Abdominoperineal resection and colostomy

1. Abdominoperineal resection and colostomy Kathleen Hahn, Dietetic Intern

2. Learning Objectives: • Identify an abdominoperineal resection and colostomy procedure • Discuss the nutritional impact of an abdominoperineal resection and a colostomy • State the importance of early nutrition intervention for a malnourished patient

3. Pretest #1 • An abdominoperineal resection typically results in a colostomy, but the colostomy is generally reversed after healing. True or False

4. Pretest #2 • An abdominoperineal resection removes which portion(s) of the GI tract? • The lower portion of the ileum and the entire colon, rectum and anus • The entire colon, rectum and anus • The lower portion of the colon and the entire rectum and anus • The rectum and anus

5. Pretest #3 • Which foods need to be eliminated from the diet to prevent a stoma blockage with a colostomy bag? • Popcorn and nuts • Corn, salad greens, and vegetable skins • All fruits and vegetables • A and B • None of the above

6. Pretest #4 • The following nutritional guidelines are important for a patient with a colostomy bag (select all that apply) • Drink plenty of fluids • Chew food well • Avoid excess weight gain • Eliminate all potential odor-producing foods

7. Pretest #5 • When a malnourished patient is admitted to the hospital and is NPO, it is acceptable to wait 7 - 10 days for diet advancement or initiation of nutrition support. True or False

8. Why I chose this patient: • Condition pertinent to nutrition care • Followed three times • Made a difference in the patient’s care

9. Patient: • TJM • 54 year old Caucasian male • Married and lives with wife who is primary caretaker • No children • Deputy warden - Retired in 1996 • Admitted on 3/19/17 for scheduled Abdominoperineal Resection (APR) and Colostomy due to rectal adenocarcinoma

10. What is an abdominoperineal resection and colostomy? • Technique developed more than 100 years ago • Treatment for rectal cancer – 49% • Complete removal of lower portion of the colon, rectum, and anus • Open surgery • Laparoscopic surgery • Perianal incision • Results in a permanent colostomy • Typically done electively rather than emergently

11. Pre-surgery Post-surgery

13. Preparation for APR and Colostomy Creation: • Patient must under go mechanical bowel preparation the day before surgery • Clear liquid diet day before • NPO after midnight • Miralax – will cause frequent bowel movements • Heparin to prevent cardiac issues • Antibiotics to prevent infection

14. Potential Complications of APR: • One of the most complex surgical procedures • Cardiac and pulmonary complications • Should be assessed preoperatively to reduce mortality risk • Intraabdominal or pelvic abscess – 32% of early problems • Nerve injury impacting sexual or urinary function that may resolve or be permanent • Bladder and ureter injuries – typically repaired • Perineal wound – • Closed with sutures – restrictions on sitting, lying down and activities until healed

15. Colostomy Complications • Short term: Ischemia, necrosis, stricture • Retraction due to significant weight gain or parastomal herniation • Improper site placement • Psychosocial and medical implications – important to go through lengthy preoperative discussion and preparation

16. Post-Operative: • 3-7 days • Take a stool-softener to prevent constipation • Diet Progression: ice chips thin liquids solid foods • May take a few days for digestive system to become active again • Discharge: • May have abdominal bloating or mild nausea • Can resume a normal diet • Appetite typically returns to normal within a week or two • Colostomy nutritional recommendations

17. Post-Operative: • Typically are undergoing chemotherapy and/or radiation • 40% return to work after this procedure • 5 year cancer-specific survival rate - 62% • Future: plastic surgery – artificial sphincters and muscle transposition to reconstruct rectum • Eliminates need for colostomy

18. Nutritional Recommendations for a Colostomy Bag • Should not change your enjoyment of food • Can return to normal diet within 6 weeks after surgery • Eat 3 or more meals per day • Chew food well • Try new foods one at a time • Avoid gaining excess weight • Drink a lot of fluid each day • Personal experience • Potassium and Sodium – replace by increasing these in the diet

19. Preventing Colostomy Blockage • Eat in small amounts and chew well:

20. Preventing Colostomy Odor • Potential odor-producing foods: • Certain vitamins and drugs can cause odor • Odor-reducing foods: Buttermilk, parsley, kefir, yogurt

21. Preventing Gas, Constipation and Diarrhea with a Colostomy • Reducing gas • Eat regularly • Avoid swallowing air • Avoid chewing gum and drinking through a straw • Avoid/eliminate certain foods: asparagus, beer, Brussels sprouts, broccoli, nuts, soda, sweets, fish, dried peas and beans, radishes, onions • Reducing Constipation • Drink plenty of fluids • Eat high fiber foods and/or try coffee, chocolate, lemon juice or prune juice • Exercise • Diarrhea • Foods that may improve symptoms: Applesauce, bananas, boiled milk, cream of rice, peanut butter, rice

22. TM’s Past Medical/Surgical History: • 2003- Malignant neoplasm of prostate and right upper lobe of lung • Received radiation • Diverticulitis of colon • Acute duodenal ulcer with perforation • Resection and temporary colostomy • 2013 - Tonsil cancer • Percutaneous endoscopic gastrostomy (PEG) placement • Radiation, Chemotherapy • Dysphagia- Nutren 1.5 @ 250 ml – 5 times per day (1875 kcal and 75 gm protein) • Lymphadenectomy • 2014 – Cervical Lymphadenectomy (Nutren 1.5 – 4 per day) • PEG removed

23. Past Medical/Surgical History: • 2016 – Admission for cholelithiasis • 2016 - Carcinoma of base of tongue • August – PEG tube placement • September – laryngectomy / tracheostomy • Admission for pharngocutaneous fistula • October: restart tube feeds • Impact Peptide 1.5 – 250 ml 5 times/day (1875 kcal and 118 gm protein) • Nutren 2.0 – 250 ml 4-5 times/day (2000-2500 kcal and 84-105 gm protein) • Rectal Adenocarcinoma • Radiation and chemotherapy • December – Admission for Pneumonia

24. Past Medical/Surgical History: • February: only able to drink 1 - 2 cans of Nutren 2.0 due to cramping and diarrhea • Recommended to try Peptamen 1.5 with Prebio OR add 2 scoops of Benefiber to Nutren 2.0 • March 2017: Admission for ileus • Peripherally Inserted Central Catheter (PICC) inserted and started on TPN • 2,000 ml/day, 90 gm amino acids, 200 gm dextrose (increased to 267 gm), 63 gm lipids daily – 14 hour cycle

25. Patient History: • Relevant Family History: • Aunt – lung cancer • Brother – testicular cancer • Mother – kidney cancer • Father – stroke & neurological disorder • Smoked a pack/day for 35 years (quit in 2013) • Drank 6 - 12 beers per day until sometime in 2016

26. Present Admission • Admitted on 3/19 for scheduled Abdominoperineal Resection (APR) and Colostomy due to rectal adenocarcinoma

27. Medications / Supplementation: *throughout admission

28. Pertinent Labs:

29. Physical findings: • Height: 6’ • Weight: 60.2 kg (133 pounds) • Usual body weight of 175 pounds several years ago • BMI: 18.04 – Thin • Weight loss of 7% in 3 months • Poor appetite, compromised swallow function - Laryngectomy • Colostomy • Last bowel movement: prior to admission (3/20) • Surgical incision

30. What do you think his diagnosis should be? • Predicted suboptimal oral intake • Suboptimal oral intake • Increased nutrient needs • Altered GI function • Chewing difficulty • Malnutrition • Swallowing difficulty • Suboptimal protein-energy intake • Impaired nutrient utilization

31. Nutrition Diagnosis: • Altered GI function related to rectal cancer as evidenced by NPO status. • Malnutrition moderate related to chronic illness as evidenced by patient consuming less than 75% of estimated energy requirements x 1 month and 7% weight loss x 3 months. • Swallowing difficulty related to laryngectomy as evidenced by patient requiring non-oral route of nutrition. • Increased nutrient needs (protein and energy) related to cancer as evidenced by catabolic nature of the condition.

32. What do you think his intervention should be? • Clear liquid diet • Low fiber diet • Regular diet • Enteral nutrition into the stomach • Enteral nutrition post-pyloric • Peripheral parenteral nutrition • Total parenteral nutrition

33. Nutrition Intervention: • Recommended Initiation of Total Parenteral Nutrition (TPN) • Recommended Nutrition Support Consult • Action: Paged the resident to recommend initiation of TPN • Goal: Initiation of parenteral nutrition within 24 - 48 hours.

34. Monitoring and Evaluation: • TPN: formula, rate, progress, potential for refeeding syndrome • Weight for trends

35. Follow-up Visits: • 3/23 • TPN not initiated – Patient frustrated • Abdominal pain • Additional Dx: Inability to swallow related to laryngectomy as evidenced by patient report of inability to take anything PO. • Goal – not resolved • Recommendation: same as previous • Paged resident again

36. Follow-up Visits: • 3/27 • Enteral nutrition started – patient felt good and ready to go home. • Recommendations: • Advance feeds to a 16 hour cycle for discharge • Follow up in home tube feed clinic in 2-4 weeks • No new Dx – removed Altered GI function • Goal met – Enteral nutrition initiated

37. Telephone Encounters: • 3/29: Tube feeds going well – wants to use up Nutren 2.0 • 3/31: Gas, bloating, high ostomy output • Recommend switching to only Nutren 1.5 – wants to switch to 2 bolus cans and 3 overnight at rate of 95 ml/hr • 4/7: Bloating, cramping diarrhea, only 3 cans instead of 6, 2 L ostomy output, no weight gain • Recommend trying Peptamen 1.5 with Prebio

38. Home Tube Feeding Clinic • 4/27: Met with outpatient dietitian • Peptamen 1.5 with Prebio – 5 cartons per day • Only able to do 3 / day due to pain • Flushing tube before & after feedings: 160 ml water • Weight is stable, but down two pounds since hospital admission • BMI: 17.82 • Dx: Swallowing difficulty related to neck fistula as evidenced by NPO status with need for enteral nutrition • Continue enteral but consider TPN • Gas and diarrhea • Return in 4 weeks for follow-up

39. Comparison to typical patient with APR and colostomy:

40. Post-test #1 • An abdominoperineal resection typically results in a colostomy, but the colostomy is generally reversed after healing. True or False

41. Post-test #2 • An abdominoperineal resection removes which portion of the GI tract? • The lower portion of the ileum and the entire colon, rectum and anus • The entire colon, rectum and anus • The lower portion of the colon and the entire rectum and anus • The rectum and anus

42. Post-test #3 • Which foods need to be eliminated from the diet to prevent a stoma blockage with a colostomy bag? • Popcorn and nuts • Corn, salad greens, and vegetable skins • All fruits and vegetables • A and B • None of the above

43. Post-test #4 • The following nutritional guidelines are important for a patient with a colostomy bag (select all that apply) • Drink plenty of fluids • Chew food well • Avoid excess weight gain • Eliminate all potential odor-producing foods

44. Post-test #5 • When a malnourished patient is admitted to the hospital and is NPO, it is acceptable to wait 7 - 10 days for diet advancement or initiation of nutrition support. True or False

45. Things to Remember: • An abdominoperineal resection is the removal of the lower portion of the colon, all of the rectum and anus and results in a permanent colostomy. • Do not eliminate foods unnecessarily with a colostomy. • It is important to eat regularly, drink plenty of fluids, and avoid excess weight gain with a colostomy. • Advocate for your patient.

46. Thanks to… • Sharon Madalis • CorynKalwanaski

47. Resources: • https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789508/ • https://www.mskcc.org/cancer-care/patient-education/about-your-abdominal-perineal-resection-surgery • http://www.augusta.edu/mcg/surgery/midds/patient_education/abdominoperineal_resection.php • http://www.colorectal-cancer.ca/en/treating-cancer/treatment-cancer/ - image • http://www.upmc.com/patients-visitors/education/nutrition/Pages/ostomy-nutrition-guide.aspx • http://drugs.com