Part 1 Continent Diversions: The New Gold Standards of Ileoanal Reservoir and Neobladder
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C ontemporary surgical techniques have revolutionized the therapy of persons affected by severe colorectal or urinary bladder disease. Two approaches, ileoanal reservoir (IAR) and orthotopic bladder reconstruction (neobladder), have become the new "gold standards" of definitive care because their functional outcomes have been so positive and they preserve patients' native sphincters. This article examines these two innovations, their surgical construction, indications, contraindications, medical and surgical care issues, and nursing implications. Research to discern optimal surgical techniques, assess the long-term outcomes of these procedures, develop definitive diagnostic instruments for Crohn's disease, and ascertain the potential effects of medical treatments for conditions such as inflammatory bowel disease and bladder cancer is needed.
Until the last decade or so, persons affected by familial adenomatous polyposis (FAP), severe chronic ulcerative colitis (CUC), or cancer of the urinary bladder were faced with a difficult choice. They could undergo a traditional noncontinent fecal or urinary diversion or face even longer surgery and adaptation by the creation of a catheterizable continent fecal or urinary diversion. Although research suggests that quality of life can be good for persons with an ileostomy or ileal conduit (urostomy),1 both involve wearing an external appliance for life. The alternative to a continent ileostomy or urostomy eradicates the need for an external "bag" but involves more intricate surgery and necessitates multiple daily intubations. In addition, the "nipple valve" continence mechanisms of the various continent fecal and urinary pouches can deteriorate over time and require surgical revision or conversion to a traditional diversion.
Improved anesthetic techniques and surgical technology (especially stapling devices) have empowered surgeons to accomplish one of the noteworthy developments in elimination surgery - a move away from permanent incontinent stomas. Now, IAR and neobladder innovations have become the "gold standard" or treatment of choice.2,3 Many of these complex surgeries now can be performed laparoscopically, further shortening recovery time. The enormous advantage is that trans-anal defecation or transurethral urination is preserved with near normal continence. For many persons with life-threatening diagnoses, the worst of times has become the best of times.
The IAR should be distinguished from two other procedures - ie, the coloanal reservoir performed for rectal cancer and the straight ileoanal pull-through for the treatment of CUC or FAP. In the former restorative procedure, a neo-rectum is constructed using descending colon, making a colonic pouch. The pouch is attached to the anal canal similar to the IAR approach. Many adaptation issues that IAR patients face are not present with the coloanal pouch because the entire colon is not removed.4
The IAR differs from the straight ileoanal pull-through - the pull-through involves a proctocolectomy and direct attachment of the ileum to the rectum. The pull-through is associated with much poorer outcomes, prolonged severe diarrhea, and fecal incontinence.5
Epidemiology and Pathophysiology: FAP, CUC, and Bladder Cancer
The IAR is known by several names, including restorative proctocolectomy, Park's Pouch (after Sir Alan Parks who first published about the IAR), and ileal pouch anal anastomosis (IPAA), among others.3 The two common indications for use include FAP and CUC. The negative consequences of both disorders mandate a surgical curative approach. The IAR offers definitive cure and spares the person's natural sphincter, allowing near-normal continence.
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