Post on 19-Aug-2020
10/11/2019
1
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Welcome to the World of WCET®
The World Council of Enterostomal Therapists®
www.wcetn.org
WCET® Webinar on
Low Anterior Resection Syndrome After Stoma Closure
Denise Hibbert
Moderator: Alison CrawshawNurse Consultant, Scotland, UKWCET® Treasurer
Thank you to:
WCET® Education Committee
Jen Wood WCET® Central Office Administrator
In Celebration of World Ostomy Day
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Membership Benefits
• WCET® Journal (English, Chinese, Spanish & French)
• WCET® BullETin
• Reduced registra on WCET® Congress
• Eligible for WCET® scholarships
• Discount at Excelsior College
• Networking, educational opportunities and communities of practice
1
2
10/11/2019
2
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Free to MembersBullETin
WCET® JournalEnglish Chinese Spanish French
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Ostomy Pocket Guide in English, Chinese & Spanish
Stoma Marking Pocket Guide in English, Chinese & Spanish
These resources can be found on the WCET® online store https://wcet‐online‐store.myshopify.com/collections/all
Also webinars are available to access in English & other languages on the WCET® website www.wcetn.org
© WCET® 2018
WCET® Educational ResourcesAvailable in English, Chinese & Spanish
3
4
10/11/2019
3
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
WCET® Educational ResourcesThese resources can be found on the WCET® online store https://wcet‐online‐store.myshopify.com/collections/all
IOG Guideline Wound Education Toolkit
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
WCET®‐ASCN UK 2020 Joint Congress!11‐14th October 2020
Early Bird: (1st Oct 2019 – 30th June 2020) £335.00 (members); £435.00 (non‐members) Standard: £375.00 (members); £475.00 (non‐members)Late: £415.00 (members); £515.00 (non‐members)220.00
Abstract submission deadline – 29th February 2020
5
6
10/11/2019
4
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Central Office Contact Information• Email: admin@wcetn.org
Skype: wcet.admin
• Postal address
1000 Potomac Street NW
Suite 108
Washington, DC 20007
United States of America
• Phone: +1 202‐567‐3030
Fax: +1 202‐833‐3636
www.wcetn.org
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Low Anterior Resection Syndrome After Stoma Closure
Denise Hibbert, RGN, MSc(WHTR), BSc, DipHE, ONC, STN, FSSCRS
Consultant in Colorectal & OWC NursingEditorial Board Annals of Saudi MedicineSaudi ArabiaWCET® Education Chair 2016‐2020
In Celebration of World Ostomy Day
7
8
10/11/2019
5
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Goals & Objectives
• Describe normal defaecation process & continence mechanisms
• Discuss definition of low anterior resection syndrome (LARS) & patient reported symptoms
• Describe anatomical & functional changes following rectal resection
• Identify patient & treatment related risk factors
• Discuss assessment & management in relation to current practice
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
LARS – Definition
Low Anterior Resection Syndrome:
“Disordered bowel function after rectal resection leading to a detriment to quality of life” (Bryant et al 2012)
• Occurs 25‐80% ‐ severity & duration varies
Graphics free public domain
9
10
10/11/2019
6
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Background Globally 1.8 million new cases of colorectal cancer 2018
Rectal Cancer accounts for 1/3rd of all colorectal cancers
Sphincter sparing surgery – LAR, now surgery of choice
Advances in treatment – increasing colorectal cancer survivorship – more individuals with LARS
Pathogenesis LARS poorly understood & poorly managed
Common risks ‐ lower anastomosis & radiation
ETs/OWC Nurses, well positioned to assess & manage symptoms
(Kapiteijn et al 2001, Pachler et al 2005 & 2012, Desnoo et al 2006, Cornish et al 2007, Bryant et al 2012, Bleier et al 2013, Pucciani 2013, Martalucci 2016, Chen 2016, Steineck et al 2016, Tenti et al 2018, Croese et al 2018, World Cancer Research Fund 2018, Kupsch et al 2018, Jimenez‐Gomez et al 2018)
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Symptoms– Frequency of stool
– Urgency
– Inability to distinguish gas from stool
– Faecal/Gas incontinence
– Clustering of bowel motions within 1st few hours – after meal
– Fragmentation of stool, incomplete emptying
Unpredictable ‐ vary in severity and typeOften combined with urinary & sexual dysfunctionAnxiety exacerbates symptoms
Affect on QOL
(Bryant et al 2012, Bleier et al 2013, Pucciani 2013, Emmertsen et al 2012, Martalucci 2016, Chen 2016, Steineck et al 2016, Keane et. Al 2019)
11
12
10/11/2019
7
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Normal Anorectal Anatomy
By Lesion at English Wikipedia, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=32927673
A PuborectalisB Rectum
C Anorectal Angle
D Anal Canal
E Anal Verge
F Internal & External Anal Sphincter
G Coccyx & Sacrum
H Pubic Symphysis
I Ischium
J Pubic bone
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Dynamics of Normal Defaecation Mass movement in colon, propagated by gastrocolic reflex
Rectal distention – stretch receptors ‐ urge defaecate
Involuntary relaxation internal anal sphincter (IAS) – rectoanal inhibitory reflex (RAIR) ‐ sampling mechanism
Sensory awareness (cerebral cortex) ‐ gas, liquid, solid (?urgent)
Motor impulses, rectosigmoid contraction, aided by raising intra‐abdominal pressure (pressure gradient)
Relaxation of puborectalis & anal sphincter ‐ defaecation
Closing reflex ‐ IAS
(Sagar 1996, Bharucha et al 2006, Palit et al 2012)
13
14
10/11/2019
8
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Anorectum & Continence
Rectum, delay defaecation – capacity, compliance & retrograde movement of stool
Puborectalis – anorectal angle
Transitional zone – sensory receptors – messages cerebral cortex
Length & pressure of anal canal Internal anal sphincter 75‐85% resting pressure – involuntary
External anal sphincter – motor response voluntary squeeze
Delay defaecation several hours (depends stool consistency)
(Rao et al 2004, Bharucha et al 2006)
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Rectal Cancer Treatment
• Early stages – surgical resection or local excision, type depends on distance from anal verge
– APR (permanent stoma) or LAR (sphincter sparing)
• Clinical cancer stage II and above
– Neoadjuvant chemoradiation
– Surgical resection ‐ >50% temporary stoma (ileostomy)
– Adjuvant chemotherapy
– Closure ileostomy (delays are not uncommon)
(Kapiteijn et al 2001, National Comprehensive Cancer Network 2018)
15
16
10/11/2019
9
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Low Anterior Resection
16cm ‐ anal verge to sigmoid Colon
Rectum
Dentate Line
IAS
EAS
Sigmoid Colon
Anal Canal 4cmAnal Canal 4cm
12‐16cm upper rectum
8‐12cm Middle rectum
4‐8cm lower rectum Level levator ani
Anal Verge
LAR if tumour within 8cm AV
Graphics by Denise Hibbert
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Total Mesorectal Excision (TME)• First described by Heald 1982• Dissection tissue surrounding rectum ‐ containing lymph nodes• Improves oncological outcomes reduces recurrence rates
Mesorectum is dissected down to level of pelvic floor
By Lesion at English Wikipedia, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=32927673
17
18
10/11/2019
10
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Mobilisation of Colon
Graphics by Denise Hibbert
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Type of Anastomosis ‐ Pouch
Straight A
Side to end A
Transverse coloplasty
Colopouch
Graphics by Denise Hibbert
19
20
10/11/2019
11
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Defunctioning Ileostomy
Graphics & photograph by Denise Hibbert
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Anastomotic Leak Feared
• Occurs in 2‐15% of LAR cases
• More than doubles mortality rate
• Poorer oncological outcomes
• Worse LARS symptoms
• Poorer QOL
(Rullier et al 1998, Lu et al 2016, Bostrom et al 2018)
21
22
10/11/2019
12
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Risk Factors LARSTreatment factors not fully understood ‐ multifactorial
Rectal resection
Total Mesorectal Excision
Direct trauma to sphincter
Level of anastomosis
Type anastomosis (neorectum)
Mobilisation colon
Defunctioning stoma ‐ time to stoma closure
Radiation
Anastomotic leak
AgePre‐op continenceDietComorbiditiesSmoking
(Kapitgeijn 2001, Herrmann et al 2003, Pollock et al 2006, Alves et al 2008, Emmertson et al 2013, Lee et al 2008, Bryant et al 2012, Bakx et al 2009, Martellucci 2016, Brown et al 2008, Portier et al 2005, Fazio et al 2013, Bregendahl et al 2013, Wells 2014, Brennan et al 2007, Kennedy et al 2008, Woo et al 2008, Chen et al 2015, Nuytens et al 2018, Haas et al 2018, Croese et al 2018, Son et al 2013, Baek et al 2014, Kupsch et al 2018, Jimenez‐Gomez et al 2018, Bostrom et al 2018, Keane et al 2019)
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Patient Experience– Relief surgery over‐fear of recurrence
– Unexpected psychological difficulties after stoma closure
– Loss control/dignity‐uncertainty from day to day
“Not in control of body…Regaining control or managing control…Tied to the toilet” (Taylor et al 2010)
(Worster & Holmes 2009, Taylor et al 2011)
Graphics free public domain
23
24
10/11/2019
13
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Health Related Quality of Life
Complex‐multifactorial – individualized Affected culture/spirituality
“No apparent differences in QOL are found in rectal cancer patients with a permanent stoma when compared to non‐stoma patients”
(Kuzu et al 2002 & 2011, Camilleri‐Brennan and Steele 2001, Engel et al 2003, Guren et al 2005, Arndt et al 2006, Cornish et al 2007, Campos‐Lobato et al 2011, Pachler and Wille‐Jorgensen 2005 & 2012)
Graphics free public domain
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Patient Reported Outcomes
• 21,802 survivors ‐ 12 and 36 months
• 22% little or no control of their bowels‐ 7% significant diarrhoea
• 38% sexual dysfunction
• 18% significant social distress(DOH 2015)
25
26
10/11/2019
14
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Clinical history & exam – symptoms
Patient Reported Outcomes
ARM (sphincter pressures, sensation, capacity, compliance)
Transit studies (time via colon)
MRI defaecography (action of pouch and pelvic floor)
Graphics free public domainPossible investigations
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Measures
Faecal Incontinence scores
• Faecal incontinence severity index (FISI)
• Wexner scale (Cleveland Clinic)
• St Marks Continence Score (Vaizey Score)
LARS Score – internationally validated
+ QOL
MSKCC‐BFI – for pelvic radiation – lengthy
– EORTC module CR30 & CR29
– FACT‐C
– FIQL
– B‐QOL(Emmertsen et al 2012, Ihn et al 2014, Keane et al 2019)
27
28
10/11/2019
15
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Emmertsen KJ, Laurberg S
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Sex stratified random sample ‐ 3440 Danish population (Civil Reg)
Aged 20‐89 years – F 50%
• Postal / electronic survey including LARS Score
Response rate all 54.5% ‐ F=54%; aged group 50‐79 = 70.5%
18.8% F and 9.6% M had LARS score >30 p=0.001
Statistically more likely physical disease
• LARS common Danish community
• Normative data now available comparison after LAR
29
30
10/11/2019
16
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Treatment
• No one treatment for all patients
• Management is in accordance with individuals’ symptoms
• Based on knowledge ‐ management of faecal incontinence & defaecatory disorders
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
General Guidance Preoperative information & counseling
Pre‐stoma closure advise, education, counseling, exercises
Clinical Nurse Specialist –follow‐up (telephone advise)
QOL measurement (Bowel QOL)
Accurate measurement & documentation symptoms‐LARS score
Bowel management program
Psychosexual / social counselingGraphics free public domain
31
32
10/11/2019
17
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Management
Empower knowledge – changed anatomy & new function
Proper position toilet – squatting
Dietary manipulation‐bowel diary
Medication manipulation‐stool consistency
Containment‐skin care
Exercises, retraining, biofeedback
Bowel management – suppositories, enemas
Coping‐waiting
Promote positive attitude
Stoma‐last resort
(Gosselink et al 2005, Koch et al 2009, Marris et al 2013, Bazzel et al 2016)
Graphics free public domain
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Diet• Eat regularly – do not over eat
Increase soluble fibre Reduce insoluble fibre
Oatmeal and oat bran
Apples, citrus fruits, and strawberries
Barley
Rice bran
• Avoid sugar, artificial sweetener, fructose
• Avoid alcohol and caffeine
• Avoid hot spicy & fatty foods
• Avoid dairy if lactose intolerant
• Avoid gas making foods & activities
Wheat bran, whole grains & cereals Whole‐wheat breads & wheat branSeedsSkins fruits and vegetables
33
34
10/11/2019
18
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Diarrhoea ‐ Foods that Thicken Stool
• Starchy carbohydrates
– Potatoes
– White bread, rice & pasta
• Bananas
• Apples & pears skin removed
• Jelly products
• Marshmallows
• Smooth peanut butter
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Medications
• Loperamide (Imodium) 2‐16 mg per day, titrate ‐ stool soft formed
– Start once per day & increase (30 mins before breakfast)
– 1‐2 capsules 30 mins before meals and at night if necessary, or
– Liquid 5ml = 1mg (easier titrate)
• Psyllium once a day at bedtime (soluble fibre)
• Codeine – may cause sleepiness
• Probiotics may help some patients
35
36
10/11/2019
19
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Sphincter Exercises
Performed minimum 5 sets, 5 x per day
• Strength – squeeze as hard as you can
• Endurance – squeeze as long as you can
• Speed of recruitment – squeeze as quickly as you can
Number and type individualised to patient
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Retraining / Biofeedback
• Behavioral therapy‐ greater awareness of physiological functions – improve condition
• Explain normal anatomy & function – changes
• Sphincter isolation, identification
• Exercises – Strength – Endurance – Speed recruitment
• Brace procedure‐ oblique muscle recruitment
• Sensitivity & balloon volume training
• Develop healthy coping mechanisms
• Therapeutic relationshipGraphics & photograph free in public domain
Audio/visual instrumentation
37
38
10/11/2019
20
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Pelvic floor rehabilitation & biofeedback
125 identified, 5 studies met criteria, 321 patients
4 studies included biofeedback
FI scores, QOL scores, ARM in 3 studies
“PFR useful improving functional outcome after a LAR… studies of limited quality… available evidence points to the effectiveness of the procedure”
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Transanal Irrigation
Quantitative studies of function
Transanal irrigation 250cc water (1000) may be useful
Generates colonic mass movements ‐?? rehabilitative effect on colonic motility or pseudo continence
(Koch et al 2009; Gosselink et al 2004, Rosen et al 2011)
39
40
10/11/2019
21
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Qualitative study ‐ Single Center, UK – LARS score > 20N=21 Diagnosed LARS ‐ irrigation n=12Minimum 3 months > stoma closureM=93%; age 36 ‐79y40% neoadjuvent radiation, 20% defunctioning stoma87% major LARSFU 1, 2 & 6 months
Results:• Decrease mean LARS from 35.93 to 17.73• Decrease FI score from 9.73 to 3.20• Pts perceiving major symptoms benefitted most‐ Improved QOL
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Single center ‐ Italy – n=331 month after surgery ‐ Major LARS score (early LARS)6 months after surgery if Major LARS score (Chronic LARS)Transanal irrigation 6 months crossed over enemas 3 months
Results: • 19 early LARS, 8 chronic LARS completed• Decrease median number daily BM ‐ 7 to 1 at 6m & 4 at 9m• Decreased median LARS score 35.1 to 12.2 at 6m and 27 at 9m• No difference between early and chronic LARS• QOL improved – irrigation SF 36
41
42
10/11/2019
22
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Single center – France
24% LAR ‐ 72% CAA ‐ 4% perineal colostomy
N=25 ACE
Reported
• Improved LARS 33 v 4 p=<0.001 &
• QOL‐GIQI 73 vs 104 p=<0.001
• 12% failure rate catheter problems
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Functional differences – hand‐sewn CAA & ultralow stapled A Single‐surgeon series – 11 stapled, 9 hand‐sewn
Mean FU 2.95 years
ARM testing, Wexner FIS, (LARS) Score; SF36 HRQOL
Reported stapled anastomosis – better function no difference ARM or global QOL
Small sample, slightly more irradiated in hand‐sewn group
43
44
10/11/2019
23
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Single Center Study – Netherlands
• N=54 ‐ Laparoscopic LAR 50% ‐ TaTME 50%
• Single Surgeon experience
• FU at least 6.6 months
• Surveys included EORTC C30 and CR29 and LARS
• Reported no Sig Diff ‐ LARS Scores or QOL,
• Non‐sig higher FI scores TaTME
• Conclude TaTME still evolving ‐ may be safe alternative
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
8 studies identified included 1‐9 patients – most looking at faecal incontinence
45
46
10/11/2019
24
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
N=12 SNS Median, FU 34 monthsMedian improvement - faecal incontinence 90% & QoL 80% Small study looking at faecal incontinence
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Pilot study Single center – Spain
N=21 – LARS
12 session PTNS (30 minutes)
Decreased median LARS score from 32 to 27 p=0.009
• Small numbers, treatment only 30 mins ?? QOL & cost benefit
Photograph free in public domain
47
48
10/11/2019
25
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• 117 websites, 25 met criteria
“Current online information on LARS is suboptimal
“Websites are highly variable, important content is often lacking and material is too complex for patients”.
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• Focus group session, Danish population – post LARn=16, F=50%
• Audiotaped sessions x 3 – over 5 yearsInductive content analysisThemes: illness perception – preoperative care – postoperative support
Identified: • Need better screening LARS• Extension pre‐operative counseling• Social support• Better postoperative FU, contact & support
49
50
10/11/2019
26
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
• 242 health‐care professionals participated ‐ survey.
Most estimated prevalence major LARS is 20–40% after LAR
Only 10% of surgeons use LARS screening tools
Fewer than half surgeons use LARS scores before or after a LAR
“Majority of surgeons indicated more information & patient counselling would improve the quality of life of their patients”
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Pre‐op LARS Score – predict individual risk
51
52
10/11/2019
27
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
ConclusionPatients should be well informed on what to expect before surgery
Information reinforced after surgery
Validated measurement instruments – used in clinical practice
PROMS ‐ QOL
ETs (OWC) nurses ideally positioned as knowledgeable experts
Advocacy, navigation, education, empathy, counseling
Prepare patients psychologically & physically
Manage chronic symptoms
Support adaptation & coping
A world of expert professional nursing care for people with ostomy, wound or continence needsTM
Email your webinar questions to:WCET.webinars@wcetn.org
W C E T ®
© WCET® 2019 www.wcetn.org
53
54