Bowel Management - Bowel Management In Communities With Limited Resources

I just tell you next and you go on, right? Yeah, perfect. So we're looking at your first slide, bowel management communities with limited resources. OK, so good afternoon. First of all, I'd like to thank you for the opportunity to be participating in this bowel management symposium. And now I'll share with you some of our experience with the bowel management in communities with limited resources. OK, I can't see. There's light on the full screen. Uh, if you're, if you're looking at the Globalcast site, are you looking at Adobe or Globalcast? Adobe. Oh, now, now it's OK. I can see it now. OK, so 3 years ago we had the opportunity to visit the Cincinnati Colorectal Center for Children and attend a 1 week bowel management there where we learned the basis for how to treat kids with fecal incontinence, but back home we're faced with a challenge how to institute, how to adapt this bowel management program in our community since we work in a community with different socioeconomic conditions. And the patients we deal with are not the same, don't have the same economic conditions that those we saw in the United States. So, the next one, please. Next slide, yep, we're looking at it. If you're looking on the Adobe site, yeah, OK, OK. Oh, that's OK. So we work in a public hospital. It's a children's and maternity hospital located in Brasilia. That's Brazil's capital. Our hospital is a reference for neonatal surgery. Yeah. OK, next one. Uh, you can go ahead. We're seeing your slide. Oh, just sliding, OK. Um No, just go back. Doctor Sasa, do you have a printout of your slides? Oh, just a minute. Yeah, if you have a physical paper printout, OK, OK, it's OK now. Just let me, OK, I find it here. So, um, To engage in our bowel management program, the patients are referred to our hospital due to fecal incontinence or constipation. Those patients are patients from our city or they come from cities nearby and include those patients with anorectal malformation that were previously operated on by us in our hospital. So, to start the management, so they have an appointment at the office with the doctor and the nurse. We do this on the on the Friday, usually the last Friday of the month during the morning period and we see an average of 8 patients at a time. Uh, we have a complete history and physical exam of the patient. We ask for a contrast enema with hydrosolid contrast material to see if the colon is dilated or non-dilated, as you saw, uh, in the speaker of Doctor Andrea, and this helps us to guide, uh, the management, and we also have to calculate the sacral ratio. The big difference we have in the mamanagement is that we have to do an inpatient program and not an outpatient program, so the patient has to be admitted to the hospital because we deal with patients that don't have good economic conditions and they live far from the hospital, so they cannot be coming and. Going home and coming to the hospital every day, so we really have to have them inside the hospital, so we schedule a date and we admit one patient at a time for one week admission. Sometimes they go home a little earlier, sometimes they have to stay longer at the hospital. When they come to the hospital, the first thing we have an abdominal x-ray and we see if they are sly infected, then we do the enemas to disinfect. After we confirm x-ray that those patients are disinfected, then we start the bowel management. We use Senna laxatives for those patients with constipation and uh overflow through incontinence, and we use enemas for those patients who are full fecal incontinent. Um, another big difference is that our nurses have to teach parents hands on how to administer the enema, so they get the kids and they. Show the parents until the parents feel confident about administering the enema. We use uh we have a ready-made glycerin enema that is uh what we use preferably, we have good results with it. We also use saline and if needed, if you need something more irritating, then we add phosphates. Well, when we reach the right enema for the patient, the animal that cleans the colon and the patient is clean, then we can discharge the patient from the hospital, but the patient stays with them all material they need for the first month of management. We have to give them this material so they can start the management and then they keep coming back so we can give the material to them or they go to another health services to get everything they need. And we also see those patients in our clinics every 6 months. Well, we know that the key for, for the success of bowel management is dedication and sensitivity on the part of the medical team, but besides this, we also have to play a role in social assistance for our patients due to our limited conditions. So we have to write medical reports for those patients so that they can go to government and health entities or to hospitals near their houses and they can get all the material they need for the bowel management. And we also have a problem with the laxatives because they are very expensive here, so those patients also need to look for help to buy those laxatives with the government entities and we've got to help them with that. And we have some failures and recurrences mainly due to noncompliance, and this noncompliance is because of social and economic reasons. And sometimes what happens is that the patient stops taking laxatives. And then constipation suddenly recurs and you have a vicious cycle and we have to admit those patients again to disimpact them and start it all over again. Sometimes also we prefer laxatives, but those are the most expensive we have here. So sometimes the patients, they just, the parents just change the type of the medication we're doing. And to something that is less expensive, and we have problems with that also. Well, uh, we are just starting our experience, so we have only an initial experience. We don't have a big number yet of kids treated. I have, uh, 50 kids that we The treatment for fecal incontinence, 12 of those patients have true fecal incontinence, 11 of those have anorectal malformations, 1 Histon's disease, and we have a 90% success management with enemas. And 38 patients with pseudo incontinence overflow we have many patients with idiopathic constipation, 21 patients, 9 anorectal malformations, and 8 history disease. We have a 95% success rate, but I have to tell that we also have many recurrences, especially in this group, due to the high cost of laxatives we have here, so. It happens what I've told you, the patients stop taking the medications and uh they come back again, they're impacted and well, we try to do our best to help them, but that's, that is actually what what what happens. Well, when we started our bomb management program, we had, we, we were honored by Dr. F and Dr. Andrea's visit to our hospital. We're very honored to death. And although we deal with patients that have limited resources, we have the privilege to live in a country that has unlimited natural resources. Thank you very much. Thank you very much. I think that was a very good explanation of, I think that's much more common. And then we think is that we really need to apply all the stuff we're talking about today to not only the tertiary centers, uh, but through centers all over the world that, that may have different resources and I think that clearly points it out to us. So thank you very much, uh, Ana, for that talk.