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Consists of the:
Mouth
Oesophagus
Stomach
Small Bowel
Large Bowel
Anus
About 5-7 meters long, and 7-10m2 in surface
Consists of three main parts:
Duodenum
Jejunum
Ileum
1. Food is being broken down
2. Absorption of nutrients and majority of water
Absorption of nutrients:Fats: upper part of IleumCarbohydrates & proteins: Ileum & JejunumSalts: Ileum (& partially Colon)Vitamin B12: terminal Ileum
About 8 litres produced daily,And around 7 litres absorbedSalvia: 1 litreGastric juice: 2 litrePancreatic juice: 1 litreBile: 1 litreIntestinal juices: 3 litre
app. 4 hours
Is 1-2 meters long, Divided into several sections:
Ascending
Transverse
Descending
Sigmoid
Rectum
Anus
Principal functions: Absorption of water, bile salts and electrolytes Reservoir for faeces until convenient to evacuate from anus
12-18 hours
ILEOSTOMY
Ileostomy
Open, Transparent bag
Permanent ileostomy end ileostomy
Temporary ileostomies end ileostomy
loop ileostomy
Newly operatedSutures are pulling the skinSeparation (beginning)Skin slightly macerated Post-op oedema
” Perfect” ileostomyNormal colour and sizeNice round shapeSurrounding skin normal
Oral: 3-4 cm (everted)Anal: skin level
Oedema
Normally 1500-2000 mL fluid /day enters the colon from the ileum
ILEOSTOMY OUTPUT : 1. POD 1 – 3 : effluent is bilious & liquid 2. POD 3/5 : output stabilizes or slightly3. – 6-8 weeks : steadily until a steady state
* 200 – 700 mL/day High stomal output in the perioperative period is
managed by aggressive rehydration & replacement of depleted electrolytes
4 – 6 month post op : - effluent volume varies little - consistency is porridge-like :
yellow brown colour & food particles (+)
Ileostomy effluent : 90% water Correlation between body mass & output :
* 40 kg individu ~ output 300-400 mL/day* 80 kg individu ~ output 800 mL/day( Hill GL, et al )
Ileostomy adaptation : - slowing small bowel transit time
Gastrointestinal Transit After ProctocolectomyGroup (mean ± SD)------ -----------------------------Control Ileostomy
Parameter (min) ( n = 8 ) ( n = 5 ) p value----------------------------------------------------Gastric emptying 120±22 109±10 NS
Small bowel transit 243±32 348±12 <0.01----------------------------------------------------
Soper NJ et al. Gastrointestinal transit after proctocolectomy with ileal pouch-anal anastomosis or ileostomy, J Surg Res 46:300, 1989 from Taylor WE, Pemberton JH, Stoma Physiology in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
Water intake : - no role in determining ileostomy output
Dehydration : - output, - thicker consistency
Fasting : output 50 – 100 mL/day Elemental diet :
output & [ digestive enzymes & bile salt ] High fat content :
increase output to 20% > baseline Increases in fiber content > 16g/day :
: - output by 20-25%, - stool frequency & flatus
diet Na volume of stomal output Grape & Fruit juices : stool’s wet weight Majority of patients :
- maintaining or gaining weight- tolerance of most food types
Normal nutrition is the goal As terminal ileal resections are < 100 cm, there
are few nutritional consequences
Taylor WE, Pemberton JH, Stoma Physiology in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
Na lost in ileostomy effluent ± 60 mEq/day;via normal person’s stool : 2-10 mEq/day
Symptomatic salt depletion is rare :urine output & Na excretion are decreased( enhanced renal conservation of salt & water )
Ileal Na loss is normally overcome w standard diet
However, onset of volume depletion is rapid if high ileostomy output developed
Terminal ileum is important for water & Na resorption
Extent of small bowel resection directly effects the ileostomy adaptation process
Losses of fat & nitrogen > in more extensive bowel resection influence water & electrolyte loss
A proximal located loop ileostomy extended ileal resection
Normal individu = ileostomy patient loses 9 mEq K/day
Mature ileostomy excretes ± 1.5 g N daily Cooper et al :
- ileal resection 4 cm : normal body weight, normal fat & water content, reduced total body N & K implying a fat free body mass- ileal resected > 50 cm : total body weight , due to total fat
Extensive ileal resection : Ca & Mg loss
Taylor WE, Pemberton JH, Stoma Physiology in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
After ileostomy : intermediate in nature between small bowel & colon
80 x organisms in terminal ileum Coliforms > 2500 x than in normal ileal fluid Staphylococci, streptococci & fungi Bacteroides fragilis was rarely found
Urinary stone formation :|- 3-13%- predisposing factors : high output ileostomy & extensive ileal resection- related to dehydration & excess Na losses- 60% uric acid stones - Christie et al : * ileostomy & IPAA patients : urine volume & pH * [ Ca & Oxalat ] * ileostomies’ patients were at increased risk for forming uric acid & calcium stones
Prophylaxis : daily fluid intake & urine output
Taylor WE, Pemberton JH, Stoma Physiology in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
Gallstone formation :well adapted pts excrete bile acid = normal person
Extensive terminal ileal resection or inflammation :- enterohepatic circulation is disrupted- alters saturation of bile in GB precipitation stone formation
COLOSTOMY
Closed-end bag Colostomy
Open-end bag
Permanent colostomies
sigmoid colostomy
Temporary colostomies sigmoid colostomy a.m. Hartmann
loop transverse colostomy
divided transverse colostomy
Rectal amputation
+ sigmoid colostomy
Sigmoid colostomy
a.m. Hartmann
Newly operatedSkin looks fineAseptic post-op inflammationPost-op oedema
” Perfect” OstomyNormal colour and sizeNice round shapeSurrounding skin normal
Below the costal angle,usually to the right
1-3 cm above skin level
Diameter 6-10 cm, oval shape
Semi-firm - thin faeces
Relatively large amount of gas
Malodorous faeces
Faeces damaging to the skin
Loop colostomy Divided colostomy
Ability to create a healthy, well functioning, easily manageable colostomy is essential for all abdominal surgeons
A frequent part of emergent colon surgery Almost any abdominal procedure carries some
risk of requiring a colostomy or ileostomy OSTOMY = anastomosis between an endothelially
lined organ & the skin
Cataldo TE, End Sigmoid/Descending Colostomy in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
Stoma should be free of complication : retraction, stricture & prolaps
Temporary : many are in place or months to years every stoma should be created as if it was the only mode of defecation for life !
To achieve best functional outcome :_ tension free construction- adequate blood supply- minimal tissue manipulation
Stoma
Adhesion area
Area of discolouration
2
The area of discolouration is 25–50% of the total adhesion area
Therefore, the area score = 2
Stoma will frequently be a significantly life altering event
Whenever possible, it is best to have the patient & family well educated prior to surgery
Preoperative evaluation & marking by a qualified ETN will greatly improved patient satisfaction & funtional result
Cataldo TE, End Sigmoid/Descending Colostomy in Cataldo PA, MacKeigan, Intestinal Stomas,Principles,Techniques, and Management, 2004
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