Continent ileostomy

The anatomy and physiology of the ileal pouch and its relevance to pouch dysfunction

For the last 40 years, the ileal pouch-anal anastomosis has been used in patients with ulcerative colitis, familial adenomatous polyposis, and occasionally severe constipation to reconstruct the gastrointestinal tract after proctocolectomy. Although the procedure has generally been successful in helping patients avoid an ileostomy, it has come with its own set of problems. These include complications of the surgery such as fistulas and bowel obstruction, persistent inflammation of the pouch known as pouchitis, and functional problems related to the lack of expulsive peristalsis in the pouch. It is this last group of problems that is exacerbated by a poor diet, ill-advised anti-diarrheal medications, anal stenosis and pouch twists. As a consequence, patients with pouch problems are frequently referred for radiologic evaluation, with pouchography, defecation studies, and small bowel imaging commonly requested. In this review, the basic anatomy and physiology of the ileal pouch are discussed to provide a logical baseline against which to measure the anatomy of pouches and its relationship to the symptoms of pouch dysfunction.

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.

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.

Bladder augmentation and urinary diversion in patients with neurogenic bladder: surgical considerations

In patients with a neurogenic bladder, the primary goal is preservation of renal function and prevention of urinary tract infection, with urinary continence as the secondary goal. After failure of conservative treatment (clean intermittent catheterisation and pharmacotherapy) urinary diversion should be considered. In this review, the surgical options with their advantages and disadvantages are discussed. In patients with a hyper-reflexive, small-capacity and/or low-compliance bladder with normal upper urinary tract, bladder augmentation (bowel segments/ureter) is an option. To those who are unable to perform clean intermittent catheterisation via urethra, a continent cutaneous stoma can be offered. In patients with irreparable sphincter defects a continent cutaneous diversion is an option. For patients who are not suitable for a continent diversion (incompliant±chronic renal failure), a colonic conduit for incontinent diversion is preferred. Surgical complications specific to urinary diversion include: ureterointestinal stenosis, stomal stenosis, stone formation, bladder perforation, and shunt infection and obstruction. Surgical revision is required in around one third of patients. Careful lifelong follow-up of these patients is necessary, as some of these complications can occur late.

Reconstructive lower urinary tract surgery in incontinent adolescents with exstrophy/epispadias complex

OBJECTIVES

To outline the management strategies applied to the adolescent patient population with exstrophy/epispadias and incontinence at our institution. These patients present a difficult management problem. At the same time they are dealing with difficult issues, including body image and sexual awareness, the added burden of ongoing incontinence causes major anxieties and lifestyle restrictions. In many, incontinence has persisted despite numerous operations.

METHODS

A total of 25 (19 male and 6 female) patients who remained incontinent into adolescence or early adulthood were reviewed. Of the 25 patients, 19 had exstrophy, 4 had cloacal exstrophy, and 1 male and 1 female had epispadias. Six patients had undergone eight prior attempts at continent reconstruction, one had undergone cutaneous diversion, and one had problems after ureterosigmoidostomy.

RESULTS

The mean age at continence surgery was 12.9 years. Of the 25 patients, 18 underwent bladder augmentation, with a continent stoma in 17 and an artificial sphincter in 1. An additional 5 patients underwent bladder neck transection, with a new continent stoma in 3. The ureterosigmoidostomy was converted to a Mainz II pouch. One patient underwent continent neobladder formation. Nine patients (36%) developed complications during follow-up. Three required stoma revision for stenosis and one for prolapse. Pouch stones occurred in 4 patients, and vesicocutaneous fistula developed in 1. All achieved full urinary continence. The mean follow-up was 72.4 months.

CONCLUSIONS

Some children with exstrophy/epispadias reach adolescence and remain incontinent. For these patients, modern reconstructive techniques provide hope of continence. With careful preoperative assessment, exact surgical precision, and regular follow-up, a successful outcome can be expected in virtually all cases without the need for external urine collection devices.

Hydrostatic characteristics of the ileocolic valve and intussuscepted nipple valves: an animal model

The ileocolic valve, in the dog, decelerates the passage of stools and prevents fecal reflux. A loss of anterograde resistance worsens the symptoms of short bowel syndrome. The absence of fecal reflux control enhances the risk of recurrence of Crohn's disease. The aim of the present study was to examine what length of intussusception-like nipple valve (INV) should be constructed in order to restore the hydrostatic characteristics of the normal ileocecal valve. The anterograde and retrograde hydrostatic resistances of INVs of different lengths (4, 5, 6, or 7 cm) were compared with those of the normal ileocolic valve by using a contrast enema and x-ray monitoring in a canine model. It was found that the 4-cm-long INV may be sufficient to achieve an appropriate antireflux efficacy (59.60 +/- 4.26 cm H(2)O) versus the ileocolic valve (25.80 +/- 4.92 cm H(2)O), but this does not furnish an anterograde resistance comparable to that of the normal ileocolic valve (10.70 +/- 1.15 cm H(2)O vs. 21.60 +/- 3.96 cm H(2)O). We found that the appropriate length of the INV with which the anterograde resistance of the ileocolic valve could be attained in our model was between 6 and 7 cm. Thus, the shortest possible constructed INV should be effective in clinical conditions such as Crohn's disease, but the recommended length in short bowel syndrome should be greater than this.

Preservation of rectal function after low anterior resection with formation of a neorectum

Recent advances in surgery have enabled low rectal cancers to be resected, while at the same time restoring bowel continuity and preserving the anal sphincter. Although a permanent stoma is avoided and the operation is oncologically sound, function may be compromised. Many patients with a straight coloanal anstomosis suffer from urgency, incontinence, and bowel frequency-the so-called anterior resection syndrome. Over the last 15 years, surgical developments have aimed at improving function after restoration of bowel continuity, essentially by creating a neorectum. The best known and most widely practiced operation involves formation of a colonic J-pouch. The physiological and functional outcomes of the colonic J-pouch are discussed, along with controversies surrounding construction. Although a J-pouch improves some aspects of function, the results are not perfect. Alternatives to the colonic J-pouch are appraised, indicating future areas of development.

Antiperistaltic ileostomy using the long terminal ileal segment

PURPOSE

This study was undertaken to determine whether reversed terminal ileal segments can be used to decrease ileostomy output in patients who have undergone total proctocolectomy and ileostomy for ulcerative colitis or familial adenomatous polyposis.

METHODS

An approximately 25-cm length of terminal ileum was reversed in an antiperistaltic manner, and the new terminal ileal end was used for the ileostomy constructed in the usual manner. Six patients underwent this procedure and were compared with six patients who had conventional total proctocolectomy and ileostomy. Variables studied included weight of ileostomy output and the weight of the filtered fluid component. Data were obtained on seven different occasions during a two-month period beginning three months after the operation. Analysis was done using Student's t-test.

RESULTS

There was a statistically significant decrease in the weight of the average 24-hour ileostomy effluent in those patients undergoing reversed antiperistaltic loop procedures. There was also a statistically significant decrease in the filterable liquid proportions.

CONCLUSIONS

The antiperistaltic ileostomy is effective in reducing the daily amount of ileostomy effluent and facilitates stoma care, owing to its diminished liquid component.

Surgical therapy for ulcerative colitis and Crohn's disease

Over the past 2 decades there has been considerable progress in the surgical management of inflammatory bowel disease. Crohn's disease is a chronic, nonspecific inflammatory disease of the gastrointestinal tract of unknown cause. It involves mainly the ileum, colon, and rectum, most often producing symptoms of obstruction or localized perforation with fistula. Although surgical treatment is palliative, operative excision in combination with strictureplasty, where appropriate, provides effective symptomatic relief and reasonable long-term benefit. Chronic ulcerative colitis is a diffuse inflammatory disease of the mucosal lining of the colon and rectum. Total removal of the colon and rectum provides a complete cure. Newer surgical alternatives, developed over the last 2 decades, have eliminated the need for a permanent ileostomy following definitive resection of the involved colon and rectum.

Heterotopic continent urinary diversions: Statistic evaluation in Northern Italy

– A questionnaire was sent to all Urological Centres in Northern Italy in order to assess their opinion about continent cutaneous urinary diversions. Results were somewhat surprising and brought out many controversial aspects. Although good results of the heterotopic pouches were reported by 12 (31.6%) Units, the ileal conduit is still considered the “gold standard” for more than 50% of Urological Departments, while ureterosigmoidostomy is still widely performed (31.6%). Some new concepts about uretero-intestinal anastomosis and the criteria of exclusion are emerging.

Colonic bladder replacement: Our experience

Our preliminary results of ileal bladder replacements convinced us that these reservoirs are not ideal for all patients and prompted us to perform colonic neobladders. The aim of this work is to evaluate the mid-term results of sigmoid and right colonic bladder substitutions, discussing the indications for use of the colon for the orthotopic urinary diversion. From April 1992 to June 1995 we performed sigmoid neobladder in 38 patients and right colic reservoirs in 27. Thirty patients with left colonic bladder replacement and 12 with reservoir constructed according to an original technique (modified Goldwasser) were evaluated. The mean follow-up was 21.5 months in the first group and 30.5 in the second. Compared to data in literature, there were no differences with regard to continence, urodynamic findings and early and late complications. There are advantages and disadvantages with every bowel segment when constructing orthotopic reservoirs. Weighing up the results of sigmoid neobladders, we consider the ideal candidates for this type of derivation to be elderly patients, those intellectually less compliant and those who have difficulty in reaching the unit for follow-up controls. Both ileal or right colonic reservoirs can be constructed in other types of patients, but we think the latter should be perfbrmed in the case of urinary tract dilatation, chronic renal failure, large ureteral demolition, short and thick mesentery and obesity. Finally we do not believe that the urologist should tackle bladder replacement with a dogmatic attitude, but should choose the most suitable reservoir for the patient according to individual characteristics and anatomical conditions noted on the operating table.

Sonography of the Koch's Pouch for Ileostomy

A case is presented that demonstrates hydronephrosis in a patient with a Kock's pouch form of ileostomy. This occurrence emphasizes the importance of having the patient catheterize the ileostomy to ensure that a false-positive diagnosis of a dilated renal collecting system is avoided. The Kock's pouch procedure for ileostomy is briefly reviewed.

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.

Creation of a pedicle valve unit (PVU) for establishment of enteric continence. Experimental observations

The aim of this study was to develop a natural tissue valve that could be anastomosed into any area of the gastrointestinal (GI) tract to act as a fecal "brake" and so establish enteric continence at that site. A 4-cm-long valve created from an intussuscepted small bowel pedicle was anastomosed into the cecum and brought out through the abdominal wall as a stoma in 11 rabbits. The animals were re-explored five weeks later for assessment of valve viability and continence and microscopic appearance. In all cases, the valve was fully continent in vivo. All valves were viable, and there was no anastomotic leakage. Pressure testing of the valve at reoperation revealed that 7 of 10 valves tested withstood pressures of 30 mmHg before and after catheterization and 6 of 10 were fully continent to cecal "blanching" pressure (50 mmHg). Valve failure was due to deintussusception in three cases. In four cases, valves were continent over 50 mmHg and showed no tendency to incontinence to bursting pressure of the cecum. We conclude that a continent pedicle valve unit (PVU) for placement in a variety of locations in the GI tract is feasible. The PVU has implications in the management of short-gut syndrome, incontinent ileostomy, continent cecostomy, and as a continent valve placed in the perineum for restoration of perineal defecation following proctectomy.

Surgery after colectomy for ulcerative colitis

The need for surgery after colectomy in patients with ulcerative colitis in Stockholm County over a 30-year period, 1955 to 1984, was investigated. During this time 483 patients were discharged from the hospital after colectomy. The mean period of observation from colectomy was 11.6 years. In 325 (67 percent) of the 483 patients there was need for further surgery (932 surgical procedures) during the period of observation. In 95 (20 percent) patients 115 small intestinal obstructions requiring surgery developed. The 2-year and 15-year cumulative probabilities of a first small intestinal obstruction were 11 percent (confidence intervals [CI] 8-14 percent) and 23 percent (CI 19-27 percent), respectively. In 42 (16 percent) of 255 patients treated by proctocolectomy and ileostomy there was need for 64 ileostomy revisions. The 2-year and 15-year cumulative probabilities of a first ileostomy revision were 9 percent (CI 6-12 percent) and 19 percent (CI 14-24 percent), respectively. Ninety-one Kock's pouches were constructed and a total of 125 revisions of Kock's pouch were performed. The 2-year and 15-year cumulative probabilities of a first Kock's pouch revision were 52 percent (CI 41-63 percent) and 57 percent (CI 46-68 percent), respectively. In 75 patients a pelvic pouch and ileoanal anastomosis was constructed. In 32 patients 73 surgical procedures due to pouch-related dysfunction were performed. Alterations in ileoanal pouch technique and increasing surgical experience has resulted in a markedly decreasing frequency of complications during the last years. There was no need for further surgery in 116 (45 percent) of the 255 patients treated by proctocolectomy and ileostomy, in 31 (34 percent) of the 91 patients with Kock's pouch, in 20 (39 percent) of the 51 patients with ileorectal anastomosis, and in 43 (57 percent) of the 75 patients with pelvic pouch and ileoanal anastomosis (closure of loop ileostomy excluded).

Gastric conduit urinary diversion in normal dogs. Part I, Upper urinary tract structure, function, and sepsis

The urinary bladder of 10 clinically normal dogs was excised and the ureters were implanted into an isolated, vagotomized gastric segment derived from the fundic region of the stomach. The gastric segment was closed to form a conduit. Continence was maintained with a modified Kock "nipple valve" created from an isolated segment of ileum. Four dogs were euthanatized by day 30 because of complications related to the early onset of renal failure and electrolyte alterations. Six dogs were euthanatized on day 150. Ureteral dilatation, hydronephrosis, and decreased endogenous creatinine clearance rates were measured in all dogs at the end of the survival period. Pyelonephritis was diagnosed histologically in seven dogs. Positive renal cultures were obtained from seven dogs at necropsy. It was concluded that gastric conduit urinary diversion is unsatisfactory for long-term or short-term clinical use in dogs.

Absorption studies after ileal J-pouch anastomosis for ulcerative colitis. A prospective study

Absorption studies were performed in 17 patients with ulcerative colitis operated on with colectomy and an ileal two-limbed J-pouch anastomosis. The patients were studied 3 and greater than or equal to 18 months after closure of the temporary ileostomy. Increased stool mass (median, 609 g/24 h) was found in all patients and was unchanged with time. Moderate steatorrhoea was present in 29% of the patients 3 months postoperatively, but faecal fat excretion normalized with time. Calcium absorption was normal in all but one patient regardless of time after operation. An abnormal bacterial deconjugation, evaluated by a 14C-glycocholic acid breath test was present in 27% of the patients and increased significantly with time. Forty per cent of the patients had increased faecal bile acid excretion. B12 malabsorption was present in 29-35% of the patients. In conclusion, ileal J-pouch anastomosis for ulcerative colitis causes increased stool mass in all patients and produces moderate bile acid deconjugation and malabsorption in about one-third to half. Substitution therapy with vitamin B12 is necessary in about one-third of the patients. Intestinal adaptation as far as absorption is concerned is minimal after the first 3 postoperative months.

Restorative proctocolectomy: a procedure for the district general hospital?

Restorative proctocolectomy is widely regarded as the surgical procedure of choice for patients with ulcerative colitis or familial adenomatous polyposis, the majority being carried out within specialised regional centres. The use of this procedure outside such centres has been investigated by reviewing the results from a District General Hospital (DGH) over the 8 year period 1981-1989. Seventeen patients (11 male and 6 female with a median age of 36 years) underwent total colectomy and ileoanal anastomosis with formation of a pelvic reservoir (TC-IA). Fourteen had ulcerative colitis (UC), 2 familial adenomatous polyposis (FAP) and one a colonic and rectal cancer. Three pouch designs were used ("S" in 7, "J" in 8 and "W" in 2) with no operative or perioperative deaths. Further laparotomy was required in two patients for adhesions and pelvic sepsis. Functional results were assessed in 16 patients at a mean of 5 years after surgery. The median daily stool frequency was 5 (range 2-6). Twelve of the 16 patients defaecate spontaneously, 2 regularly self-catheterized and 2 do so occasionally. None of the patients is incontinent of formed or liquid stool but one has occasional soiling. These results suggest that TC-IA may be satisfactorily performed outside a specialised unit.

Current status of ileorectal anastomosis for inflammatory bowel disease

Between September 1959 and December 1986, a total of 210 patients in a consecutive series were operated on for inflammatory bowel disease. One hundred ten (66 percent) had ileorectal anastomosis performed. There were no postoperative deaths. There were six failures in 53 ileorectal anastomoses for ulcerative colitis (11 percent), and five failures (8 percent) in 61 for Crohn's disease. The overall failure rate was 11 in 110 (10 percent). Ileorectal anastomosis, in suitable patients, is still a viable operation in the late 1980s.

Ulcerative colitis and polyposis coli. Surgical options

Until a medical cure for ulcerative colitis is available, it is up to the surgeon to provide a solution. With the wealth of experience now available, the operation of ileal pouch with anal anastomosis must be considered as an option in treating the young or well-motivated patient. Screening of families in whom polyposis coli has been found can prevent colon cancer developing. For this group of patients, who may be totally asymptomatic, to be able to offer a reconstructive operation may make it easier for such patients to accept colectomy. The value of consultation between medical and surgical gastroenterologists in order to time surgery is vital, and an exact histologic diagnosis in inflammatory bowel disease may prevent the potential disaster of constructing an ileal pouch in a patient with Crohn's disease. The construction of a pouch is not difficult, being made up of several familiar surgical steps in an unfamiliar setting. However, it is a long operation, frequently taking more than 4 hours, and mucosal protectomy can be rather awkward. For these reasons and the problems with patient counseling, we believe ileal pouch with anal anastomosis operations should be performed at referral centers. We still have to decide on the best type of pouch to use, but it is encouraging that better antibiotics, safer anesthesia, and new techniques such as the intraluminal bypass tube and rectal sleeve dissection have helped to make this operation more successful for a greater number of patients.

Achieving enteric continence: principles and applications

Continence may be defined broadly as the ability to defer the passage of enteric content voluntarily to a socially acceptable time and place. In health, continence is provided by the anorectum; several factors interplay to achieve control. When the colon and rectum are removed because of intractable inflammatory bowel disease, a Brooke ileostomy that is incontinent of stool and gas is traditionally constructed, and control of the stoma is provided by an external appliance. Although the functional results after a Brooke ileostomy are good, we believe that restoration of continence would enhance the quality of life. The methods by which continence is restored surgically have undergone evolutionary changes based on an expanding knowledge of the principles of continence gained in the laboratory. In this report, we detail the current status of our understanding of anorectal continence mechanisms and of the principles of ileal continence, in order to examine how "ileo-anal" continence has been achieved in patients who require proctocolectomy.

Continent catheterizable urinary diversion using the ileocecal segment with stapled intussusception of the ileocecal valve

A continent ileocecal reservoir was created as an alternative to ileal loop urinary diversion in 7 patients. In 3 patients the bladder neck was closed, the in situ bladder was augmented and a continent stoma was formed by intussusception of the ileocecal valve. In the remaining 4 patients an isolated cecal reservoir with a continent stoma replaced the bladder. Creation of a stoma that was continent and easy to catheterize was achieved by intussusception of the ileocecal valve with stabilization of the intussuscepted nipple using a Marlex collar. In most cases the cecal segment was hyperactive but this was controlled with anticholinergic medication. All 7 patients have a satisfactory capacity and a continent stoma without significant catheterization difficulties.

Long term follow-up of surgical treatment for ulcerative colitis--with special reference to recurrence and the quality of life

From 1961 to 1984, fifty-one patients with ulcerative colitis were surgically treated at Tohoku University Hospital. The results of various types of surgical treatments for ulcerative colitis were analysed and discussed with special reference to recurrence and the quality of life at the time of follow-up. Total colitis and left-sided colitis were observed in 42 and 9 patients, respectively. There were five operative deaths. Thirteen patients received total proctocolectomy and 38 patients received various types of conservative operations at the first operation. In seven patients there was a recurrence of the disease in the retained colon or rectum and proctocolectomy with ileostomy was carried out. Forty-six patients were followed. Four died of other diseases and two were lost to follow-up. The periods of follow-up after the final operation ranged from 3-29 years. The types of operative procedures were ileostomy in 19, ascendicostomy in 14, ileoproctostomy in 6 and ascendicoproctostomy in 1 patient. Following treatment of recurrence of the disease, in most patients who had undergone various surgical treatments, favorable results of quality of life were attained, even in those with ileostomy. These results indicate that it is important to select the most proper types of operative procedures for surgical treatment of ulcerative colitis by individualizing each case.

The pelvic pouch and ileoanal anastomosis procedure. Surgical technique and initial results

The pelvic pouch and ileoanal anastomosis procedure should be considered a reasonable alternative for selected patients with ulcerative colitis and familial polyposis. Patients can expect an improved quality of life without a stoma, particularly those with ulcerative colitis. The long-term effects of the reservoir are not completely known; however, from previous reports and from experience with the Kock's ileostomy reservoir, it seems unlikely that there will be a long-term metabolic problems. It appears that a reservoir is essential in adults to minimize stool frequency to an acceptable level and that there is an inverse correlation between pouch size and stool frequency. We still consider this to be an evolutionary procedure and, as such, it should be confined to specialized centers where larger experiences can be accumulated. For the majority of patients who are being considered for proctocolectomy and ileostomy, we urge that they be made aware of alternative forms of therapy and that retaining the rectum should be considered in these patients due to the possibility of reconstructive surgery at a future date.

A model for a bladder replacement plasty by an ileal reservoir--an experimental study in dogs

Cutaneous urinary diversion requires appliances, unless a pouch and a valve mechanism are used (Kock-pouch). In order to avoid a stoma, repeated self-catheterizations, and the complications which may occur from malfunction of the distal valve, we created a modified ileal pouch with the advantages of a low-pressure system with good capacity and no reflux. By anastomosing the distal part of the reservoir to the urethra and using the male patient's own sphincter, the second nipple can be avoided and a urostoma is obviated. The feasibility of this procedure has been studied in 4 dogs.

Reflux from the continent ileostomy reservoir. A radiologic evaluation combined with pressure recording

The reflux from the continent ileostomy reservoir was studied with radiologic and pressure recording techniques in ten patients. The contrast used was poly-iodine-styrene with a density of 0.8 to 1.1 gm/cm3. Reflux into the afferent loop was demonstrated in all patients at a filling volume of approximately 30 percent of the maximal volume capacity of the reservoir. The magnitude of reflux increased with the increasing volume of the reservoir contents and a rise in reservoir pressure. The reflux could temporarily be influenced by antiperistaltic or isoperistaltic motor activity in the afferent loop. Although no adverse effects were seen from the amount of reflux demonstrated in the present investigation, the finding of increasing reflux with increased fullness and intraluminal pressure of the reservoir would indicate that the reservoir should be emptied at regular intervals and before high pressures are built up.

Continent caecal reservoir in urinary diversion

Construction of a continent urinary reservoir was attempted in 18 patients with carcinoma of the bladder. The caecum was used as the reservoir and an intussuscepted ileal nipple was created to provide continence. Fifteen patients are alive and have been observed for 7 to 68 months. The most common complication was malfunction of the nipple valve with urinary leakage and/or difficulty in catheterisation. Revision of the outlet was performed one or more times in 11 cases. The technique of nipple valve construction was successively evolved, with improvement in the functional results. Stricture of one uretero-intestinal anastomosis occurred in three patients. Construction of a continent caecal reservoir is a complex procedure and the problem of a stable, continence-ensuring mechanism in the outlet has not been conclusively solved. The enhanced quality of life offered by a successful continent reservoir nevertheless warrants continued clinical trials in selected patients.

[Bladder replacement by a continent ileocolonic intestinal reservoir wih antireflux-plasty--experimental study in the dog]

The purpose of this experimental study was to try to develop a continent appliance-free urinary diversion with a non-refluxing urinary reservoir to be emptied by intermittent catheterization. A reliable antireflux plasty can be performed only on the large bowel wall. Continence can only be achieved using small bowel. For these reasons an ileo-colic urinary reservoir was conceived and experienced in 20 beagle dogs of both sexes. The posterior wall of the reservoir is formed by an intestinal plate constructed with two ileal loops. Continence is achieved by intussuscepting the terminal ileum in a retrograde fashion into the reservoir for a distance of 5 cm, thus creating a competent nipple valve between the pouch and the ileostoma. The anterior wall of the reservoir is formed using a colonic plate obtained by dividing the excluded sigmoid colon at the antimesenteric border. A long submucuous tunnel is created in the colon in which to lay the ureter. Thus renal infection and chronic pyelonephritis are avoided. Continence of the stoma is both socially and economically acceptable and improves the quality of life.

Ileal reservoirs: an experimental study of motility in the Kock and triplicated pelvic ileal pouches

Motor activity in the Kock ileostomy reservoir and the triplicated pelvic ileal reservoir was studied experimentally in dogs and compared with normal terminal ileum under identical conditions. Despite claims to the contrary, both reservoirs possessed significant motor activity under basal conditions and on filling. This was reduced, however, compared with normal terminal ileum. The design of the Kock reservoir does not seem to have any distinct advantages over the triplicated ileal reservoir which may be used either as an abdominal or pelvic pouch.

The Kock reservoir ileostomy: a review of its development, problems and role in modern surgical practice

The Kock continent ileostomy reservoir was designed in an attempt to overcome many of the problems associated with the conventional ileostomy. An account is given of the technical developments of this procedure since its inception. An intussusception valve within the reservoir is necessary for continence. However, valve failure is a common problem and the developments in construction which have helped to overcome this are described. The major complications associated with the continent ileostomy are discussed in detail, and an attempt is made to define its present role in the treatment of inflammatory disease of the colon.

Five years of the pediatric Kock pouch

Since 1976, 16 teenagers at the Hospital for Sick Children, Toronto, have had a Kock pouch constructed. This group consists of 10 females and 6 males ranging in age from 13 to 19 yr. These were all elective pouches: 9 were converted from standard ileostomies, 5 were converted along with proctectomy or Hartmann procedure, and 2 had total colectomies along with a Kock pouch. Two of these conversions were for failed Swenson and Soave procedures. The complications directly related to the Kock pouch were stoma stricture, prolapsed nipple valve, long outflow tract, fecal fistula, salt loss, slipped nipple valve, chronic small bowel obstruction, and "pouchitis." These 8 complications required a total of 16 operations to correct (1.4 operations per patient). The 100% follow-up shows all but 3 followed for more than 1 yr. They are all well, continent, happy, and back to a virtually normal life that includes marriage in 3. The Kock pouch should be an elective procedure and must be done only when the total colon has been removed. There must be rigid selection of pediatric patients for this operation and no children younger than teenage should receive this pouch. Moreover, it may even by worthwhile letting such a child have a standard ileostomy for a while until his or her general condition (both physical and mental) is best able to cope with a Kock pouch.

Urinary diversion via a continent ileal reservoir: clinical results in 12 patients

Urinary diversion via a continent ileal reservoir has been performed in 12 patients. An isolated ileal reservoir was constructed using the technique described for patients with a continent ileostomy. The ureters were implanted into an afferent segment provided with a reflux-preventing nipple valve. There were few operative complications and no operative mortality. Late complications involving malfunction of the nipple valves occurred in 8 patients and were corrected surgically. Postoperative followup presently is between 9 months and 6 1/2 years. Two patients have died: 1 in an accident and 1 of metastatic bladder carcinoma. The remaining 10 patients are continent and without reflux to the upper urinary tract. The reservoir generally is emptied by intermittent self-catheterization between 3 to 6 times daily. The volume capacity of the reservoir is more than 500 ml. Urinary cultures have been constantly negative in 7 patients and the contents of the reservoir more or less permanently contained bacteria in 5. Dilatation of the upper urinary tracts, progressive renal deterioration or metabolic disturbances have not been encountered. All patients are satisfied with this type of urinary diversion, especially those who have undergone other types of diversion previously.

Construction of a continent ileostomy using a porcine aortic valve. A preliminary report

Problems associated with the nipple valve of the continent ileostomy continue to be a major obstacle, frequently necessitating reoperation, with ongoing incontinence persisting in some patients. We have constructed a continent ileostomy in a dog using a three-loop reservoir, continence being maintained by placing a porcine aortic valve in the efferent loop of the reservoir, obviating the need for the nipple valve. A detailed description of the technique is given. Possibilities for its application to particular clinical problems are discussed.