Adjustment to the colostomy procedure was measured by means of the Olbrisch ostomy adjustment scale. RESULTS: Patient adaptation to a colostomy is primarily affected by the following factors: (1) the level of ostomy self-care, (2) psychological support, and (3) social support from family and significant others. CONCLUSION: Successful adjustment to a permanent colostomy is most likely to occur if the patient receives adequate instruction in self-care and has the appropriate psychological support to integrate the new physical changes into a healthy body image. This includes continued acceptance from family and the patient's social network.

Adaptation, Psychological↗
PubMed1998

Transplanted small bowel and expression of the insulin-like growth factor binding proteins.

The insulin-like growth factor binding proteins (IGFBPs) act to modulate the growth and differentiation of the gastrointestinal mucosa by regulating cellular responses to the important mitogens, the insulin-like growth factors (IGFs). The transplanted small bowel must maintain the normal growth factor interrelationships and signaling pathways despite the potential of host rejection. Ostomy effluent of patients after small bowel or combined liver/small bowel transplantation was assayed for IGFBPs to investigate the effect of rejection on the IGF-IGFBP axis. Seventeen patients were studied over an 18-month period. The transplanted small bowel produced no measurable IGFBPs in the ostomy effluent under normal circumstances. However, when rejection was taking place the ostomy effluent was found to have measurable IGFBP levels in 6 of 12 episodes, the 6 episodes occurring in 6 different patients. Mostly, the IGFBPs present did not exhibit a serum-like pattern indicating the secretion of IGFBPs into the effluent was not the result of loss of mucosal barrier integrity. There were no statistically significant differences in protein content of the ostomy fluids in the presence or absence of rejection. Our results suggest that the gastrointestinal IGF axis is altered during some instances of transplanted small bowel rejection, with increased secretion of IGFBPs.

Adolescent↗
PubMed2001

Ileostomy and colostomy support groups.

The first organized ostomy support group in the world was formed at The Mount Sinai Hospital, in 1950, through the efforts of a surgeon and the patients themselves. Later, similar groups were set up in other locations and some even took the name of Mount Sinai's first such society (QT). These groups had two major functions: Psychological: reassurance and understanding from other ostomates before and after the operation; advice on how to deal with oneself and others. Educational: instruction on the details of stoma management; information for surgeons on the proper location and other details of fashioning a stoma; information to the public on the existence and needs of ostomates. In order to extend services to more people and with more individual attention, a special clinic was established at The Mount Sinai Hospital devoted entirely to patients with ileostomy and colostomy. It too was the first of its kind anywhere. Years later, two surgeons arranged an all-day convention of the ostomy groups in the greater New York City, New Jersey, and Connecticut areas, at the New York Academy of Medicine. At the convention, the idea of a national society was conceived. In the following years - in Detroit, then Cleveland, and finally Los Angeles - the United Ostomy Association was developed, structured, and incorporated. The educational uses of the ostomy groups were later supplemented and partly replaced by enterostomal therapists who originally were trained and practiced in Cleveland. Now the therapists, the societies, and the ostomates themselves are available to patients with various types of stomas, whether recent or longstanding, before and after surgery.

Academic Medical Centers↗
PubMedDate not supplied

When trauma means a stoma.

Trauma is a leading cause of death and disability. When traumatic injuries require ostomy surgery, the wound, ostomy, and continence nurse acts as a crucial part of the trauma team. This literature review describes mechanisms of injury associated with creation of a stoma, key aspects of wound, ostomy, and continence nursing care in trauma populations and presents suggestions for future research.

Adaptation, Psychological↗
PubMedDate not supplied

Difficulties experienced by the ostomate after hospital discharge.

PURPOSE: This descriptive study used a mailed survey to identify difficulties related to the stoma that ostomates experience after discharge from the hospital, who they sought help from, and if the advice was perceived as helpful. SUBJECTS AND SETTING: Ostomates who are 18 years or older and have undergone a urinary or fecal diversion at a North Carolina hospital between January 1, 2003 and June 30, 2005, were asked to respond to a survey about the difficulties related to their ostomy. INSTRUMENT: The survey gathered demographic and anthropometric data, information regarding stomal complications, self-evaluation of emotional state, and contact with clinicians and support groups. RESULTS: Of the 140 surveys mailed, 43 were returned, demonstrating a return rate of 31%. Thirty-four returned surveys were useable for statistical analysis. The top 5 difficulties experienced by the respondents were peristomal skin irritation (76%), pouch leakage (62%), odor (59%), reduction in previously enjoyed activities (54%), and depression/anxiety (53%). Twenty percent of the ostomates who experienced difficulties after surgery did not seek help. Ostomates primarily sought help from nurses when they experienced problems related to the stoma and its maintenance. For mental health, sleep, and sexual problems, a medical doctor was the practitioner of choice. Ostomates were satisfied with most of the help they received from an ostomy nurse; satisfaction was lower for home health nurses and surgeon or primary care physician practices. Average wear time for a stoma pouch was 4 days. CONCLUSION: The majority of the ostomates experienced difficulty with pouch leakage, skin irritation, odor, depression or anxiety, and uneven pouching surfaces. Ostomates desire assistance with these problems and will benefit from long-term follow-up by an ostomy nurse.

Adaptation, Psychological↗
PubMed2000

[Wearing a pouch shows the difference between "being an "ostomized person" and "being a professional": analysis of a teaching strategy].

This study aimed at analyzing nurses (re)construction process regarding the meanings of ostomy, ostomized patients, nursing care and the professional role after they wore an ostomy appliance. This activity is a teaching strategy applied at the Enterostomal Therapy Nursing Education Program. Two major units were identified after the analysis of students speeches: "being an ostomized person" and "being a professional". When students wore the pouches they felt as ostomized patients experiencing a violation of their identity and quality of life that promotes profound changes in daily life. These symbolic contents cause a crisis regarding the meaning of being a professional as until this experience, nursing care seemed fragmented to them. Recognizing a previous care performed as a technical action mainly directed to the ostomy and the pouch, students were able to visualize a future care, that is holistic and considers the ostomized human being, enabling them to incorporate affective, symbolic and relational dimensions.

Activities of Daily Living↗
PubMed1998

Intestinal atresia and stenosis: a 25-year experience with 277 cases.

OBJECTIVE: To evaluate the causes, clinical presentation, diagnosis, operative management, postoperative care, and outcome in infants with intestinal atresia. DESIGN: Retrospective case series. SETTING: Pediatric tertiary care teaching hospital. PATIENTS: A population-based sample of 277 neonates with intestinal atresia and stenosis treated from July 1, 1972, through April 30, 1997. The level of obstruction was duodenal in 138 infants, jejunoileal in 128, and colonic in 21. Of the 277 neonates, 10 had obstruction in more than 1 site. Duodenal atresia was associated with prematurity (46%), maternal polyhydramnios (33%), Down syndrome (24%), annular pancreas (33%), and malrotation (28%). Jejunoileal atresia was associated with intrauterine volvulus, (27%), gastroschisis (16%), and meconium ileus (11.7%). INTERVENTIONS: Patients with duodenal obstruction were treated by duodenoduodenostomy in 119 (86%), of 138 patients duodenotomy with web excision in 9 (7%), and duodenojejunostomy in 7 (5%) A duodenostomy tube was placed in 3 critically ill neonates. Patients with jejunoileal atresia were treated with resection in 97 (76%) of 128 patients (anastomosis, 45 [46%]; tapering enteroplasty, 23 [24%]; or temporary ostomy, 29 [30%]), ostomy alone in 25 (20%), web excision in 5 (4%), and the Bianchi procedure in 1 (0.8%). Patients with colon atresia were managed with initial ostomy and delayed anastomosis in 18 (86%) of 21 patients and resection with primary anastomosis in 3 (14%). Short-bowel syndrome was noted in 32 neonates. MAIN OUTCOME MEASURES: Morbidity and early and late mortality. RESULTS: Operative mortality for neonates with duodenal atresia was 4%, with jejunoileal atresia, 0.8%, and with colonic atresia, 0%. The long-term survival rate for children with duodenal atresia was 86%; with jejunoileal atresia, 84%; and with colon atresia, 100%. The Bianchi procedure (1 patient, 0.8%) and growth hormone, glutamine, and modified diet (4 patients, 1%) reduced total parenteral nutrition dependence. CONCLUSIONS: Cardiac anomalies (with duodenal atresia) and ultrashort-bowel syndrome (<40 cm) requiring long-term total parenteral nutrition, which can be complicated by liver disease (with jejunoileal atresia), are the major causes of morbidity and mortality in these patients. Use of growth factors to enhance adaptation and advances in small bowel transplantation may improve long-term outcomes.

Colonic Diseases↗
PubMed1992

Perioperative teaching and counseling.

BACKGROUND: Patients who undergo surgery for colorectal cancer resulting in an abdominal stoma need extensive teaching and counseling to fully recover and enjoy a satisfactory quality of life. METHODS: The economics of health care, changes in length of hospital stay, what and how patients are taught, and ways in which adults learn were reviewed. Each of these influences on acquisition of self-care skills and knowledge were considered as they apply to the specific needs of stoma patients. RESULTS: Common misconceptions about ostomies should be dispelled to clear the way for adults to learn what they need to know to care for their ostomy. Postoperative teaching must wait until patients are alert and comfortable enough to attend to instruction. Educational material should be prepared at the patient's level of understanding. CONCLUSIONS: An adequate budget for education and dedicated patient education personnel are necessary for effective perioperative teaching and counseling of ostomy patients. In today's health-care system, patients who require a stoma need access to outpatient preoperative and postoperative training and emotional support.

Adult↗
PubMed1997

Pelvic exenteration: effects of surgery on quality of life and body image--a prospective longitudinal study.

OBJECTIVES: The goal of this study was to evaluate the impact of reconstructive and nonreconstructive surgical procedures on quality of life and body image for women who undergo pelvic exenteration. METHODS: Twenty-eight patients were assessed in a prospective study with a preoperative semistructured interview and an objective assessment (T1). Interviews and questionnaires were repeated 4 (T2) and 12 (T3) months postoperatively. The women were divided into groups with two, one, or no ostomies. A separate comparison was made of women with and without vaginal capacity. Quality of life was defined in terms of five categories according to the definition of health proposed by the World Health Organization: physical and psychosocial health; marital and sexual status; medical interactions. RESULTS: At all points in time, the patients' quality of life was affected most significantly by worries about the progression of the tumor. Twelve months postoperatively, patients with two ostomies reported a significantly lower quality of life (P = 0.008) and poorer body image (P = 0.002) than patients with no ostomy. At T3, patients with vaginal capacity reported fewer problems in all categories related to quality of life and significantly (P = 0.015) fewer sexual problems. CONCLUSION: An evaluation of quality of life and body image demonstrates the benefits of newer techniques for organ reconstruction. Thus, organ reconstruction should be performed whenever possible in patients with pelvic exenteration.

Adult↗
PubMed2004

Rectal complications after prostate brachytherapy.

PURPOSE: Prostate brachytherapy is gaining wide popularity as an alternative to resection for the treatment of locally advanced prostate cancer. Rectal-urethral fistula after prostate brachytherapy is a rare but serious complication, and its incidence, presentation, risk factors, and clinical management have not been well described. METHODS: From January 1997 to October 2002, seven patients with rectal-urethral fistulas were referred to two institutions (Brigham and Women's Hospital and West Roxbury Veteran's Administration Hospital) of a major teaching referral center. Clinical presentation, risk factors, prostate staging, and clinical management were examined in a retrospective fashion. RESULTS: Seven rectal-urethral fistulas developed from roughly 700 (1 percent) patients treated with prostate brachytherapy for prostate cancer. The average patient age was 67.7 years, preimplant prostate-specific antigen was 7.1, and Gleason score was 3+3. Symptoms occurred at a mean of 27.3 months after prostate brachytherapy was started and included anorectal pain (57 percent), clear mucous discharge (57 percent), diarrhea (43 percent), and rectal ulceration (43 percent). Coronary artery disease was a common comorbidity (71 percent). Previous transurethral resection of prostate (28 percent) and pelvic irradiation or external beam radiation therapy (14 percent) were not associated with increased risk of rectal-urethral fistula. All patients underwent a diverting colostomy (86 percent) or ileostomy (14 percent), and four patients went on to have definitive therapy. Definitive resection was performed between 5 and 43 months after diverting ostomy and was chosen on the basis of comorbid disease, quality of life, and degree of operation. Two patients required a second diversion after definitive resection because of anorectal pain and a colocutaneous fistula. Postoperative complications included myocardial infarction (14 percent), blood transfusion (14 percent), and bowel perforation (14 percent). Patients became symptom-free nine months after surgery. Six patients are alive and well today; one died from an unrelated cause. CONCLUSIONS: Rectal-urethral fistula after prostate brachytherapy is a rare but devastating complication. Patients should be followed for at least three years after prostate brachytherapy because symptoms can develop late in the course. Although diversion of fecal stream does not heal the fistula, all patients diagnosed with rectal-urethral fistula should first undergo diverting ostomy to alleviate symptoms. Then, one should consider definitive resection and ostomy closure.

Aged↗
PubMed1986

An antireflux procedure for use with the reversed gastric tube.

A study was undertaken to determine whether reflux could be reduced or prevented by creation of a nipple valve at the distal end of a reversed gastric tube. The gastric tube was constructed in standard fashion in six adult dogs. The tube was placed through a substernal tunnel to a cutaneous ostomy in the neck. An antireflux valve was then created by invaginating the lower end of the tube into the gastric remnant. The following observations were made before and after creation of the valve: (1) gastric distending pressure required to produce efflux of saline from the ostomy; (2) manometric pressure at the stomach-tube junction; and (3) 2-hour pH monitoring within the tube after acid infusion into the stomach. The valve shortened the gastric tube by 2.0 to 2.5 cm. It did not obstruct antegrade flow of saline. Prior to creation of the valve, reflux of saline out of the cutaneous ostomy occurred at an average pressure of 62 cm H2O (range 25 to 80). The antireflux procedure prevented reflux with distending pressures up to 200 cm H2O. Manometry revealed an average pressure of 18 cm H2O (range 5 to 25) at the lower end of the tube before creation of the valve. The antireflux procedure raised this high pressure zone to 60 cm H2O (Range 50 to 65) (P less than 0.05). Spontaneous reflux was rarely observed in the anesthetized dog when acid was infused into the stomach and the pH was monitored in the gastric tube. Acid reflux could easily be produced by application of minimal manual pressure to the closed abdomen.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed2004

Gene therapy using p21WAF-1/Cip-1 to modulate wound healing after glaucoma trabeculectomy surgery in a primate model of ocular hypertension.

Glaucoma is a common eye disease associated with elevated intraocular pressure (IOP). Lowering IOP is the only acceptable therapy for glaucoma and slows progression of the disease. Filtration surgery, which introduces a guarded ostomy through the sclera into the anterior chamber of the eye to allow the escape of aqueous humor, is the most reliable method for effective IOP lowering. Success of this surgery is limited by scarring of the ostomy, so this procedure is often accompanied by the use of antimetabolites, such as mitomycin C (MMC), to block the wound healing response. Although effective in preventing scarring, antimetabolites also yield unwanted side effects, such as hypotony and tissue degeneration due to cellular destruction. This study presents an alternative to antimetabolites by using gene therapy to introduce the human gene for p21(WAF-1/cip-1) (p21) to cause cell cycle arrest of surrounding cells rather than their destruction. In this procedure, p21 was delivered using a recombinant adenovirus to ocular hypertensive monkey eyes. These eyes then underwent filtration surgery. Results show that eyes treated with p21 exhibited open surgical ostomies by both functional and histological criteria, and did not display any side effects seen in control animals that were treated with MMC.

Adenoviridae↗
PubMed2002

Safety of the temporary loop ileostomy.

OBJECTIVE: To evaluate the complications of the temporary loop ileostomy. METHOD: A retrospective study of 222 consecutive patients with low anterior resection, ileal pouch-anal anastomosis or continent ileostomy and a diverting loop ileostomy routinely fashioned during the primary operation. The loop ileostomy was closed in 213 patients (96%) during the minimum follow-up period of 15 months. RESULTS: Four patients (2%) required preterm closure of the ostomy due to stomal retraction (n = 3) or bowel obstruction (n = 1). Four patients were readmitted due to transient bowel obstruction that resolved without surgery. After closure of the loop ileostomy a total of 27 patients (13%) had complications. In 7 patients emergency re-operation was done due to small bowel obstruction (n = 5) or intra-abdominal abscess (n = 2). Elective re-operation was done in 5 patients for hernia at the site of the previous stoma. Despite the use of a loop ileostomy there was 1 postoperative death after the initial operation in consequence of anastomotic leakage. There was 1 death in consequence of closure of the loop ileostomy after 3 weeks due to intra-abdominal sepsis and heart failure. CONCLUSION: In this series closure of the ostomy wasassociated with one death (0.5%) and overall ostomy-related morbidity included the need to re-operate in 6%.

Journal Article↗
PubMed2000

Disposable plastic liners for a colostomy appliance: a controlled trial and follow-up survey of convenience, satisfaction, and costs.

PURPOSE: The effectiveness of a disposable liner designed for a 2-piece colostomy appliance pouch was evaluated. DESIGN: Randomized, crossover trial with follow-up surveys. SETTING AND SUBJECTS: Nineteen participants were recruited from the Mayo Clinic in Scottsdale, Arizona, and the surrounding community. INSTRUMENTS: A Daily Colostomy Care Evaluation Record and tally sheet of times for ostomy care were designed by the authors. METHODS: Participants, acting as their own controls, were randomly assigned to use either an unlined or a lined appliance for 9 days. On day 10, participants switched to the opposite regimen, which was maintained through day 18. They recorded the time required for daily colostomy care and perceptions of the lined and unlined appliances. The volume of ostomy supplies and cost were recorded at baseline, 1, 3, and 5 to 9 months after the initial trial. RESULTS: Odor, bother, perceived severity of leakage, and partner acceptance were better with unlined than lined appliances. Half of the participants were using a liner > or =75% of the time 3 months after the trial. There was no difference in cost when lined versus unlined ostomy systems were compared. Participants who chose to use the liners indicated high satisfaction. Problems noted included an inadequate seal with the liner (58%), inadequate liner size (16%), retention of flatus by the liner (11%), and difficulty removing the full liner (11%). CONCLUSIONS: The study supports recommending liners to patients who have a modest amount of fecal output or flatus. However, patients who are unable to manipulate the seal or have a large output volume are unlikely to find the liners a convenience. Satisfaction with the liners was sufficient to warrant investigation and design of a lined device with an improved design, greater capacity, and tighter seal.

Aged↗
PubMed1994

Laparoscopic ileostomy and colostomy.

OBJECTIVE: The technical features of laparoscopic ileostomy and colostomy are described. SUMMARY BACKGROUND DATA: A diverting ileostomy or colostomy can be performed with minimal trauma by laparoscopic techniques. This is distinct from the complex laparoscopic and laparoscopic-assisted resections of small and large bowel. To date the technical features of creating a diverting ileostomy or colostomy have not been emphasized sufficiently. METHODS: Standard laparoscopic techniques are used to create a pneumoperitoneum. After mobilization of the ileum or colon, a stoma is made on the abdominal wall. A trocar is introduced at the site where the stoma is located, thus reducing the technical problems associated with creating and maturing a stoma while the abdomen is insufflated. RESULTS: This approach obviates the need for a laparotomy while creating an ileostomy or colostomy. The technical features of creating a double-barrel ostomy, an end-ostomy with a stapled distal limb, and a loop ostomy are described. The postoperative recovery is prompt with a rapid return of intestinal function and early discharge from the hospital. CONCLUSIONS: Laparoscopic ileostomy and colostomy are straightforward procedures that reduce postoperative discomfort and ileus, and reduce the length of hospital stay.

Adult↗
PubMed1996

Living with cancer: perceptions of well-being.

The aims of the study were, first, to provide descriptive data on the perception of psychological well-being one year after surgery in a group of patients treated for gastro-intestinal cancer; secondly, to compare aspects of psychological well-being between the group of patients living with other chronic diseases, and thirdly, to determine whether the perceptions of psychological well-being were related to coping capabilities. Sixty-nine patients with gastro-intestinal cancer and 20 patients with ostomies due to Crohn's disease or ulcerative colitis participated in the study. The most interesting finding in this study was that the cancer patients with a strong sense of coherence perceived their well-being as better than did the patients with a weaker sense of coherence. Other interesting findings were the differences in psychological well-being between younger (< 67 years) and older (> or = 67 years) cancer patients and between the younger cancer patients and non-cancer patients with ostomies. The young perceived their well-being as poorer than that of the old and the cancer patients rated their sense of psychological well-being as poorer than that of the patients with ostomies. It is concluded that nurses should focus their attention not only on the patients' physical well-being but also on their psychological well-being. Specific consideration should be given to the psychological needs of younger cancer patients.

Adaptation, Psychological↗