Research is ongoing into the causes and management of pouchitis. From the mids to the mids there were 2 very different approaches to urinary diversion: ureterostomy and ureterosigmoidostomy. Ureterostomy was a simple procedure in which the ureters were anastomosed to the abdominal wall; however, these stomas were associated with a high incidence of stenosis and infection because there was no antireflux mechanism to protect the kidneys from organisms introduced through the stoma , and they were problematic for the patient because they were small skin-level stomas that were difficult to pouch.
Ureterosigmoidostomy was initially viewed as the preferred procedure. The ureters were implanted into the sigmoid colon and elimination of the urine-stool mixture was controlled by the anal sphincter. This avoided the need to create an external stoma. However, mounting data regarding adverse effects pyelonephritis, incontinence, metabolic complications, and, most importantly, development of malignant lesions at the anastomotic line led to widespread abandonment of this procedure around Since the only alternative at the time ureterostomy was also associated with a high incidence of adverse effects, surgeons began to explore other approaches to urinary diversion.
In , Dr Bricker reported on a unique approach to urinary diversion, now commonly referred to as an ileal conduit. He isolated a segment of ileum with its mesentery intact , anastomosed the ureters to the segment in a manner that allowed reflux between conduit and kidneys, and brought the distal end of the ileal segment to the abdominal wall as a stoma.
This approach solved multiple problems associated with ureterostomy, and the ileal conduit remains the standard of care for standard urinary diversions. The ileal segment remains a standard of care because it provides free flow of urine with marked reduction in the risk of stenosis, and it provides a much more manageable stoma than earlier attempts.
However, the ileal conduit does not provide protection against ascending infection; the ureteroileal anastomoses are freely refluxing and the primary protection against infection is frequent fluid intake, which results in almost constant urine production and an ongoing washout of any organisms.
At the same time that Bricker was popularizing the ileal conduit, Gilchrist, Merricks, and coworkers 22 reported on a continent urinary diversion using the isolated ileocecal segment of the bowel; the cecum served as a urinary reservoir, the ileum was used to construct an abdominal stoma, and the naturally occurring ileocecal valve was used as the continence mechanism.
However, this procedure failed to gain acceptance, for several reasons: 1 the patient had to catheterize the reservoir multiple times daily, and clean intermittent catheterization was still considered experimental; 2 continence rates were far from acceptable. In , Kock and colleagues 23 developed a continent urinary diversion patterned after the continent ileostomy. He used a large segment of isolated ileum to construct a proximal ileal channel to which the ureters were connected, an intussusception between the ureteral anastomoses and the reservoir, a noncontractile reservoir, an abdominal stoma, and an intussusception between the reservoir and the stoma.
In the late s, surgeons built on lessons learned in development of the Kock urostomy and the ileal-cecal reservoir to develop the Indiana reservoir, which is now the most commonly performed continent urinary diversion.
The cecum is detubularized to create a noncontractile reservoir, the ureters are tunneled along the tenia coli to provide antireflux protection, continence is provided by the ileocecal valve supported by surgical plication tapering of the ileal segment, and the stoma is constructed by attaching the distal end of the tapered ileal segment to the abdominal wall.
The patient drains the reservoir every 3 to 4 hours using clean catheterization technique, and most patients have excellent outcomes.
While the Indiana Reservoir is the most common approach to continent urinary diversion, in there are many variations on this general approach. For example, various segments of bowel can be used to construct a noncontractile reservoir, and for patients with benign conditions the patient's native bladder can be used as the reservoir with or without augmentation.
Similarly, a variety of structures are used to create a continent catheterizable channel, including the appendix. In and , surgeons reported on creation of an acontractile cecal reservoir with anastomosis to the distal urethra and continence provided by the striated urethral sphincter. This procedure was subsequently modified to include the addition of an ileal segment proximal to the urinary reservoir, to which the ureters are anastomosed; this results in reduced tension on the uretero-cecal anastomoses and improved long-term outcomes.
While these procedures are performed with increasing frequency in major medical centers, there are 2 major problems that may be experienced by these patients: incomplete emptying and persistent leakage. In order to empty the reservoir, the patient must effectively relax the sphincter while performing a Valsalva maneuver; patients who are unable to effectively empty the reservoir must learn to perform clean intermittent catheterization.
Initial nocturnal leakage is very common because tone in the striated muscles is reduced during sleep; for some patients this is a persistent problem that requires consistent use of absorptive products. The first ostomy patients were truly pioneers and very much on their own; there were no appliances available and no one to turn to when they had questions or problems.
There are anecdotal reports of individuals being ostracized by their families and friends due to persistent fecal odor and soiling, and individuals who required an ileostomy also suffered severe skin breakdown.
At that time the only treatment available for peristomal denudation was to place the patient prone on a special mattress with a cutout for the stoma and a drainage receptacle placed underneath to catch the effluent. All of this began to change in the midth century, when Dr Rupert Turnbull recognized the many unmet needs of his ostomy patients and recruited a dynamic ileostomy patient Norma Gill to work with his ostomy patients as an Enterostomal Therapist.
In addition to providing education and support for individuals undergoing ostomy surgery and their caregivers , Turnbull and Gill worked with manufacturers to develop reliable pouching systems, established preoperative stoma site marking as the standard of care, established ostomy support systems, and initiated formal ET training programs. It is clear that the surgeons who developed and enhanced ostomy surgery, the patients who took on the challenge of recreating their lives with minimal or no assistance, and the rehabilitated patients who took on the role of ET all played critical roles in establishing our current level of expertise in ostomy construction and management.
It is also clear that the early ETs demonstrated the same comprehensive approach to care, enthusiastic approach to role implementation, and determination to make a difference that characterizes WOC nurses in Cataldo P. Intestinal stomas: years of digging. Dis Colo Rectum. Anderson F. History of enterostomal therapy. In: Broadwell D, Jackson B, eds. The first report of diverting the urine using the intestines comes from , by Simon in a child with a congenital abnormality.
Unfortunately the child later died. In the late 19th century and early 20th century operations using the intestines were very risky due to the lack of antibiotics in connection with peritonitis.
In the American Robert Coffey invented a technique in which the ureters were placed in the rectum. Hereby the urine and faeces were removed together. One disadvantage was that there was constantly diarrhoea. However, this technique was often used at that time. In the Netherlands Professor Dr. J A Korteweg used this technique in a somewhat modified form for the first time.
The difference was that he placed the ureters in the sigmoid just above the rectum, rather than in the rectum itself as Coffey did. In the time afterwards Zaayer and Schoemaker described for the first time a technique in which a reservoir was made of the small intestine and created a urinary stoma. The operation technique which these surgeons applied would only become popular in , after Bricker applied the same method in the United States.
Schoemaker created in for the first time in history a urinary stoma for an 18 year old woman with a shrivelled bladder due to tuberculoses. Professor Zaayer announced in he had carried out 2 operations in which he had built a urinary stoma. The first attempts to create a continent urinary stoma were done in by Tizzoni and Foggi. In Mauclaire used the rectum as a reservoir for urine. These 2 findings were essential for the development of the modern continent stoma: Kock conceived the principle of using a piece of intestine to create a low-pressure reservoir, and Lapides made catheterisation popular.
By using these two techniques a variety of continent urinary stomas were created. A relatively new variation on the continent urinary stoma is the Indiana pouch. This operation technique was developed by Mr Rowland and was first applied in in the U. To create the inner reservoir the last piece of the small and the first piece of the large intestines are used. At the transition between these two are a natural valve which prevents leakage from the reservoir.
An internal reservoir in the abdominal cavity was made of strips of small intestine attached together. The patient had to empty the tank with a catheter through an opening in the abdominal wall. Leakage remained a problem but in he solved that problem with a kind of flap in the stoma output design, which appeared to be a leakage proof mechanism.
In Berliner Rudolph Nissen had a patient from whom he had to remove the colon. He then attached the small intestine to the anus so that the patient did not need a stoma. Unfortunately this caused diarrhoea meaning that many people were not satisfied with this technique. In an attempt to reduce the diarrhoea in Peck created a reservoir pouch of the last piece of the small intestine.
Herewith the storage function of the rectum was simulated, which resolved the problem with diarrhoea. In the years to Dr. Lens taught the technique of Professor Kock in the Netherlands. By mid , he has constructed continent ileostomas and built 25 continent urinary stomas. In Parks and Nichols from England described the construction of a pouch, as the first choice in ulcerative colitis, making an ileostoma unnecessary. Parks described the pouch which has now been replaced by the J-Pouch and W-Pouch.
These are easier to create and they have a larger storage capacity. Meanwhile, many more techniques have been developed for people with bowel disease to help as much as possible, such as the INRA, a type of intestinal mucus transplantation of the rectum.
There is also the dynamic plastic gracilis, where a new sphincter is made of a muscle taken from the thigh.
Who knows what else the doctors will invent in the future! Picture source: the book Baas op eigen buik. In the past, much of the inventiveness was left to the stoma wearer as they were often sent home after surgery without any form of collection equipment. Picture source: the book Een kwart eeuw stomazorg in Nederland.
The history of stoma material is not so very old. Before that time, the quality of the collection material sometimes left a lot to be desired. In addition to collection material of rubber, which was already introduced in Germany in , people had to make do with metal, glass or porcelain bowls.
You can see below examples of this type of collection material. Although receptacles of glass were easy to clean, you would not want to consider the consequences if the glass broke. The collection containers were sometimes made with an inflatable rubber edge in order to fit the abdomen. The rubber bags were sealed with an elastic collar to a ring on the abdomen or glued hermetically with cement to the abdomen.
This collection material was very dirty, smelt and was very easily visible under clothing. They did not seal well, meaning that at that time many people suffered from leaks.
The materials also caused allergies and skin irritations. Then just before the second world war the first plastics were discovered, it became easier to use lighter materials, which could be thrown away after a single usage rather than having to be washed clean every time.
They were often themselves stoma wearers. Because they knew where the problems were to be found, they decided to develop stoma material themselves. Thus arose the first stoma brands such as Nu-Hope and Marlen. It was the producer Coloplast from Denmark who developed the first disposable plastic bags, this was back in Due to her sister received a stoma, the Danish nurse Elise Sorensen searched for a better collection material.
In they came up with the idea of using a one-piece disposable ostomy bag. This idea was developed with the help of engineer Aage Louis Hansen from Coloplast. Elise was in contact with him because his wife was a fellow nurse of hers. They were very simple bags with a zinc oxide adhesive, actually the same white waxy layer that previously was under any ordinary plaster.
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