Surgical load and long-term outcome for patients with Kock continent ileostomy

Complications and failure after Kock continent ileostomy: A systematic review and meta-analysis

BACKGROUND

A significant number of patients experience complications of the Kock pouch (KP) warranting revision or excision. This systematic review aimed to assess the pooled prevalence and risk factors for complications and failure of the KP.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)-compliant systematic review (CRD42023416961) searched PubMed, Scopus, and Web of Science for studies on adult patients with Kock continent ileostomy published after the year 2000. The main outcome measures were revision, complications, and failure of the KP. Risk factors for complications and failure were assessed using a meta-regression analysis. Risk of bias was assessed using the ROBINS-1 tool. A proportional meta-analysis of the main outcomes was performed.

RESULTS

A total of 19 studies (2042 patients) were included. The weighted mean prevalence of complications was 60.4% [95% confidence interval (CI): 46.1-74.7%], of pouch revision was 46.6% (95% CI: 38.5-54.7%), and of pouch failure was 12.9% (95% CI: 9.3-16.4%). Studies conducted in the USA had a mean failure prevalence of 12.6% (95% CI: 6.2-18.9%) comparable to studies conducted in Europe (11.1%; 95% CI: 7.5-14.7%). Factors associated with higher complications were increased body mass index (BMI) and previous ileoanal pouch anastomosis (IPAA); however, these factors were not associated with increased pouch failure.

CONCLUSIONS

The KP is a highly complex operation as shown by a pooled complication prevalence of 60%, and thus, it should be only performed by experienced surgeons. Despite the high prevalence of complications and need for revisional surgery, patients are keen to preserve their KP. Increased BMI and a previous failed IPAA are risk factors for pouch complications, but not failure.

Reoperations and Long-term Survival of Kock's Continent Ileostomy in Patients With IBD: A Population-Based National Cohort Study From Sweden

BACKGROUND

Kock's continent ileostomy is an option after proctocolectomy for patients not suitable for IPAA or ileorectal anastomosis. Ulcerative colitis is the most common indication for continent ileostomy.

OBJECTIVE

The aim of this study was to evaluate the long-term outcome of continent ileostomy.

DESIGN

Retrospective cohort register study.

SETTINGS

Data were obtained from the Swedish National Patient Registry.

PATIENTS

All patients with IBD and a continent ileostomy were identified. Data on demographics, diagnosis, reoperations, and excisions of the continent ileostomy were obtained. Patients with inconsistent diagnostic coding were classified as IBD-unclassified.

MAIN OUTCOME MEASURES

The main outcome measures were number of reoperations, time to reoperations, and time to excision of continent ileostomy.

RESULTS

We identified 727 patients, 428 (59%) with ulcerative colitis, 45 (6%) with Crohn's disease, and 254 (35%) with IBD-unclassified. After a median follow-up time of 27 (interquartile range, 21-31) years, 191 patients (26%) never had revision surgery. Some 1484 reoperations were performed on 536 patients (74%), and the median number of reoperations was 1 (interquartile range, 0-3) per patient. The continent ileostomy was excised in 77 patients (11%). Reoperation within the first year after reconstruction was associated with a higher rate of revisions (incidence rate ratio, 2.90; p < 0.001) and shorter time to excision (HR 2.38; p < 0.001). Constructing the continent ileostomy after year 2000 was associated with increased revision and excision rates (incidence rate ratio, 2.7; p < 0.001 and HR 2.74; p = 0.013). IBD-unclassified was associated with increased revisions (incidence rate ratio, 1.3; p < 0.001)' and the proportion of IBD-unclassified patients almost doubled from the 1980s (32%) to after 2000 (50%).

LIMITATIONS

Retrospective design, data from a register, and no data on quality of life were available were the limitations of this study.

CONCLUSION

Continent ileostomy is associated with substantial need for revision surgery, but most patients keep their reconstruction for a long time. See Video Abstract at http://links.lww.com/DCR/C122 .

REOPERACIONES Y SUPERVIVENCIA A LARGO PLAZO DE LA ILEOSTOMA CONTINENTE DE KOCK EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL UN ESTUDIO DE COHORTE NACIONAL BASADO EN LA POBLACIN DE SUECIA

ANTECEDENTES:La ileostomía continente de Kock es una opción después de la proctocolectomía para los pacientes que no son aptos para la anastomosis ileoanal con reservorio o la anastomosis ileorrectal. La colitis ulcerativa es la indicación más común para la ileostomía continente.OBJETIVO:El objetivo de este estudio fue evaluar el resultado a largo plazo de la ileostomía continente.DISEÑO:Estudio de registro de cohorte retrospectivo.AJUSTES:Los datos se obtuvieron del Registro Nacional de Pacientes de Suecia.PACIENTES:Se identificaron todos los pacientes con enfermedad inflamatoria intestinal e ileostomía continente. Se obtuvieron datos demograficos, diagnóstico, reoperaciones y extirpaciones de la ileostomía continente. Los pacientes con codificación diagnóstica inconsistente se clasificaron como no clasificados con EII.PRINCIPALES MEDIDAS DE RESULTADO:Las principales medidas de resultado fueron el número de reoperaciones, el tiempo hasta las reoperaciones y el tiempo hasta la escisión de la ileostomía continente.RESULTADOS:Identificamos 727 pacientes, 428 (59%) con colitis ulcerativa, 45 (6%) con enfermedad de Crohn y 254 (35%) con EII no clasificada. Después de una mediana de tiempo de seguimiento de 27 (IQR 21-31) años, 191 (26%) pacientes nunca se habían sometido a una cirugía de revisión. Se realizaron 1.484 reintervenciones en 536 (74%) pacientes, la mediana de reintervenciones fue de 1 (RIC 0-3) por paciente. La ileostomía continente se extirpó en 77 (11%) pacientes. La reoperación dentro del primer año después de la reconstrucción se asoció con una mayor tasa de revisiones (IRR 2,90 p < 0,001) y un tiempo más corto hasta la escisión (HR 2,38 p < 0,001). La construcción de la ileostomía continente después del año 2000 se asoció con mayores tasas de revisión y escisión (IRR 2,7 p < 0,001 y HR 2,74 p = 0,013). La EII no clasificada se asoció con un aumento de las revisiones (IRR 1,3 p < 0,001) y la proporción de pacientes con EII no clasificada casi se duplicó desde la década de 1980 (32%) hasta después de 2000 (50%).LIMITACIONES:Diseño retrospectivo, datos de registro. No hay datos disponibles sobre la calidad de vida.CONCLUSIÓN:La ileostomía continente se asocia con una necesidad sustancial de cirugía de revisión, pero la mayoría de los pacientes logran mantener su reconstrucción durante mucho tiempo. Consulte Video Resumen en http://links.lww.com/DCR/C122 . (Traducción-Dr. Yolanda Colorado ).

Comparing continent ileostomy (CI) conversion to repair/redo IPAA: favorable outcomes

PURPOSE

This study aims to compare the outcomes of repair/redo ileal pouch-anal anastomosis (repair/redo-IPAA) with the conversion of IPAA to continent ileostomy (CI) in an effort to prevent the need for a permanent ileostomy (IS) following IPAA failure.

METHODS

This research involved a retrospective analysis of surgical records, employing descriptive statistics and Kaplan-Meier survival analysis.

RESULTS

Among 57 patients with an IPAA, up to three revisions were necessary due to complications or complete failure. Ultimately, repair/redo-IPAA preserved the IPAA in 14 patients (24.6%), conversion to CI salvaged the pouch in 21 patients (36.8%), and IS was unavoidable in 22 patients (38.6%). The cumulative probability of requiring conversion surgery was calculated to be 54.0% at 20 years, thereby reducing the cumulative risk of IS to 32.3%. The 20-year cumulative probability of pouch salvage by repair/redo IPAA was only 21.9%. However, this rate increased to 67.7% when conversion procedures were considered. Following repair/redo-IPAA, only 8.3% of patients reported evacuation frequencies of ≤ 4 during the day, and 16.7% were evacuation-free at night. In contrast, after conversion to CI, 98.0% of patients reported a maximum of four evacuations in a 24-h period. After undergoing repair/redo IPAA, between half and two-thirds of patients reported experiencing incontinence or soiling, while complete continence was achieved in all patients following conversion to CI. Notably, the majority of patients expressed overall satisfaction with their respective procedures. A positive correlation was identified between very high subjective satisfaction and positive objective surgical outcomes exclusively in patients who underwent conversion to CI.

CONCLUSION

When complications or failure of IPAA occur, conversion to CI emerges as a highly viable alternative to repair/redo IPAA. This conclusion is supported by the observation that patient satisfaction appears to be closely tied to stable surgical outcomes. To reinforce these findings, further prospective studies are warranted.

Redo Continent Ileostomy in Patients With IBD: Valuable Lessons Learned Over 25 Years

BACKGROUND

Patients with IBD with continent ileostomies may require revision surgeries. There remains a paucity of data regarding outcomes after redo continent ileostomy.

OBJECTIVE

This study aimed to evaluate patient outcomes after redo continent ileostomy.

DESIGN

Retrospective cohort study.

SETTINGS

This study was conducted at a high-volume, specialized colorectal surgery department.

PATIENTS

We identified patients who underwent redo continent ileostomy (defined as neo-pouch construction or major operations changing the pouch configuration) for IBD between 1994 and 2020.

MAIN OUTCOME MEASURES

The main outcomes measured were patient demographics, short- and long-term outcomes, and quality of life.

RESULTS

A total of 168 patients met inclusion criteria; 102 (61%) were female, the mean age was 51 years (±13.1), and the mean BMI was 24.4 (±3.9). The median time between primary and redo continent ileostomy was 16.8 years. One hundred twenty-two patients (73%) who underwent redo surgery had ulcerative colitis, 36 (21%) had Crohn's disease, and 10 (6%) had indeterminate colitis. Slipped nipple valve and valve stricture were the most common indications for redo continent ileostomy (86%). After a median follow-up of 4 years, 48 patients (29%) required a subsequent reoperation and 27 (16%) had pouch failure requiring pouch excision. The pouch survival rate was 89% at 3 years, 84% at 5 years, and 79% at 10 years. On univariate analysis, a shorter interval between the primary and redo continent ileostomy was associated with long-term pouch failure ( p = 0.003). Cox regression multivariate analysis confirmed that a shorter interval between surgeries was independently associated with pouch failure ( p = 0.014). The mean Cleveland Clinic Global Quality of Life score was 0.61 (± 0.23) among the 70 patients who responded to the questionnaire.

LIMITATIONS

The main limitations were that this was a retrospective, single-center study and that it had a low response rate for the Global Quality of Life questionnaire.

CONCLUSIONS

Redo continent ileostomy surgery is associated with a long-term pouch retention rate of 79% and satisfactory quality of life. Therefore, redo surgery should be offered to patients who are motivated to keep their continent ileostomy. See Video Abstract at http://links.lww.com/DCR/C87 .

REHACER LA ILEOSTOMA CONTINENTE EN PACIENTES CON ENFERMEDAD INFLAMATORIA INTESTINAL VALIOSAS LECCIONES APRENDIDAS DURANTE AOS

ANTECEDENTES:Los pacientes con enfermedad inflamatoria intestinal con ileostomías continentes pueden requerir cirugías de revisión. Sigue habiendo escasez de datos con respecto a los resultados después de volver a realizar la ileostomía continente.OBJETIVO:Evaluar los resultados después de rehacer la ileostomía continente.DISEÑO:Estudio de cohorte retrospectivo.ESCENARIO:Departamento especializado en cirugía colorrectal de alto volumen.PACIENTES:Identificamos pacientes que se sometieron a una nueva ileostomía continente (definida como construcción de una nueva bolsa u operaciones mayores que cambian la configuración de la bolsa) por enfermedad inflamatoria intestinal entre 1994 y 2020.PRINCIPALES MEDIDAS DE RESULTADO:Datos demográficos de los pacientes, resultados a corto y largo plazo y calidad de vida.RESULTADOS:Un total de 168 pacientes cumplieron con los criterios de inclusión; 102 (61%) eran mujeres, la edad media fue de 51 años (±13,1) y el IMC medio fue de 24,4 (±3,9). La mediana de tiempo entre la ileostomía primaria y la nueva ileostomía continente fue de 16,8 años. Ciento veintidós pacientes (73%) que se sometieron a una nueva cirugía tenían colitis ulcerosa, 36 (21%) tenían enfermedad de Crohn y 10 (6%) tenían colitis indeterminada. El deslizamiento de la válvula del pezón y la estenosis de la válvula fueron las indicaciones más comunes para rehacer la ileostomía continente (86%). Después de una mediana de seguimiento de 4 años, 48 (29%) pacientes requirieron una reintervención posterior y 27 (16%) tuvieron falla de la bolsa que requirió la escisión de la bolsa. La tasa de supervivencia de la bolsa fue del 89 % a los 3 años, del 84% a los 5 años y del 79% a los 10 años. En el análisis univariable, un intervalo de tiempo más corto entre la ileostomía continente primaria y la nueva se asoció con falla de la bolsa a largo plazo (p = 0,003). El análisis multivariable de regresión de Cox confirmó que el intervalo más corto entre cirugías se asoció de forma independiente con el fracaso de la bolsa (p = 0,014). La puntuación media de la Calidad de Vida Global fue de 0,61 (± 0,23) entre los 70 pacientes que respondieron al cuestionario.LIMITACIONES:Estudio retrospectivo de un solo centro. Baja tasa de respuesta al cuestionario de Calidad de Vida.CONCLUSIÓN:La cirugía de ileostomía continente se asocia con una tasa de retención de la bolsa a largo plazo del 79% y una calidad de vida satisfactoria. Por lo tanto, se debe ofrecer una nueva cirugía a los pacientes que están motivados para mantener su ileostomía continente. Consulte Video Resumen en http://links.lww.com/DCR/C87 . (Traducción-Dr. Felipe Bellolio ).

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.

Salvage surgery for continent ileostomies (CI) after a first successful revision: more long-term blame on the reservoir than the nipple valve

PURPOSE

The aim of the study was to investigate the underlying cause of long-term complications in patients requiring at least one revision surgery of a continent ileostomy (CI) and to analyze functional outcome.

METHODS

Only patients with CI at least one revision were included in the retrospective data analysis. Four different classes of complications (Cl A-D) were defined: Cl A = Nipple valve (NV), Cl B = pouch, Cl C = outlet (stoma), and Cl D = afferent loop (AL). Associations between underlying disease and origin of complications were analyzed. Cumulative probabilities were calculated using Kaplan-Meier analysis.

RESULTS

A total of 77 patients were identified with a follow-up of 30 years, requiring 133 surgeries for 148 complications (c.). Cl A 49 c. (33.1%), Cl B 50 c. (33.8%), Cl C 39 c. (26.4%), and Cl D 10 c. (6.8%). Cl A and C complications were not correlated to underlying disease, whereas Cl B and D complications were only found in ulcerative colitis (UC) and Crohn's disease (CD). The cumulative probability of a second revision showed a linear rise, reaching 62.5% after 20 years. Cl A and B complications both reached 42.1%. Eleven (14.3%) patients (10 Cl B) had pouch failure in a follow-up period of 11.5 ± 8.7 years (1-31 years), whereas 66 (85.7%) had successful revisional surgery. Overall CI survival was 78.8% at 44 years.

CONCLUSION

CI survival is limited by inflammatory complications of the pouch based on the underlying disease and not by mechanical limitations of the NV.

TRIAL REGISTRATION NUMBERS

None.

Continent ileostomy: short- and long-term outcomes of a forgotten procedure

BACKGROUND

Continent ileostomy (CI) aims to provide control of gas and faecal evacuation; however, it is rarely performed. This paper reports on outcomes of CI in a large single-surgeon series.

METHODS

All consecutive patients who underwent CI between 1986 and 2015 were reviewed. Patients were classified according to the CI procedure (single stage versus two stage) and according to the underlying disease conditions (inflammatory bowel disease (IBD) versus no IBD). Primary outcome measures were early mortality and complications requiring surgical revision within 30 days (group Ia), those requiring surgical revision within 1-12 months (group Ib), and long-term complications after more than 12 months (group II). Secondary outcome measures were pouch survival and quality of life (QoL) assessed using questionnaires for occupational, sports, sexual, and travel activities; patients undergoing CI after conversion from ileostomy. Analyses were performed using descriptive statistics and Kaplan-Meier curves for the long-term outcomes.

RESULTS

Sixty-two consecutive patients (28 men, 34 women) who underwent CI were reviewed, including 48 with IBD, and 14 without inflammatory conditions. Mean(s.d.) follow-up was 14.4 (9.5) (range 1-30) years. Twenty-seven patients (44 per cent) developed group I complications, of which 25 were corrected successfully. Two patients dropped out of the analysis: one who died from sepsis and the other owing to pouch loss attributed to unsolvable nipple complications. Of the remaining 60 patients, 23 (38 per cent) developed between one and five group II complications. The cumulative probability of reoperation was 54. per cent at 25 years. Overall, pouch survival was achieved in 90 per cent. The two-stage approach led to significantly fewer complications in group Ia (single stage versus two stage: 8 of 25 versus 2 of 37; P = 0.005), whereas complication rates in group Ib (5 of 23 versus 14 of 37) and group II (9 of 23 versus 14 of 37) were similar. Four CIs failed because of IBD complications. CI pouch and function were preserved in all patients without IBD, whereas in the group with IBD 2 of 31 with ulcerative colitis and 2 of 17 with Crohn's colitis lost the CI owing to severe intractable inflammatory complications. In 16 patients who had conversion from ileostomy to CI, QoL improved significantly above precolectomy levels in all domains.

CONCLUSIONS

CI remains an alternative to conventional ileostomy. Although affected by high reoperation rates, it has the benefit of a high rate of pouch survival.

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.

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.

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.

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.

T-pouch: results of the first 10 years with a nonintussuscepting continent ileostomy

BACKGROUND

Continent ileostomy is an alternative for patients who are either not candidates for an ileo-anal pullthrough or in whom an ileo-anal pullthrough failed. We previously described a new type of continent ileostomy (T-pouch) with a nonintussuscepting valve.

OBJECTIVE

This study performed an outcomes analysis of the first 10 years with 40 patients.

DESIGN

A prospective database of patients with a T-pouch from 2000 to 2010 was retrospectively analyzed.

MAIN OUTCOME MEASURES

The primary outcomes measured were demographics and surgical recovery information and the functional data obtained via questionnaire: incontinence, difficulty of pouch intubation, restrictions (work, social, diet, and sexual), quality of health and life, and level of satisfaction with surgery, which were rated on a scale of 0 to 10.

RESULTS

Twenty-three women and 17 men (mean age, 51.2) received a T-pouch. Median follow-up was 6.2 years (range, 0.8-11 years). Five patients (12.5%) experience a leak; 3 leaks were managed conservatively and/or with drain placement. Pouch intubations were done 4 times per day in a mean of 6.8 minutes; the insertion difficulty was rated as 2.5 of 10. Ninety-two percent achieved good continence. All quality-of-life and dysfunction/restriction scores showed significant improvement. Major abdominal surgeries for pouch-related reasons were needed in 30%; minor service operations of the skin-level stoma were needed in 25% of the patients. Of the patients, 87.5% would do the surgery again; 90% would recommend it to others with the same diagnosis.

LIMITATIONS

This study was limited by the cohort size and the lack of long-term data.

CONCLUSION

Ten years with 40 patients confirmed that creation of a T-pouch is complex but could be performed with an acceptable rate of complications. It dramatically improved functional outcomes; most notably, it improved fecal control and decreased social, sexual, and work restrictions.

Integration between a percutaneous implant and the porcine small bowel

Inflammatory bowel diseases, cancer or trauma may require removal of all or part of the intestines, leaving the patient with a need to wear external stoma appliances for collection of bowel contents. By connecting the small bowel to a percutaneous port, equipped with a sealing lid, a fully continent and leak proof stoma can be created without a need for permanently wearing stoma appliance. The prerequisites for a connection between a permanent, transabdominal implant and a visceral organ are largely unexplored. Stoma ports made of titanium were implanted in the abdominal wall of domestic pigs and a branch of distal ileum was inserted through the ports. After being followed for 1-3 weeks, the ports were removed and subjected to histological evaluation to study the influence of their shape, structure, and position on the tissue response. Particular focus was attended to the attachment of the ileal serosal surface to the implants inner structure consisting of a titanium mesh. Macroscopic examination revealed fistulas and formation of abscesses in 4 of 11 the retrieved implants. Histological examination revealed regenerated and well-vascularized collagenous tissue around the mesh structure inside the implant. The integration was complete or partial for 10 of 11 ports. Despite various degrees of inflammation and tissue ingrowth, it was demonstrated for the first time that the serosal surface of ileum was firmly attached to the internal structure of the implant. These experiments provide a basis for optimization of the implant and surgical procedure before long-term functional animal experiments.

Application of a continent fecal reservoir in patients with cloacal exstrophy

PURPOSE

Initial enteric diversion in cloacal exstrophy is achieved by ileostomy or end colostomy with formal reconstruction in the form of hindgut pull-through performed in select patients. Those who are not candidates for a pull-through procedure are often left with a permanent incontinent stoma. Additionally due to congenitally deficient intestinal length, some patients with cloacal exstrophy experience short bowel syndrome. We present our surgical technique and clinical experience in 2 patients who were successfully treated with a novel continent cutaneous fecal reservoir.

MATERIALS AND METHODS

We devised a fecal reservoir in 2 patients with end ileostomies who were deemed poor candidates for pull-through of the hindgut segment. One of the patients exhibited short bowel syndrome before undergoing reconstruction. A continent cutaneous fecal reservoir was created from all available hindgut and a segment of ileum. A flap valve mechanism was used to create a continent catheterizable channel.

RESULTS

Seven years postoperatively both patients are continent of stool and neither has experienced complications attributable to enteric diversion. The patient with short bowel syndrome demonstrated significant improvement in nutritional status as evidenced by rapid weight gain and improvement in serum albumin level. Both patients and their families are highly satisfied with the surgical outcome.

CONCLUSIONS

Hindgut and ileum can be combined to create a novel continent fecal reservoir. As an alternative to diverting ileostomy or colostomy, continent diversion offers potential metabolic and social advantages. Select patients with cloacal exstrophy will benefit from this form of enteric reconstruction.

Anal fistula plug in high fistula-in-ano: an early Saudi experience

PURPOSE

The Surgisis AFP anal fistula plug is a bioabsorbable xenograft designed to assist in the closure of anorectal fistulas. Its efficacy was studied in a series of patients at King Khalid University Hospital, in Riyadh, Saudi Arabia.

METHODS

Patients with chronic and/or complicated anorectal fistulas were prospectively studied. Diagnoses were made by clinical, radiographic, or endoscopic criteria. The number of fistula tracts (based on the number of primary openings) and the duration of draining setons was recorded. Under general anesthesia, patients underwent identification and irrigation of the fistula tracts using hydrogen peroxide. The anal fistula plug was used to occlude the primary opening for each high anal/anorectal fistula not amenable to fistulotomy. The plug was securely sutured into place at the primary opening using absorbable suture.

RESULTS

Twenty-two consecutive patients were prospectively enrolled. In total, 23 fistula tracts were treated. Three anorectal fistulas failed to close early in the study, but two failures were attributed to technical error. Both patients refused to undergo a second procedure. The third failure occurred because of recurrent Crohn's disease. After a mean follow-up of 12 months, 19 of the 23 fistula tracts remained successfully closed, for an overall success rate of 83%. There was no relationship between closure of the fistula and the presence of draining setons.

CONCLUSIONS

In our experience, closure of cryptoglandular anorectal fistula tracts using the Surgisis AFP anal fistula plug is safe and successful in 83% of fistula tracts at 12 months of follow-up.