The Continent Ileostomy (or “Kock Pouch”)- update May 2014 Fran Woodhouse Advanced Nurse...
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Transcript of The Continent Ileostomy (or “Kock Pouch”)- update May 2014 Fran Woodhouse Advanced Nurse...
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The Continent Ileostomy The Continent Ileostomy (or “Kock Pouch”)- (or “Kock Pouch”)- update update May 2014May 2014
Fran WoodhouseFran WoodhouseAdvanced Nurse PractitionerAdvanced Nurse PractitionerOxford University HospitalsOxford University HospitalsNHS Trust.NHS Trust.
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Evolution of Surgeries for UCEvolution of Surgeries for UC
• 1951 Brooke end ileostomy1951 Brooke end ileostomy
• 1969 Kock pouch – “Continent ileostomy”1969 Kock pouch – “Continent ileostomy”
• 1978 Parks and Nicholls – ileo- anal 1978 Parks and Nicholls – ileo- anal pouchpouch
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BackgroundBackground
• 2007 a female patient 2007 a female patient aged 52 approached aged 52 approached Professor Mortensen. Professor Mortensen. (Oxford) To date 12 (Oxford) To date 12 patients .patients .
Western General, Western General, Edingburgh 20 over 17 Edingburgh 20 over 17 years (years (14 current14 current))
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Indications (for CI)Indications (for CI)
• UCUC• FAPFAP• Failed ileo-anal pouchFailed ileo-anal pouch• Previous proctectomyPrevious proctectomy
• Poor/absent anal Poor/absent anal sphinctersphincter
• Patient Patient preference preference psychological/social/ psychological/social/ sexual- those having sexual- those having difficulty coming to difficulty coming to terms with terms with conventional stomaconventional stoma
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Contraindications
• Physically incapable• Mentally incapable• Previous SBR• Desmoid Tumour• Crohns• Severe obesity
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So what is the Continent So what is the Continent Ileostomy?Ileostomy?
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New Dressing around K pouch catheter. Hollister 9782
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Some of the problems.........
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0
2
4
6
8
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12
14
16
18
2007-2014
Number of K poucheson Database
Males
Females
K Pouches Oxford
K Pouches Elsewhere
Valve Slippage
Fistula
Intubation problems
Pouch Excision
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• Pre-op preparation:
-Referral from consultant
-Booklet on Continent Ileostomy
-Pre-op counsel (ideally face-to-face)
-Contact with other K pouch owners
-Discuss the potential problems and re-operation rates+++
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Reasons for re-operation
-Slippage of nipple valve
-Parastomal sepsis
– Parastomal hernia– Prolapse valve– Difficulty with intubation– Ischemic valve– Fistula formation– Other
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Post op care
• Usual c/ o patient following laparotomy.• Catheter and stoma• Observe stoma TDS for blood supply-
use pen torch.• Flush medina catheter BD + more if
stops draining and patient feels bloated. 20-30mls warmed n/saline or sterile water. Do not withdraw
• Check dressing around stoma regularly. ? 2 piece appliance.
• Ensure that medina is well secured. Care on mobilising.
• Check tubing regularly for blockage.• If Medina falls out before 14 days, have
consultant/ SpReg re- insert
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Then what?
• Catheter out 2 - 3 weeks post op.
• Teach patient to catheterise.
• Order plenty of caps!!
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Medic Alert Bracelet
• “Internal pouch/Continent ileostomy/ Koch pouch.”
• Medina catheter to be inserted 4-6 hourly into pouch.
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Updates
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• Numbers of K pouches since 2007= 12
• Post op device for afixing catheter.
• Use of Marlen soft catheters
• Work with Julia Williams and Alison Crawshaw- regular telephone conferences.
• Article for BJN to be published (2014) supplement
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Booklet for patients
• In progress with Alison and Julia.
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New trial of Marlen catheters
• To study 20 patients using new Marlen catheter to determine if easier intubation with Marlen
• Asking patients for “testimonials “ to try and get these on FP10
• Currently only available in USA.
• My work with Clinimed to devise a new stoma cap for K pouchers.
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• Pre-op counsel• Collaborative working
with surgeons, e.g Endoscopy
• Booklet for medical professionals (hopefully being written by Richard Lovegrove in conjunction with Graeme Wilson and David Bartolo)
• Follow up in Nurse-led pouch clinic- hopefully the pink form to be adapted.
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MSc dissertation
• Wanting something “useful” which might benefit this group of patients.
• Literature Review.
Why? Why not collect primary data ?
Negative viewpoint
-complications +++
• Minimal published studies.
(Total of 11 from 1995-2012)
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Summary- How is QOL after a CI?
• Avoidance of an external drainable appliance.
• Improved sex life.• Improved general
enjoyment and happiness
• Less work and social restrictions.
• Anxiety about emptying the CI away from home.
• Repeated operations.• The freedom of
continence.
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Recommendations for practice• Dedicated centres.• A pre-assesment tool• Allow choice much
earlier for patients- not just as a last resort
• Clearer post-operative guidelines.
• Support groups specific to CI.
• Collaborative working with our surgical colleagues. Stoma nurses need more involvement. Would serve as a triage system and expediate care and treatment.
• Updated CI booklet with Alison Crawshaw and Julia Williams)
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• Perform our own study to replicate the research.
• Guidelines on diet and obesity.
• Address the anxiety issue re catheterising outside of home.
• Structured programme for surgeons.
• Design of a new stoma cap to manage excessive mucous.
• To work with an appliance company to create a model for patient demonstration of catheterising.
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The future of the Kock pouch?
• Interest is growing.
• Referrals from all over the UK and beyond
• Revival.
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In her own words....
“I empty it three times a day and never at night which is great. The pouch is totally continent of faeces but produces a small amount of mucous”
“I am so happy with my Kock pouch and eternally grateful to those who made it possible. It has totally changed my life for the better”
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Thank you. Any Questions?Thank you. Any Questions?