The continent ileostomy (Kock's pouch) versus the restorative proctocolectomy (pelvic pouch)

The Kock continent ileostomy and the ileoanal anastomosis with a pelvic ileal reservoir are each alternatives to conventional ileostomy in patients undergoing proctocolectomy for ulcerative colitis and polyposis coli. Problems associated with construction of the nipple valve have been the chief factor limiting the popularity of continent ileostomy, but these can be minimized by strict attention to technique. The cumulative revision rate for nipple valve dysfunction over a 7-year period has been below 30%, and continence can usually be restored by reoperation. A successful pelvic reservoir procedure maintains both the normal defecation pathway and satisfactory continence, although rectal sensation is impaired; pelvic sepsis is the major postoperative risk (15–20%). Both types of operation are associated with nonspecific inflammation of the reservoir (pouchitis) in some 20% of patients. The pelvic pouch procedure is likely to become the chief method for preserving fecal continence after proctocolectomy, but the Kock pouch should be considered for inappropriate or unsuccessful cases.

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Résumen La creación de una ileostomía continente de Kock y la anastomosis ileoanal con bolsa o reservorio ileal pélvico son las alternativas a una ileostomía convencional en pacientes que requieran proctocolectomía por colitis ulcerativa o poliposis familiar. Los problemas asociados con la construcción de la válvula mamelonada han constituido el factor limitante principal de la popularización de la ileostomía continente de Kock; éstos, sin embargo, pueden ser reducidos a un mínimo mediante estricta atención a la técnica quirÚrgica. La tasa acumulativa de revisión por disfunción de la válvula mamelonada en la ileostomía continente de Kock a lo largo de un periodo de 7 años de observación ha sido inferior a 30%; la función continente usualmente puede ser restablecida mediante la operación. Un exitoso procedimiento para crear un reservorio pélvico resulta en la conservación de la via de tránsito fecal normal y de la función continente, aun cuando la sensación rectal queda afectada. La sepsis pélvica representa el mayor riesgo postoperatorio (15–20%). Ambos tipos de operación se hallan asociados con inflamación no específica de la bolsa o reservorio (bolsitis) en alrededor del 20% de los pacientes. Es probable que el procedimiento de creación de la bolsa perineal se convierta en el método principal de preservación de la continencia fecal después de proctocolectomía, pero la bolsa de Kock debe ser considerada en casos no exitosos o en los cuales aquel no se considere el procedimiento apropiado.

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Résumé L'iléostomie continente de Kock et l'anastomose iléorectale avec constitution d'un réservoir iléal pelvien représentent les 2 alternatives qui s'opposent à l'iléostomie classique chez les opérés qui subissent une proctocolectomie pour traiter la colite ulcéreuse et la polypose colique. Les problèmes engendrés par la constitution de l'iléostomie valvulaire ont limité la réputation de l'iléostomie continente mais ils peuvent Être surmontés en observant une technique parfaite. Au cours d'une période de 7 ans le taux des cas observés de dysfonctionnement n'a pas dépassé 30% et la continence put Être rétablie en réintervenant. L'anastomose iléoanale avec constitution d'un réservoir pelvien assure à la fois une défécation et une continence normales bien que la sensibilité rectale soit altérée; l'infection pelvienne (15% des cas) représente le risque opératoire majeur. Les deux interventions peuvent se compliquer d'une inflammation de la poche réservoir chez 20% des opérés. Actuellement l'intervention pelvienne est préférée à l'opération de Kock mais celle-ci reste l'ultime recours en cas d'échec de celle-là.

     

The Kock continent ileostomy: a preliminary report.

A review is presented of seven patients who have undergone a continent type of ileostomy, as described by Professor Kock. There has been no mortality. Two of the early patients had considerable difficulty with the functioning of the valve and required re-operation. No patient in the series now wears an external appliance. Six of the seven are fully continent; the seventh reports occasional leakage, but is satisfied with the operation. The operation is considered to be still under trial, but is regarded as having great potential and likely to be much more widely practised in the future.     

Complications of continent ileostomy.

Immediate postoperative complications occurred in 15 per cent of 39 patients undergoing continent ileostomy, and late complications developed in 46 per cent of these patients. Age over 40 years, obesity, and Crohn's disease were related to the morbidity rate, but corticosteroid therapy was not a factor. Results of primary operations were superior to those of secondary continent ileostomies. With careful selection of patients and attention to technical detail, success in 90 per cent of initial continent ileostomy operations is a realistic goal.     

Quality of life: the continent ileostomy.

Ten patients are presented in whom a continent ileostomy (internal ileal reservoir or Kock Pouch) was constructed. The series is unique in that it includes the first such ileostomy successfully constructed in this country. The other 9 patients, for a variety of reasons, sought conversion from a standard ileostomy with an external appliance, to a continent ileostomy. Eight of 9 were successfully converted. Subsequent loss of continence has occurred in 2 of the patients due to reduction or intususception of the nipple valve. In one of the two, a satisfactory level of continence appears related to adequate pouch size. The second patient is seriously inconvenienced by a varying level of continence in part related to slow development of pouch size. Seven of the 10 attest to a dramatic improvement in life style, and illustrate the high level of patient satisfaction with a continent ileostomy.     

Current status of the continent ileostomy

The continent ileostomy has substantial advantages over the standard ileostomy in that it provides a socially acceptable, odourless, appliance-free stoma. The author presents the experience at the Toronto General Hospital from 1977 to 1984 with this procedure which was performed on 123 patients, in conjunction with proctocolectomy (36) and as a conversion from an ileostomy or colostomy (87). There were no postoperative deaths. Modifications to prevent nipple valve sliding have included the addition of staples across the valve and synthetic mesh slings around the outlet. Reservoir ileitis remains a difficult problem, most likely due to stagnant bacterial overgrowth. The operation should not be performed on patients with Crohn's disease, and in the obese, technical difficulties present considerable risk. The procedure should be confined to large centres where the surgeons are experienced in the procedure.     

Bellevue pouch: Ileocolonic continent urinary reservoir

The technique for the Bellevue Pouch, another continent intestinal reservoir, is described. A large-capacity low-pressure reservoir is created from detubularized ascending colon, cecum, and terminal ileum. Continence is achieved by means of an intussuscepted segment of ileum and a modulating colonic pressure cuff wrapped around it. The operation has been performed on 19 patients, all of whom achieved satisfactory continence. Two patients were converted to free drainage systems at a later date. Average follow-up was twenty-five months.     

The continent ileostomy: Long-term durability and patient satisfaction

The long-term results of the continent ileostomy are controversial. Durability and patient satisfaction were evaluated by analyzing the outcome in 129 consecutive patients who had a continent ileostomy performed by one surgeon at the University of California, San Francisco, between 1975 and 1995. A quality-of-life questionnaire was sent to all patients for whom addresses were available (n = 121). Late outcome data could be obtained for 85 (66%) of the 129 patients. Three of the 85 patients died with their continent ileostomies but of unrelated causes. Fifty-one (60%) of 85 patients currently have the continent ileostomy (group A) (mean 15.1 years, range 2.7 to 21.7 years), whereas 31 (36%) of 85 have undergone conversion of continent ileostomy to conventional ileostomy (group B) (mean 5.4 years, range 0.2 to 20.4 years). Patients in group A underwent fewer major postoperative revisions (mean 0.7, range 0 to 4) than patients in group B (mean 1.3, range 0 to 8) (t test, P = 0.088). The indications for pouch removal included valve dysfunction (42%), refractory pouchitis (23%), multiple fistulas (26%), Crohn’s disease (6%), and other (16%) (four patients had two indications). Eighty-seven percent of survey respondents in group A considered their present state of health to be better than before their continent ileostomies. Fifty-seven percent and 82 % of respondents in group A were not limited at all in regard to vigorous or moderate activity, respectively. Although in approximately one third of patients the pouch had to be removed, 97% of the remaining two thirds have a good to excellent outcome. Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998 (poster presentation).     

Quality of life with the continent ileostomy

A survey of 71 patients with continent ileostomies was undertaken to determine their life-style. Comparison of life-style in patients with a conventional ileostomy compared to those with a continent ileostomy was possible because 40 of the 71 patients previously had conventional ileostomies. Approximately 50% of them had been restricted in work, hobbies, and travel, and 90% were restricted in clothing selection and athletic activities. About 10% of the patients with continent ileostomies experienced limitations in one of these parameters. With either ileostomy, dietary restrictions were encountered by 54%. The mean cost of supplies was $200 with the continent ileostomy compared with $475 with the conventional ileostomy. Following conversion from a conventional to a continent ileostomy, 68% of the patients noted an improved sex life and 80% noted an improved body image. All would choose retrospectively to have a continent ileostomy and 96% found the result to be as good as or better than their preoperative expectations. If complications were to arise, 97% of patients would undergo revisional surgery rather than have removal of the continent ileostomy. We conclude that patient satisfaction with the continent ileostomy is high. Fewer limitations are encountered with the continent ileostomy than with the conventional ileostomy.

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Resumen Muchos pacientes con colitis ulcerosa tarde o temprano requieren operación. En el pasado el tratamiento médico era mantenido hasta llegar a las fases crónica o crítica de la enfermedad. En la actualidad, gracias a los avances en la construcción de la ileostomía y en los implementos y equipos, los pacientes osteomizados pueden llevar vidas relativamente normales.Para aquellos pacientes que encuentran indeseable o inaceptable la ileostomía convencional, la bolsa de Kock, o ileostomía continente, es una buena alternativa. La ileostomía continente, que se compone de un reservorio intestinal con una válvula de pezón, logra controlar la evacuación de heces y evita el tener que portar un aditamento externo; los pacientes se intuban a sí mismos para vaciar el reservorio, y en los intervalos sólo deben llevar un parche de gasa para cubrir el estoma.Una encuesta realizada sobre 71 pacientes reveló un alto grado de aceptación de la ileostomía continente. 40 de ellos habían llevado ileostomías convencionales previamente, lo cual facilitó la comparación de los estilos de vida con la ileostomía convencional y con la ileostomía continente.La continencia fué lograda en la mayoría de los pacientes (86%). Las restricciones consiguientes a la ileostomía convencional fueron obviadas y en la mayor parte de las situaciones el estilo de vida alcanzado fué casi normal. En general los pacientes se mostraron agradecidos y satisfechos y solo con renuencia aceptarían la remoción de la ileostomía continente. Todos escogerían retrospectivamente una ileostomía continente y el 96% halló los resultados tan buenos o mejores que sus expectativas preoperatorias. En presencia de complicaciones, el 97% de los pacientes aceptarían revisión quirÚrgica de su ileostomía continente en vez de remoción de la misma. Aun cuando la ileostomía convencional probablemente continuará siendo el procedimiento estándar, la ileostomía continente, sin embargo, es una alternativa para el paciente ostomizado motivado pero insatisfecho.

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Résumé L'étude de 71 malades présentant une iléostomie continente a montré qu'elle était parfaitement acceptée. La continence était effective dans la majorité des cas. Les contraintes entraÎnées par l'iléostomie conventionnelle étant évitées, les opérés menaient une existence proche de la vie normale. Ils en étaient heureux et reconnaissants et n'envisageaient qu'avec réticence la possibilité de la suppression de l'iléostomie continente.Si l'iléostomie classique reste l'opération standard, l'iléostomie continente représente une alternative attrayante pour l'iléostomisé insatisfait mais motivé.

     

A continent colonic urinary reservoir: the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.     

Conversion of malfunctioning J pouch to Kock's pouch. Case report

A patient with ulcerative colitis previously treated with restorative proctocolectomy and ileal J-pouch anal anastomosis had recurrent pelvic abscess and poor functional results for 3 years postoperatively. To improve the quality of life, the J pouch was converted to a Kock's pouch. The successful result implies that Kock's continent ileostomy is a good replacement for failed pelvic pouch.     

The use of an ileostomy connector to diminish the frequency of defecation prior to ileostomy closure in patients with a pelvic pouch

A new method for allowing stool passage into the pelvic pouch before ileostomy closure to verify the defecation state and diminish stool frequency is reported herein. This was accomplished by fitting an ileostomy connector connecting the proximal and distal openings of the diverting loop stoma. The ileostomy connector was initially in place for 6 h a day, the length of time being gradually increased until it was able to be left in for 24 h a day over a 3-month period. The calculated daily frequency of stools decreased from 24 to 6 or 7 times, and the mean daily frequency immediately after ileostomy closure was 6.5 times. Physiological study also showed an improvement, with squeeze pressure increasing from 35 cmH₂O to 116 cmH₂O and the maximum tolerated volume increasing from 35 ml before, to 90 ml 3 months following the use of an ileostomy connector. Thus, we conclude that an ileostomy connector may be useful to predict postoperative functional outcome and its complications, and to diminish the frequency of defecation before ileostomy closure in patients with a covering loop stoma.This study was submitted as a poster presentation at the meeting of the XIVth Biennial Congress of the University of Colon and Rectal Surgeons in Creta, Greece, October 25–29, 1992.     

Comparison of ileostomists' sexual life before and after conversion to continent ileostomy

To compare ileostomists' sexual life before and after conversion from a conventional spout to a continent pouch ileostomy, questionnaires were sent to 48 ileostomists with experience with both types of ileostomy. Forty-two patients (88%) returned their questionnaires; 29 were women. In answer to the question about the effect of their ileostomy on their sexual performance, 98% replied that they had sometimes felt embarrassed, uncertain, or inhibited because of the conventional ileostomy, whereas only 24% felt so after conversion to a continent ileostomy. Eighty-five percent felt that the conventional ileostomy negatively influenced their body image, whereas only 5% considered this to be the case after conversion to continent ileostomy. Eighty-five percent of the patients claimed that the quality of their sexual life had improved after conversion to continent ileostomy. The results suggest that a conventional ileostomy influences sexual life more than is generally recognized, and that conversion to continent ileostomy can improve the quality of sexual life in such patients.

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Résumé Des questionnaires ont été envoyés à 48 opérés d'iléostomie concernant leur vie sexuelle avant et après la conversion de leur iléostomie classique en une iléostomie continente. Quarante-deux patients (88%) ont répondu au questionnaire, 29 étaient du sexe feminin. En réponse à la question concernant leur vie sexuelle, 98% ont répondu qu'ils se trouvaient quelque peu embarrassés, peu certains d'eux mêmes ou même inhibés après l'iléostomie conventionnelle, alors que 24% seulement se trouvaient gênés dans leur vie sexuelle après la conversion en iléostomie continente. Quatre-vingt-cinq pour-cent déclarèrent que l'iléostomie conventionnelle avait une influence négative sur l'image corporelle qu'ils se faisaient d'eux mêmes, alors que seulement 5% avaient cette sensation après la conversion. Quatrevingt-cinq pour-cent de tous les malades constatèrent que la qualité de leur vie sexuelle s'était améliorée après cette conversion. Ces résultats suggèrent que l'iléostomie conventionnelle influence la vie sexuelle plus qu'on ne le reconnait généralement et que la conversion en iléostomie continente améliore la qualité de la vie sexuelle chez ces opérés.

     

Conversion of an ileal conduit to a continent catheterizable stoma.

A technique is described by which a previously constructed ileal conduit is used as an efferent limb of a continent urinary reservoir. The ileal segment is tapered; 1 end is tunneled submucosally into a reconfigured colonic reservoir and the other end is brought to the skin as a catheterizable stoma. This modification of the Mitrofanoff principle provides a highly continent stoma that is easily catheterized, and allows for preservation of the terminal ileum and ileocecal valve within the gastrointestinal tract.     

Urinary tract stones: a complication of the Kock pouch continent urinary diversion

Urinary tract stone disease has been found to be a later complication associated with the construction of the Kock pouch continent urinary diversion. Of 383 patients who underwent Kock pouch diversion between August 1982 and December 1986 stones developed in the pouch in 64 (16.7%), usually on exposed staples or eroded Marlex used to construct the nipple valves. Stones have recurred in 13 of the 64 patients (22%). Most stones were removed endoscopically with techniques similar to those used for percutaneous stone removal. Risk factors for stone formation include Marlex collar erosion and acute pyelonephritis. Changes in surgical techniques with elimination of the Marlex collar and a reduction in the number of staples have reduced the incidence of this later complication to 10%.     

Clinical experience of Kock pouch continent urinary diversion

Kock continent ileal reservoir for urinary diversion was performed in 53 patients with invasive bladder cancer (52) or neurogenic bladder (1). The postoperative follow-up period was from six to thirty-nine months. The clinical results showed no metabolic disturbance of blood electrolytes or acidity. Prolapse of efferent nipple valve developed in 4 patients (7.6%); and 2 underwent revisional surgery with a good result. Another 4 patients (7.6%) suffered from poor continence and relatively frequent catheterization to empty the pouch was necessary to prevent urine leakage through the stoma. Urodynamic study of the Kock pouch in these 4 patients showed a short functional nipple valve length and small pouch capacity. The other 45 patients (84.8%) had good continence. Urodynamic study of the pouch in 20 patients showed low pressure (mean of 13.3 cm H2O) in the pouch and high pressure (mean of 72.1 cm H2O) at the efferent nipple valve. Three patients had unilateral hydronephrosis in the follow-up intravenous urography. Corrective surgery for stenosis at the right ureteroileal anastomosis was done in 1 patient with normalization of the upper urinary tract afterward. The other 2 patients were managed by close observation for the mild hydronephrosis. Symptomatic bacteriuria developed in only 3 patients (5.7%) and responded well to antibiotic management. Reservoirography demonstrated no reflux into the upper urinary tract in all the follow-up patients. There was no significant change of the renal function at twenty-four months after operation detected by radionuclide (131I-Hippuran) renal functional study. All patients were satisfied with Kock urinary diversion.     

Reconstruction of malfunctioning ileoanal pouch procedures as an alternative to permanent ileostomy

During the past 13 years, 261 patients with ulcerative colitis and 29 with colonic polyposis underwent endorectal pullthrough (ERP) at UCLA Medical Center. Of the first 111 consecutive patients to undergo ERP, 5 returned to a permanent ileostomy because of persistent symptoms related to reservoir stasis. Transabdominal shortening of the reservoir was performed in 38 of the 111 patients; 24 experienced marked clinical improvement. Fourteen of the 38 patients had persistent stasis and required shortening of the ileal spout either transanally (5 patients) or via an abdominoperineal approach (9 patients). Eighteen of the initial 111 patients underwent one-stage abdominoperineal reservoir reconstruction. During the past 4 years, 8 of 149 consecutive patients with a primary lateral isoperistaltic reservoir underwent subsequent abdominoperineal reservoir reconstruction. Fourteen of 18 patients with a straight pullthrough with reservoir underwent reconstruction to a lateral isoperistaltic reservoir. An aggressive operative approach to the management of pouchitis and reservoir stasis (diarrhea, frequency, urgency, incomplete emptying) has resulted in only 4 of the last 246 consecutive patients returning to a permanent ileostomy. Several changes in the operative technique have evolved during the 13-year period. Important features for optimal pouch function appear to include: (1) a short rectal muscle cuff, (2) a small ileal reservoir, (3) a short ileal spout, (4) removal of all rectal mucosa, and (5) aggressive correction of rectal strictures.     

Rome pouch: pre-peritoneal continent ileal reservoir with hydraulic valve.

We present our experience with a modified technique for constructing a continent ileal reservoir, using the terminal ileum in a pre-peritoneal position. The ureters were implanted using the Le Duc-Camey technique; the Benchekroun valve was used as a continence mechanism. This technique was used in 18 patients and its advantages and complications are discussed.     

阑尾原位脐部造口的可控性回结肠膀胱术

目的尝试根据Ｍｉｔｒｏｆａｎｏｆｆ原理，将阑尾不加任何处理直接从脐孔穿出，构成可控性回结肠膀胱的排出管道。方法 选取末段回肠和肓肠升结肠各约２０ｃｍ，保留阑尾，沿肠系膜对侧缘纵行劈开肠管，远近端对折缝合形成囊袋。双侧输尿管与囊袋以粘膜下隧道法吻合，阑尾末端开放，并直接从脐部戳孔引出固定，形成可控性回结肠膀胱。结果 ８例患者术后随访１０￣３０个月，回结肠膀胱脐部阑尾排出道控尿能力满意，患者自行插管排