ABDOMINOPERIN EAL RESECTION AND COLOSTOMY Kathleen Hahn Dietetic

ABDOMINOPERIN EAL RESECTION AND COLOSTOMY Kathleen Hahn, Dietetic Intern

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

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

Pretest #2 § An abdominoperineal resection removes which portion(s) of the GI tract? a. The lower portion of the ileum and the entire colon, rectum and anus b. The entire colon, rectum and anus c. The lower portion of the colon and the entire rectum and anus d. The rectum and anus

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

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

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

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

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

What is an abdominoperinea l 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

Pre-surgery Post-surgery

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

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

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

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

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

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

Preventing Colostomy Blockage ■ Eat in small amounts and chew well: Nuts and seeds Peas Coleslaw Popcorn Chinese vegetables Raw pineapple Dried fruit Vegetable skins Mushrooms Coconut Salad greens Relishes Raisins Celery Corn

Preventing Colostomy Odor ■ Potential odor-producing foods: Alcohol Fish Baked beans Cauliflower Brussels sprouts Cheese Asparagus Cabbage Eggs Broccoli Onions Corn Raisins Celery ■ Certain vitamins and drugs can cause odor ■ Odor-reducing foods: Buttermilk, parsley, kefir, yogurt

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

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

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

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

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

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

Medications / Supplementation: Medications*: Purpose: Pepcid Decreases stomach acid; prevents heartburn Heparin Blood thinner – used preoperatively to prevent blood clots Levoxyl Thyroid hormone replacement Pneumovax Prevent infection of the lungs Roxicodone Opioid – pain reliever Colace Stool softener - prevent constipation Lovenox Blood thinner – prevents blood clots in the lungs Senokot Laxative Dilaudid Opioid – pain reliever Magnesium sulfate Supplementation Potassium chloride Supplementation *throughout admission

Pertinent Labs: 3/21 3/23 3/27 Resolution: Phosphorus: 2. 0 (Low) 2. 2 (Low) Resolved Supplementatio n

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

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

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.

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

Nutrition Intervention: ■ Recommended Initiation of Total Parenteral Nutrition (TPN) TPN: 83 ml/hr Nutrition Prescription* Calories: 1727 1806 - 2107 Protein: 90 gm 78 - 90 Dextrose: 200 gm Lipids: 63 gm *based on current weight ■ Recommended Nutrition Support Consult ■ Action: Paged the resident to recommend initiation of TPN ■ Goal: Initiation of parenteral nutrition within 24 - 48 hours.

Monitoring and Evaluation: ■ TPN: formula, rate, progress, potential for refeeding syndrome ■ Weight for trends

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

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 Nutren 1. 5 @ 55 ml/hr (24 hrs) Recommendation: Nutren 1. 5 - 85 ml/hr (16 hours) Goal: Nutren 1. 5 @ 110 ml/hr (12 hours) Nutrition Prescription* Calories: 1980 2040 1980 1806 - 2107 Protein: 90 gm 92 gm 90 gm 78 - 90 Free water: 1003 ml 1034 ml 1003 ml Per nutrition support Free water flushes: 240 ml/day 60 ml QIH (240 ml/day) *based on current weight

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

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

Comparison to typical patient with APR and colostomy: Preparation: Potential Complications: Typical TM Blood thinner, antibiotics Heparin, Pneumovax, Lovenox Ischemia, nerve injury, abscess, bladder and ureter injuries None Constipation prevention: Stool softener Colace, Senokot Post-op Stay: 3 - 7 days 8 days Diet progression: Clear liquid diet to regular diet; resume normal diet Recovery: Does not take anything by mouth, TPN, Nutren 1. 5 Abdominal bloating or mild Malnutrition from prior nausea; return to normal within condition, continued bloating, 1 - 2 weeks gas, and weight loss

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

Post-test #2 1. An abdominoperineal resection removes which portion of the GI tract? a. The lower portion of the ileum and the entire colon, rectum and anus b. The entire colon, rectum and anus c. The lower portion of the colon and the entire rectum and anus d. The rectum and anus

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

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

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

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.

Thanks to… ■ Sharon Madalis ■ Coryn Kalwanaski

Resources: ■ https: //www. ncbi. nlm. nih. gov/pmc/articles/PMC 2789508/ ■ https: //www. mskcc. org/cancer-care/patient-education/about-your-abdominalperineal-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/ostomynutrition-guide. aspx ■ http: //drugs. com