Information Day 2015

Date: Saturday October 24th

Venue: John Radcliffe Hospital, Oxford

From 10:00  Registration, with Coffee on Arrival

10:30  Welcome & domestics – Laura Dunn: Kangaroo Club Chairman

10:40   People, Places and Pouches

Professor Neil Mortensen: Colorectal Surgeon OUH NHS Trust, Professor ofColorectal Surgery University of Oxford Medical School, Fellow of Green Templeton College.

Professor Neil Mortensen,” taking a trip down memory lane” wore a white coat for his talk. He spoke about being the founder of the Kangaroo Club and said he had decided to name his talk, People, Places and Pouches as he had been asked to talk about his career at the OUH NHS trust (place) and the origin and evolution of pouches and of course pouches belong to people.

Professor Neil Mortensen said it had been a great privilege to have met so many people along the way, including everyone there that day.

Pouch Development

The ileo – anal pouch was developed at St Marks Hospital by Parks and Nichols, publishing its development in the BMJ in 1978. Since then approximately 40,000 pouches had been made around the world (see slide) with Oxford being the place where the second most have been developed.

The first pouches were made in a W-shaped design, this was later changed to a J shaped design. This was partly to make their creation easier and partly because changing the design didn’t make a significant effect on the frequency of need to empty the pouch.

Pouch Complications

Professor Mortensen said that prior to 1986, there hadn’t been a single pouch re-do undertaken at Oxford, however by 2014 re-dos had risen to 20% of pouch their operations. These result from Pouch complications:

  • Bleeding
  • Infarction
  • Peritonitis
  • Leak
  • Pouch and fistula
  • Pouch vaginal fistula
  • Stricture
  • Small bowel stricture

Septic complications are the most common. A fifth of these a due to a leak around the join. “We don’t sleep the night following a pouch operation worrying about leaks.”

These arise because the stapling devices used aren’t perfect, and “patients aren’t perfect”.

Where the whole pouch operation is performed in one go leakage is more of a risk. If the Colectomy has been performed previously, the risk reduces from about a third to 12%.

If the patient is on steroids at the time of the operation there is more chance their pouch will leak.

Any pouch sepsis will take place shortly after surgery. Most pouch failures will occur either very early on or slowly years later. (see slides for details)

So what can be done?

Early diagnosis is key. There is also the option of vacuum assisted healing. Or the pouch might need re-doing.

Salvage

Professor Mortensen drew sketches on the white board (not captured) to explain the reasons why a pouch might need salvaging or redoing. The reasons can be:

Mechanical:

  • Long efferent limb
  • Small pouch
  • Long blind limb
  • Twisted pouch
  • Intra pouch prolapse – or ‘hour glassing’
  • Anastomic stricture

Sepsis –“ infection as discussed before””

  • Partial anastomotic separation
  • Anastomotic sinus
  • Anastomic stenosis

See slides for the results of re-dos, which show that the most promising candidates for a successful outcome are those with mechanical failures.

Professor Mortensen summarised the take home message as: “overall 70% of redo operations are successful”.

He then explored complications after redo surgery, stating that pouch failure after redo surgery is around three times more likely than after the initial pouch surgery. (See slides for details.)

What if reconstruction is not possible?

There are basically three options:

  • Pouch Excision
  • Permanent diversion
  • Convert to a Koch Pouch

Pouch Excision (removal) is not for the feint hearted. It’s a big operation with potential for complications.

There is growing evidence that leaving the pouch in place, but diverting the bowel is the safest option.

The conversion of the ileo anal pouch to a Koch Pouch is “tough on the patient, tough on the surgeon and tricky country altogether.”

Value slips are a common occurrence and require a full tummy operation to repair.

So what’s the key message?

The key message for surgeons is to “get it right first time”. Be in a surgical team who frequently undertake pouch operations – in one of the top ten.

The key message for patients – ensure that your surgical team are one of the top ten teams for frequency of pouch operations.

Looking back:

Over the last 30-40 years we have seen:

  • The creation of pouch surgery – which is now performed all around the world.
  • Technical refinement
  • Advances in medical treatment for pouch problems – although this is still not brilliant re pouchitis
  • Were now in the age of redo surgery – which is no longer last ditch, 70% of re-dos have a good outcome.

Professor Mortensen concluded by saying that it had been an enormous pleasure and privilege to have helped people during a tough time like pouch surgery and he thanked the Kangaroo Club for their support.

Questions:

Q: What are fistulas?

A: There are 3 kinds:

  • Anal gland fistula – lots of treatment options just as for non-pouch owners.
  • Fistula from pouch join to perineum or vergina – difficult to fix, generally need to redo the pouch.
  • Fistula from pouch join to urethra –  rare, are things that can be done about it.

Q: What level of exercise can people with pouches undertake?

A: Once healed following the operation, pretty much everything. Perhaps be cautious about lifting massive weights.

Q: What are the potential long term problems with pouches?

Q: How likely is it that a pouch owner will suffer from pouchitis?

A: 10% of pouch patients required long term or continuous anti-biotics?

There is a lot of interest in which bugs are doing the damage. It is an evolving story – there will be more information and treatments down the road.

Please click here to download the presentation: People Pouches and Places

 

11:20 – Presentation to Professor Neil Mortensen on the occasion of his retirement on the behalf of the Kangaroo Club – Emma Harris: Kangaroo Club


11:30 – Pouch Support at the OUH NHS Trust – Simon Turley: Advanced Nurse Practitioner OUH NHS Trust

Simon explained that face- to-face nurse led Pouch Support clinics are held twice a month alongside Professor Mortensen’s clinic at the OUH NHS Trust. The team also give reviews over the telephone – during which they ask exactly the same questions as when face-to-face, the only difference is that the pouch owner needs to get their blood tests done at their GPs prior to the call and either ask for the results to be sent to the Pouch Support team or follow up with the GP for the results.

Please click here to download the presentation.

 

11: 35 – The OUH NHS Trust without Professor Mortensen – Mr Bruce George: Kangaroo Club Chairman, Colorectal Surgeon OUH NHS Trust

Mr Bruce George said that Professor Mortensen has seen pouch surgery from the onset and over a career of 30 to 40 years had had a massive influence on a large number of people.

However, he wanted to reassure everyone that the OUH NHS Trust will be carrying on with pouch surgery at the same quality after Professor Mortensen’s retirement.

Volume of surgery is key

The key factor is the volume of surgery undertaken. (See slide)

Less than 20 cases over 8 years translates broadly into worse outcomes. This is not just re the technicality, but also in the decision making. Is pouch surgery the right thing to do?

St Mark’s, London has the biggest volume, followed by Oxford – although perhaps currently number one in the year 2015.

The future: as envisioned in 2010

Bruce George said that in 2010 he had given a talk on the future of Pouch Surgery, which he had summarised as follows:

  • Laparoscopic colectomy
  • Laparoscopic pouch formation
  • Emergence of” re-do” pouch surgery and the Koch pouch.

In fact, in 2015 Oxford they don’t do any totally laparoscopic surgery, they do “laparoscopic assisted” surgery.  Increasingly the thought is that really difficult technical surgery is better done through open surgery, as this is less likely to lead to complications.

(See slides)

Over the last couple of year there has indeed been an increase in the number of re-dos and also Koch pouches formed. These have often been performed by two surgeons to increase institutional knowledge and prepare for Professor Mortensen’s retirement (he will however be returning to assist with very complicated cases following his retirement).

In 2015 the big new surgical development is taTME or ‘trans anal or bottom-up’ surgery. This is pioneering surgery, which is minimally invasive, but if, and it’s a big if, the patient is large with a narrow pelvis, it is very difficult to get the join to the pouch in the right place.

Robotic techniques are also technological advances (see slides), but they are not yet mainstream and the cost is currently pretty massive.

The future: as envisioned in 2015

So the future of Pouch surgery in Oxford as expected in 2015?

  • Maintaining high volume, high quality pouch surgery
  • Maintaining challenging re-do and Koch surgery
  • Introducing robotics and new techniques as they come on-stream.

Q: What is a koch pouch?

A: Basically it is a continent ileostomy (Click here for more details (link to) http://www.kangarooclub.org.uk/?page_id=139 ). Surgically and for the patient, this is a big undertaking, it needs a lot of thinking through.

Making the continent valve is a big challenge.

Q: What is the minimum number of pouches that a patient should expect their surgeon to have made?

A: At least 10 per year is probably acceptable. At Oxford we make 20-30 a year– this level will be continuing.

Q: What is the life span for a pouch?

A: No-one really knows, as the first pouches were made in 1978/79. Generally, there is a bit of deterioration in bowel function as we get older, but this isn’t necessarily worse for pouch owners.

Q: How do you ensure the best outcome from pouch surgery?

A: The greatest problem is predicting the outcome of pouch surgery. Sometimes everything goes well, but pouch function is poor- for no identifiable reason. However, generally the outcome is better when you are in generally good health when you have the pouch surgery.

Please click here to download the presentation: OUH without Professor Mortenson

 

12:00 – The next phase for the Kangaroo Club, including AGM – Laura Dunn


12:30 – Lunch – Sandwiches, cake and fruit and an opportunity to meet and chat with other pouch  owners and their partners


13:20 – The Ileo Anal Pouch and Nutrition – Karen Jackson: Dietitian and Nutrition Specialist, OUH NHS Trust

What is the function of the colon?

It is to:

  • Re-absorb electrolytes (salts) & water
  • Form stools
  • Fermentation
  • Synthesize & absorb vitamins  (Vit K, B12, thiamine)

Post pouch op guidelines

Are to edge back to a normal diet. Reintroduce foods in small quantities (especially fibrous foods) and chew well. (See slide)

What should you eat to maintain a healthy body?

The normal guidelines for the whole population apply:

Carbs: 55%

Fat 30%

Protein: 15%

See slides for 5 food groups.

Fluid Intake

This is very important for the function of the pouch and general health. High caffeine drinks increase pouch output as can hyper tonic drinks such as fruit juice etc dehydrating further.

It is important to remember that a high output is also likely to result in low potassium which should be replaced. Ripe bananas have a high potassium content.

The WHO rehydration formula is very effective and can be found on-line, one version is here: http://rehydrate.org/solutions/homemade.htm#recipe

Special dietary considerations

If you are limiting your diet at all, take into account your calcium intake.

If you are taking additional vitamins and minerals – speak to a dietician. Too many can be a problem, competing against each other and as they are processed by the liver causing toxins.

The dysfunctional pouch

Studies show that lifestyle impacts the way that the pouch is maintained.

The following can all have an impact:

  • Erratic eating habits
  • High caffeine intake
  • High alcohol intake
  • High fibre diet
  • High fat intake
  • Poor fluid intake
  • Sorbital intake – this is a sugar substitute which is increasingly found added to products to prolong their shelf life. Is also added to liquid medications. It can irritate the bowel and create high output.
  • Irritable bowel syndrome
  • Food intolerance – might be developed when unwell pre-surgery, or if suffering from pouchitis
  • Pouchitis

Get back to basics and really know what you are eating.

Do Probiotics help?

The studies have only involved very small numbers – see slide- the Cochrane library looked at all the evidence in 2010, only 11 trials world-wide significant enough to form an opinion. On the basis of these, they said VSL#3 is more effective than a placebo.

It should be used for a minimum of 3 months.

Foods to thicken output

See slide.

NB Mashed potatoes shouldn’t have any skins.

Banana should be ripe.

Foods that increase pouch output

See slide.

Also chickpeas, baked beans, peas, blueberries, strawberries, raspberries.

But don’t avoid, unless in high output.

Optimising pouch function

Eat freshly cooked carbohydrate e.g. fresh pasta not dried.

Avoid foods that cause you irritation – this varies from person to person.

If need s be get a formal assessment from a dietitian.

Good nutrition and healthy eating make a difference!

Please click here to download the presentation: Ileoanal Pouch & Diet

 

14:00 – Discussion Groups:

  • Diet (Group discussion led by Karen Jackson and Martin Brandt)

The main comments captured were as follows:

Be careful about ready meals and processed foods – it hard to know what’s in them.

If you like foods that cause wind and you re at home, don’t worry about it!

Experiment with quantities.

Eat something before you eat salad.

  • Lifestyle and exercise (Group discussion led by Laura Dunn and Emma Harris)

The benefits of Pilates were discussed: building up core stability, strengthening the pelvic floor, protecting your back by having strong core muscles. Helpful for other exercise – such as cycling, core strength is really important for controlling the bike. There are many DVDs on Pilates exercises, covering the basics for beginners and onwards.

It was agreed that the key thing is to get out there, do some exercise and live your life. Find reasons to get out, especially to the countryside

Walking works well, the impact helps with bone density.

After the pouch operations, just take it easy and build up. People had used the tread mill, bike, cross trainer – after they were well, they had done virtually everything.

One of the group recommended mediation, lots of people felt it was important to get your mind in the right place. It was felt that it is easy to be negative and important to have a positive frame of mind.

It was generally felt that stress makes pouch function worse, but that it can’t always be avoided. Singing makes some of the group feel positive – and it was agreed that you should do what makes you feel good

 

14:30 – Brief Break


14:35 – Question and Answer Session – Simon Turley: Colorectal Nursing OUH NHS Trust and Angie Perrin:

Q: If I have a pouch because of FAP, rather than UC, does that mean I am less likely to get pouchitis?

A: Yes, it would be extremely unusual.

Q: How do I reduce pouch output from 14 times a day?

A: Take loperamide – half and hour to an hour before you eat. Consider all the facts talked about diet and make sure that you empty your pouch fully. Tilt your pelvis and use your core muscles.

Q: Ocne the colon has been removed, are there additional manifestations of UC?

A: Skin conditions and inflammatory arthritis are the most common

Q: When should you begin taking loperamide?

A: Establish a pattern of eating after surgery and once this is settled introduce loperamide as needed. Learn to adjust the dose as needed

The following leaflets might be useful:

  • Holidays and travel
  • Anal skin care
  • Sports and fitness
  • Sphincter exercises

 

14:35 – Looking to the Future for Pouch Owners – Laura Dunn: Pouch owner since 1985

 

15:30 –  End


There was plenty of opportunity to meet and chat with (other) pouch owners and their partners during the day.

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