Barnett continent intestinal reservoir. Multicenter experience with an alternative to the Brooke ileostomy

Construction of and Conversion to Continent Ileostomy: A Systematic Review

BACKGROUND

Continent ileostomy was first introduced by Nils Kock in 1969 as Kock pouch (K-pouch). Its most characteristic feature, the nipple valve that offers continence' was a later addition. Even though today's continent ileostomy is sidelined by ileal pouch-anal anastomosis as the gold standard of restorative procedures for colectomy patients, it remains an excellent option for select patients, offering an alternative to end-ileostomy or a poorly functioning ileoanal pouch.

OBJECTIVE

The study aimed to summarize principles and techniques behind K-pouch construction, both de novo and as "J to K" conversion, as well as examine surgical outcomes following the procedure in the modern era regardless of indication.

DATA SOURCES

Data sources included PubMed and the Cochrane Library up to July 2021.

STUDY SELECTION

The study selection materials included articles reviewing continent ileostomy procedures and outcomes between 2000-2021. Case reports and series <15 were excluded.

RESULTS

Fifteen articles were selected for review, describing 958 patients with a K-pouch, 510 patients who had undergone a Barnett continent intestinal reservoir, and 40 who had undergone construction of a T-pouch.

CONCLUSION

Continent ileostomies carried out in specialized centers by experienced surgeons can be a great option for patients who would otherwise be confined by an end ileostomy. High pouch survival rates with higher quality-of-life scores than end ileostomy and comparable with IPAA make continent ileostomy a great option, even if we consider the less than ideal reoperation and complication rates. However, it is of paramount importance that patients are carefully selected, thoroughly educated, highly motivated, and engaged in their care. Specifically, for patients with Crohn's disease, further research is needed to help elucidate factors that affect pouch survival and candidacy for K-pouch creation. Finally, continuous surgical technique modifications and refinements can allow even more patients to be considered suitable for the procedure.

Don't Forget about the K-Pouch!

The continent ileostomy (CI) was popularized by Nils Kock as a means to provide fecal continence to patients, most commonly in those with ulcerative colitis, after proctocolectomy. Although the ileal pouch-anal anastomosis (IPAA) now represents the most common method to restore continence after total proctocolectomy, CI remains a suitable option for highly selected patients who are not candidates for IPAA or have uncorrectable IPAA dysfunction but still desire fecal continence. The CI has exhibited a fascinating and marked evolution over the past several decades, from the advent of the nipple-valve to a distinct pouch design, giving the so-inclined and so-trained colorectal surgeon a technique that provides the unique patient with another option to restore continence. The CI continues to offer a means for appropriately selected patients to achieve the highest possible quality of life (QOL) and functional status after total proctocolectomy.

Long-term outcome and quality of life after continent ileostomy for ulcerative colitis: A systematic review

AIM

The continent ileostomy allows evacuation of an ileal reservoir at a time convenient to the patient. It is a surgical option for patients with ulcerative colitis (UC) when a restorative option is not suitable or has not succeeded and the patient does not want a conventional end ileostomy. Continent ileostomy types include the Kock pouch, Barnett continent intestinal reservoir and T-pouch. All of the published evidence on the long-term outcome and quality of life after continent ileostomy for UC was systematically reviewed.

METHODS

A systematic review was performed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 1990 and 2020 were included. A descriptive synthesis was used due to the clinical heterogeneity.

RESULTS

The search returned 1655 abstracts and after screening of abstracts and full text review, 19 were included in the final review, involving 1602 patients. Operative mortality is low (0%-3.6%) after all types of continent ileostomy but reoperation rates are high (20.8%-65%) because of valve mechanism failures. Rates of fistulae (0%-25.5%) and stomal stenosis (0%-25%) can be relatively high postoperatively. Quality of life scores improve for most patients undergoing continent ileostomy, especially for patients converted from ileal pouch anal anastomosis. Overall, continent ileostomy retention is high in the long-term.

DISCUSSION

In the long-term, patients report high satisfaction and a good quality of life with continent ileostomy, despite high reoperation rates and complications. Newer technologies may reinvigorate interest in the continent ileostomy for this population.

Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International Ileal Pouch Consortium

Restorative proctocolectomy with ileal pouch-anal anastomosis is an option for most patients with ulcerative colitis or familial adenomatous polyposis who require colectomy. Although the construction of an ileal pouch substantially improves patients' health-related quality of life, the surgery is, directly or indirectly, associated with various structural, inflammatory, and functional adverse sequelae. Furthermore, the surgical procedure does not completely abolish the risk for neoplasia. Patients with ileal pouches often present with extraintestinal, systemic inflammatory conditions. The International Ileal Pouch Consortium was established to create this consensus document on the diagnosis and classification of ileal pouch disorders using available evidence and the panellists' expertise. In a given individual, the condition of the pouch can change over time. Therefore, close monitoring of the activity and progression of the disease is essential to make accurate modifications in the diagnosis and classification in a timely manner.

Long-term Follow-up, Patient Satisfaction, and Quality of Life for Patients With Kock's Continent Ileostomy

BACKGROUND

Continent ileostomy is a solution for patients after proctocolectomy.

OBJECTIVE

The aim of this study was to assess the long-term complications and failure rate alongside patient satisfaction, function, and quality of life for patients with a continent ileostomy.

DESIGN

This was a retrospective, descriptive cross-sectional study.

SETTINGS

All patients were operated in 1 center between 1980 and 2016.

PATIENTS

A total of 85 patients received a de novo continent ileostomy in our institution. Sixty-nine patients (80%) had ulcerative colitis, 12 (14%) had Crohn's disease, 2 had indeterminate colitis, and 1 each had familial adenomatous polyposis and anal atresia.

MAIN OUTCOME MEASURES

Medical charts were reviewed for reoperations and pouchitis. The 36-Item Short Form, Short Health Scale, and a local continent ileostomy questionnaire were used to assess quality of life, function, and satisfaction.

RESULTS

After a median follow-up of 24 years, 67 patients (79%) underwent a total of 237 reoperations, of which 15 were conversions to end ileostomies, that is, failures. Fifty patients (59%) underwent repeat laparotomies, excluding loop ileostomy closures. Nipple detachment was the most common cause for repeat laparotomy, and fistulation was the most common cause for pouch removal. IPAA before continent ileostomy was associated with an increased risk for failure. Crohn's disease was not associated with an increased risk for reoperation or failure. Forty-three patients (84%) reported that they were satisfied. Seventy patients were available for questionnaires, and 50 patients (71%) answered. There was no difference in the 36-Item Short Form between the continent ileostomy population and an age-matched control population.

LIMITATIONS

The retrospective, single-center design of the study alongside <100% response rate are to be considered limitations.

CONCLUSIONS

Despite large numbers of complications, patients are generally satisfied with their continent ileostomies, and their quality of life is comparable to the general population. See Video Abstract at http://links.lww.com/DCR/B444.

SEGUIMIENTO A LARGO PLAZO, SATISFACCIN DEL PACIENTE Y CALIDAD DE VIDA PARA PACIENTES CON ILEOSTOMA CONTINENTE DE KOCK

ANTECEDENTES:La ileostomía continente es una solución para los pacientes después de una proctocolectomía.OBJETIVO:El objetivo de este estudio fue evaluar las complicaciones a largo plazo y la tasa de fracaso junto con la satisfacción del paciente, la función y la calidad de vida de los pacientes con una ileostomía continente.AJUSTES:Todos los pacientes fueron operados en un centro entre 1980 y 2016.DISEÑO:Estudio retrospectivo, descriptivo y transversal.PACIENTES:Un total de 85 pacientes recibieron una ileostomía continente de novo en nuestra institución. Sesenta y nueve (80%) pacientes tenían colitis ulcerosa, doce (14%) enfermedad de Crohn, dos, colitis indeterminada y uno de poliposis adenomatosa familiar y atresia anal respectivamente.PRINCIPALES MEDIDAS DE RESULTADO:Se revisaron los registros médicos en busca de reintervenciones y pouchitis. Se utilizó SF-36, escala de salud corta y un cuestionario de ileostomía continente local para evaluar la calidad de vida, la función y la satisfacción.RESULTADOS:Después de una mediana de seguimiento de 24 años, 67 (79%) pacientes fueron sometidos a un total de 237 reoperaciones, de las cuales 15 fueron conversiones para terminar con ileostomías, es decir, fracasos. 50 (59%) pacientes se sometieron a laparotomías repetidas, excluyendo los cierres de ileostomía en asa. El desprendimiento del pezón fue la causa más común de repetición de laparotomía y la fistulación fue la causa más común de retiro de la bolsa. La anastomosis anal de la bolsa ileal antes de la ileostomía continente se asoció con un mayor riesgo de fracaso. La enfermedad de Crohn no se asoció con un mayor riesgo de reoperación o fracaso. 43 pacientes (84%) informaron que estaban satisfechos. 70 pacientes estuvieron disponibles para cuestionarios y 50 pacientes (71%) respondieron. No hubo diferencia en SF-36 entre la población de ileostomía continente y una población de control de la misma edad.LIMITACIONES:El diseño retrospectivo y unicéntrico del estudio junto con una tasa de respuesta inferior al 100% deben considerarse limitaciones.CONCLUSIÓN:A pesar del gran número de complicaciones, los pacientes generalmente están satisfechos con sus ileostomías continentes y su calidad de vida es comparable a la de la población general. Consulte Video Resumen en http://links.lww.com/DCR/B444.

Continent Ileostomy as an Alternative to End Ileostomy

Continent ileostomy (CI) was once a prevalent surgical technique for patients who required total proctocolectomy but then gave way to ileal pouch-anal anastomosis (IPAA) after 1980. Although IPAA has been the gold standard procedure preferred by most patients when total proctocolectomy is required, due to its imitation of physiological function of rectum and preserved function of anus, various complications have been observed with a relatively high rate of morbidity that could affect pouch longevity. Once serious complications such as pelvic abscesses and/or fistula occur, the pouch often needs to be removed. In addition, for some patients with a shortened small intestine or foreshortened mesentery, it is impossible for the ileal pouch to reach the pelvic floor, thus making the creation of an IPAA difficult. Previously, most of these patients would be referred for an end ileostomy, with an associated poor quality of life. In this circumstance, we propose that CI may deserve a reappraisal and serve as an alternative. In this article, we review the indications, contraindications, technique evolution, and outcomes of CI.

Is Conversion of a Failed IPAA to a Continent Ileostomy a Risk Factor for Long-term Failure?

BACKGROUND

A continent ileostomy may be offered to patients in hopes of avoiding permanent ileostomy. Data on the outcomes of continent ileostomy patients with a history of a failed IPAA are limited.

OBJECTIVE

This study aimed to assess whether a history of previous failed IPAA had an effect on continent ileostomy survival and the long-term outcomes.

DESIGN

This was a retrospective cohort study.

SETTINGS

This investigation took place in a high-volume, specialized colorectal surgery department.

PATIENTS

Patients who underwent continent ileostomy construction after IPAA failure between 1982 and 2013 were evaluated and compared with patients who have no history of IPAA surgery.

MAIN OUTCOME MEASURES

Functional outcomes and long-term complications were compared.

RESULTS

A total of 67 patients fulfilled the case-matching criteria and were included in the analysis. Requirement of major (52% vs 61%; p = 0.756) and minor (15% vs 19%; p = 0.492) revisions were comparable between patients who had continent ileostomy after a failed IPAA and those who had continent ileostomy without having a previous restorative procedure. Intubations per day (5 vs 5; p = 0.804) and per night (1 vs 1; p = 0.700) were similar in both groups. Our data show no clear relationship between failure of continent ileostomy and history of failed IPAA (p = 0.638). The most common cause of continent ileostomy failure was enterocutaneous/enteroenteric fistula (n = 14). Six patients died during the study period because of other causes unrelated to continent ileostomy.

LIMITATIONS

This study was limited by its retrospective and nonrandomized nature.

CONCLUSIONS

Converting a failed IPAA to a continent ileostomy did not worsen continent ileostomy outcomes in this selected group of patients. When a redo IPAA is not feasible, continent ileostomy can be offered as an alternative to conventional end ileostomy in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/A803.

The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease

AIM

There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology.

METHODS

Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines.

RESULTS

All aspects of surgical care for IBD have been included along with 157 recommendations for management.

CONCLUSION

These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.

Is there still a role for continent ileostomy in the surgical treatment of inflammatory bowel disease?

The continent ileostomy (CI) was first described in 1969 as an important advancement in the surgical treatment of patients with ulcerative colitis, providing an option for fecal continence to patients who would otherwise require a conventional ileostomy. The CI enjoyed a brief period of relative popularity during the 1970s before being displaced by today's gold standard for the surgical treatment of ulcerative colitis, the restorative proctocolectomy (ileal pouch-anal anastomosis [IPAA]). Although the CI is only rarely performed today, it still has a role to play in the treatment of patients with inflammatory bowel disease who have failed medical treatment. Current indications are patients with failed IPAAs who are not candidates for redo-IPAA, patients who require total proctocolectomy but cannot be reconstructed with IPAA, and patients with an existing conventional ileostomy that is adversely affecting their quality of life. CI, however, is a complex procedure that carries significant risk of both postoperative complications and the need for reoperation over the long term due to slippage of the nipple valve. Patients being considered for this procedure should undergo extensive preoperative counseling and must have a thorough understanding of the associated risks and a realistic vision of anticipated benefits. In well-selected and properly motivated patients, however, CI can be durable in the majority with long-term pouch survival rates approaching 80%. Published data suggest that these patients enjoy greater quality of life than their counterparts with a conventional ileostomy and that 95% would choose to undergo the procedure again or recommend it to another.

Evolution of continent ileostomy

Continent ileostomy can be defined as a surgical procedure that facilitates planned intermittent evacuation of a bowel reservoir through an ileostomy. It was devised by Nils Kock in 1969. Subsequently, continent ileostomy (or Kock pouch) became a viable alternative in the management of patients who had traditionally required an end ileostomy. Kock pouch appeared to provide substantial physical and psychosocial benefits over a conventional ileostomy. The procedure became popular until ileal pouch anal anastomosis (IPAA) was introduced in 1980. Despite its benefits, continent ileostomy had many short term complications including intubation problems, ileus, anastomotic leaks, peritonitis and valve problems. Operative mortalities have also been reported in the literature. Most of these problems have been eliminated with increasing experience; however, valve-related problems remain as an “Achilles’ heel” of the technique. Many modifications have been introduced to prevent this problem. Some patients have had their pouch removed because of complications mainly related to valve dysfunction. Although revision rates can be high, most of the patients who retain their reservoirs are satisfied with regard to their health status and quality of life. Today, this procedure is still appropriate for selected patients for whom pouch surgery is not possible or for patients who have failed IPAA. Both the patient and their physician must be highly motivated to accept the risk of failure and the subsequent need for revisional operations.

The continent ileostomy: an alternative to end ileostomy? Short and long-term results of a single institution series

INTRODUCTION

Total proctocolectomy, ensuring eradication of all diseased colorectal mucosa is the treatment of choice for ulcerative colitis, familial adenomatous polyposis. Before the era of ileal pouch anal anastomosis, definitive ileostomy was required. The aim of this study is to define both early and late morbidity and the functional result of continent ileostomy.

METHODS

All patients' chart who had a continent ileostomy in our department were reviewed. The functional result was evaluated in 43 patients.

RESULTS

Forty-nine patients (34 women) with a mean age of 42 years (range: 17-69) underwent a continent ileostomy, 32 following a restorative proctocolectomy. The mean follow-up was 20.5 (range: 3-34) years. Seventeen patients (35%) experienced an early postoperative complication requiring reintervention in two patients. There was no mortality, and conversion to an end ileostomy was not required. Twenty-two patients developed late complications requiring 50 reoperations. The mean number of catheterisations per 24h was 4.4. The SF36 questionnaire showed values close to those of the general population.

CONCLUSION

Continent ileostomy carries a significant risk of non-severe complications. In selected patients, it represents a valuable alternative to an end ileostomy, in particular when restorative proctocolectomy has failed.

Continent ileostomy: current status

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached its height of popularity in the late 1960s and early 1970s, but has been supplanted by restorative proctocolectomy, an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for restorative proctocolectomy, for whom restorative proctocolectomy or end ileostomy have failed, and in a few other selected cases. Complication rates have decreased during the past three decades following technical improvements, but remain significant. In this review, the author summarizes the current indications for continent ileostomy, examines recent technical modifications, and discusses the management of complications.

Continent ileostomy: current experience

PURPOSE

This study was designed to review our recent experience with continent ileostomies and evaluate patient outcomes.

METHODS

Retrospective chart reviews and phone interviews of patients who underwent a continent ileostomy operation from 1993 to 2003 at the Ochsner Clinic Foundation were performed.

RESULTS

Twenty-four patients (19 females; age range, 22-73 years) had construction of continent ileostomies (modified Kock pouch). There were no intraoperative mortalities or stoma-related deaths. The mean operating room time for primary construction was 3.9 +/- 0.57 hours with a mean length of stay of 7 +/- 2 days. The average follow-up period was 66 (range, 6-134) months. The most common underlying indication for the construction of a continent ileostomy was ulcerative colitis (71 percent). Thirteen patients had a continent ileostomy created for conversion of a Brooke ileostomy and seven for a failed ileoanal pouch. Other indications included colonic inertia and incontinence in three patients and one patient who had failed multiple operations for Hirschsprung's disease. A total of 28 revisions were performed in 14 patients (58 percent). Six patients required multiple procedures. Operative revisions included 12 skin level revision for stenosis, 11 operations for valve repairs, and 1 each for peristomal hernia repair, stomal relocation, and pouch repair for fistulas. Two patients had their pouches removed (Crohn's disease and inability to manage pouch). The need for revision by 12 months was 29 percent, and the average time period before the first revision was 24 months (range, 4 days to 109 months). The overall failure rate (converted to conventional ileostomy) was only 8.3 percent. Ninety percent of the patients have continent pouches and are satisfied with their pouch function.

CONCLUSIONS

Continent ileostomies continue to have a high rate of reoperations, reasonable functional results, and are a viable option for failed ileal pouch-anal pouch patients. Surgeons electing to perform continent ileostomies must carefully select their patients and advise them of the high potential for reoperations. Despite a high reoperation rate, patients are pleased with their continent ileostomies.

Experimental model of continent colostomy using rectus abdominis neosphincteroplasty

Background

Use of dynamic myoplasty to create a continent stoma has produced promising results, but long-term stoma continence has not been achieved. The aim of the study was to establish and test a new model.

Methods

Three types of dynamic rectus abdominis sphincteroplasty around a colostomy and two conditioning protocols were tested in ten domestic pigs. Continence was assessed by means of conventional defaecography and neosphincter manometry after 8 and 12 weeks. The neosphincter muscle was studied histologically to assess the transformation of muscle type.

Results

Use of a distal rectus muscle sling surrounding the stoma by 270° with a low-frequency conditioning protocol achieved a continent colostomy for more than 12 h on each of 5 consecutive days. The neosphincter had a 40-mm high-pressure segment with mean pressure of 74 (range 67–82) mmHg. The proportion of type I muscle fibres increased from 38 (range 32–42) to 74 (range 66–78) per cent after 12 weeks of conditioning.

Conclusion

This pilot study demonstrated the feasibility of a continent stoma in an animal model with a dynamic rectus neosphincter. Long-term results should be confirmed in a larger series before use in humans can be considered.

Conversion of failed ileal pouch-anal anastomosis to continent ileostomy

PURPOSE

We report the results of converting 42 failed ileal pouch-anal anastomoses to a continent ileostomy (using the Barnett modification of the Kock pouch) performed in the course of 1,334 consecutive continent ostomy procedures.

METHOD

Results were obtained from a data registry that tracks long-term outcomes of consecutive continent ostomy procedures performed by 12 surgeons in five centers in the United States.

RESULTS

Forty of the 42 patients with failed ileal pouch-anal anastomoses have a functioning continent ostomy. Two patients have had pouch excision. Quality of life for the patients with ileal pouch-anal anastomoses as measured by the SF-36 index improved postoperatively. Long-term outcomes for the patients with ileal pouch-anal anastomoses were similar to those for the larger population of patients who underwent the continent ostomy procedure for other reasons.

CONCLUSION

Conversion of a failed ileal pouch-anal anastomosis to a continent ileostomy is a satisfactory alternative to the Brooke ileostomy in appropriate cases.