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Continent Ileostomy
Leif Hultén and Helge E. Myrvold
1 0
Key Points
• The continent ileostomy is a low-pressure reservoir
capable of distension and holding capacity, allowing 3–4 evacuations/day.
• Stabilization of the nipple valve requires debulking
of surrounding mesenteric fat tissues, four staple
rows, anchoring of the pouch to the abdominal wall,
and strict adherence to postoperative management
routines to allow a gradual extension of the drainage period.
• Salvage procedures of nipple valve dysfunction
include either rotating the reservoir and construction of a new nipple valve on the “former inlet” or
construction of a new nipple valve on a transposed
ileal segment.
• Dysplastic transformation in continent ileostomies
is a rare phenomenon, and the risk of progression to
cancer is small. Patients operated upon for familial
polyposis are exceptions, as mucosal adenomas
may develop. Regular endoscopic surveillance is
mandatory.
• Persistent leakage after numerous nipple valve revisions, unsuccessful fi stula operations, intractable
pouchitis, and Crohn’s disease are the common
indications for excision.
L. Hultén , MD, PhD, FACS, ACGBI (Hon),
ISUCRS (Hon), SICCR (Hon) (
The Colorectal Unit, Department of Surgery ,
Sahlgrenska University Hospital SU/O ,
Göteborg 416 85 , Sweden
e-mail: leif.hulten@surgery.gu.se
H. E. Myrvold , MD, PhD, SEC (Hon)
Department of Cancer Research and Molecular Medicine ,
Norwegian University of Science and Technology ,
Trondheim N-7491 , Norway
e-mail: helge.myrvold@ntnu.no
*)
The Continent Ileostomy: Complications, Their Management, and Its Place in the Future
Key Concept : Despite a relative decrease in its use , surgeons
should be aware of how to interrogate a continent ileostomy
and manage its potential complications .
Historical notes . The modern era of pouch surgery started
with the introduction of the continent ileostomy in 1969 by
Nils G. Kock. Originally Kock constructed a low-pressure
reservoir by double folding a detubularized ileum segment to
be used as a bladder substitute after total cystectomy.
Subsequently he applied the same construction to create an
intra-abdominal reservoir for collection and storage of intestinal effl uent—the Kock pouch [ 1 ]. The construction was of
a similar kind as that constructed by Tasker in the 1950s [ 2 ].
The intestine was split open, folded once, but instead of folding from side to side, according to the Tasker procedure, he
folded the bowel from down upside or from upside down
(Fig. 10.1 ). The motor activity is greatly reduced, resulting
in virtually no pressure peaks up to a fi lling of ~300–400 ml.
In the few fi rst patients, the corner of the pouch was taken
out through the abdominal wall as a conventional stoma in
the belief that the rectus muscle might function as a closing
mechanism. Leakage occurred frequently in this fi rst series
of patients, however, and several other techniques were put
on trial subsequently in an attempt to improve continence.
The “nipple valve”, a short intussusception of the outlet segment, proved to be the most promising measure (Fig. 10.2 ).
In the 1970s and 1980s, the continent ileostomy gained
popularity mainly in the USA and Canada, as well as in
Europe—predominantly in Sweden, Norway, and Finland.
Several modifi cations, such as the Barnett continent ileostomy and the T-pouch, have since evolved over the years.
While the basic principle for the pouch construction is identical with the Kock pouch, the techniques used to achieve
continence differ markedly.
Sir Alan Park used the ileal reservoir developed by Kock for
endoanal anastomosis with preservation of the sphincter
S.R. Steele et al. (eds.), Complexities in Colorectal Surgery,
DOI 10.1007/978-1-4614-9022-7_10, © Springer Science+Business Media New York 2014
157
158
L. Hultén and H.E. Myrvold
c
b
a
Fig. 10.1 The original procedure ( a ) Segment of terminal ileum (Arrow points to distal) ( b ) Folding of the bowel on itself and formation of the
posterior wall. ( c ) Creation of the anterior wall of the pouch. ( d ) Completed pouch
continent ileostomy continues to be routinely performed in a
d
few specialized centres and other surgeons are often called
upon to evaluate patients with troublesome continent ileostomies. The goals of this chapter are therefore to provide insight
into the evaluation and management of potential complications
associated with these pouches and allow surgeons to be more
comfortable in caring for patients with continent ileostomies.
The Kock Pouch
Formation of the Ileal Pouch
Key Concept : Pouch construction uses terminal ileum for
formation , with several different confi gurations .
The ileal pouch constructed according to the Kock original technique has proved to be an intestinal reservoir well
designed to eliminate intraluminal pressure at fi lling and
allowing to expand on distension. It has been convincingly
demonstrated that the “double-folded” technique used offers
Fig. 10.2 The Kock reservoir with nipple valve
mechanism and published the fi rst results on “restorative proctocolectomy” in 1978 [ 3 ]. This method is at present the pre-
ferred option worldwide for the surgical treatment of ulcerative
colitis and familial adenomatous polyposis, and the demand for
continent ileostomy is considerably reduced. However, the
a fi nal pouch volume signifi cantly larger than in pouches
where the detubularized segment is folded side-to-side only
[
4 , 5 ]. The reservoir will gradually reach a volume of 400–
600 ml, a volume that will keep the number of evacuations to
about three per day. For construction as suggested by Kock
[ 6 ], 45 cm of the terminal ileum is suffi cient—15 cm for the
pouch outlet and nipple valve and 30 cm for the formation of
the reservoir—while other authors [
7 ], preferring a three- limb
10 Continent Ileostomy
ab
Fig. 10.3 Nipple valve sliding. ( a ) Arrow points to afferent limb. ( b ) The nipple valve has disappeared leading to intubation diffi culties
159
ileal pouch, use a signifi cantly longer segment of the terminal ileum for construction, though no improvement in function or in complication rate can be demonstrated.
Although the “nipple valve” was a promising technique to
preserve continence, failures were common. When the reservoir distends, it stretches on the mesentery and puts stress on
the valve. Over time, the valve may become reduced or
fi nally disappear, leading to intubation diffi culties and incontinence problems (Fig. 10.3 ). The method had to be changed
several times over the years, until a stapling technique was
introduced that ultimately has provided promising results.
Nevertheless, the main problem in regard to the Kock pouch
construction is the nipple valve construction, which remains
“the Achilles heel” of the procedure to this day.
Formation of the Nipple Valve
Key Concept : While the nipple valve is the most diffi cult portion of the pouch construction , several technical points will
minimize complications .
For a safe stabilization of the nipple valve, special attention
and care should therefore be given to the following measures:
• Stripping of the peritoneal leaves and “defattening” of the
nipple valve segment are important measures to reduce the
bulk of tissue interposed in the intussusception (Fig. 10.4 ).
• The nipple valve should be stabilized by means of four
staple rows: one staple row on each side of the mesentery,
one on the antimesenteric side, and—to further prevent
sliding and prolapse—one staple row anchoring the nip-
ple valve to the wall of the reservoir (Fig. 10.5 ). To avoid
necrosis of the tip of the nipple valve, removal of ten
Fig. 10.4 Mesenteric stripping
staples near the hinge of the stapling device is an important precaution.
• Moreover, a careful and correct construction of the exit
conduit channel with fi rm anchoring of the reservoir to
the abdominal wall is necessary.
160
L. Hultén and H.E. Myrvold
ab
Fig. 10.5 Stapling and anchoring of the nipple valve to the reservoir wall. ( a ) Stapling of the nipple valve. ( b )Anchoring the valve to the reservoir wall
• Strict adherence to routines in the early postoperative
management of the pouch—extending the drainage period
in a gradual fashion for about 4 weeks—is another important measure contributing to stabilization of the nipple
valve. Although detailed instructions on the postoperative
care of the continent ileostomy have been given extensive
space in many recent articles, the importance of this last
point has often been neglected.
The T-pouch is an alternative technique developed to
replace the troublesome nipple valve [ 8 , 9 ]. A unique antire-
afferent limb of the small bowel is used to construct the nipple
valve and outlet. To improve continence, an intestinal segment
with its lumen remaining in continuity with the pouch is
wrapped as an intestinal collar around the base of the nipple
valve, similar to a gastric fundoplication [ 11 ]. Collective results
from fi ve hospitals revealed similar complication rates and failures as with the traditional types of continent ileostomy commonly used [ 12 , 13 ]. The procedure is complicated and the
Barnett pouch has also not received general acceptance. The
importance of this modifi cation is still scientifi cally unproven.
fl ux mechanism is created by anchoring an isolated ileal segment as an outlet between the two limbs of the bowel “U”,
which will form the reservoir (Fig. 10.6 ). Results have been
reported in a 10-year follow-up study [
10 ], demonstrating an
acceptable rate of complications and excellent functional
results. Unfortunately, the technique is diffi cult and the procedure has yet to reach wide acceptance for faecal diversion.
The Barnett continent intestinal reservoir is another modifi -
cation of the Kock pouch procedure. In this confi guration, the
Complications and Their Management
While there have been keen advocators for the continent ileostomy over the years, many surgeons have been reluctant to
adopt the method considering the high postoperative morbidity—despite modifi cations in surgical technique and postoperative management.
10 Continent Ileostomy
161
Late complications with pouch operations include those
that are similar to any other bowel surgery, such as obstruction, stricture, and hernia. However, continent ileostomies
have a unique set of late complications that are often related
to the nipple valve including:
• Sliding and/or prolapse each render the pouch incontinent.
• Nipple valve slippage and stenosis are the most common
causes of reoperation [ 14 – 17 ]. Overall revision rates
range between 12.5 % [ 18 ] and 52 % [ 19 ].
• A fi stula developing through the base of the nipple valve
will also result in leakage of intestinal contents due to
bypassing the valve. The complication seems to be an
infrequent reason for reoperation however [ 14 , 17 ].
The collective results imply that revisional surgery due to
any of the above-mentioned defects has decreased from 40 to
50 % with the early techniques to about 20–25 % with the
introduction of the currently most popular method of mesenteric stripping and stapling of the nipple valve. The need for
reoperations has decreased signifi cantly with increased experience of the surgical team to below 10 % [ 6 , 18 , 20 , 21 ]. In
concordance with the reduced rate of complications, surgical
experience, and success of revisional surgery, the failure rate
has decreased signifi cantly and is currently reported between
4 and 10 % [ 6 , 14 , 17 , 20 – 24 ], a failure rate which is compa-
rable to that after restorative proctocolectomy [ 25 – 29 ].
Fig. 10.6 The T-pouch
Early Complications
Key Concept : Early complications with the continent ileostomy are similar to any other bowel surgery .
With increasing experience on the part of surgeons, the
early morbidity rate in terms of anastomotic leaks with peritonitis and/or intra-abdominal abscess, fi stulas, and wound
sepsis and dehiscence has been markedly reduced. Intestinal
obstruction, local abscess, necrosis of the nipple valve, and
fi stula are reported to occur in about 10 %.
Late Complications
Key Concept : Most of the complications developing later in
the postoperative course are related to the nipple valve , and
the success of the operation stands with the competence and
stability of this intussusception .
Management of Complications
Key Concept : The continent ileostomy is a demanding procedure with a high potential for complications , and special
skill and experience are required for their recognition and
management .
Early Complications
• Local or diffuse peritonitis refl ecting suture leakage or
abscess require immediate and proper treatment. A local
peritonitis with or without abscess should be drained. It is
usually best to establish a loop ileostomy proximal to the
affected area.
• A fi stula either may heal spontaneously on this treatment
or could be subject to revision by another operation 2 or
3 months later.
• Ischemic necrosis of the pouch outlet and/or the nipple
valve may also occasionally develop in the early postoperative phase, a vascular complication mostly due to a
faulty technique. Depending on its extension of the ischaemia, it may be successfully treated either conservatively by prolonged tube drainage of the pouch or, when
more extensive as judged, by ileoscopy and be primarily
managed by establishment of a defunctioning loop ileostomy. In both situations, revisional surgery may then be
performed at a convenient time a few months later.
162
L. Hultén and H.E. Myrvold
• Bleeding within the pouch during the fi rst postoperative
days is common, and the irrigation fl uid will sometimes
be heavily bloodstained. Profuse bleeding may sometimes occur, even after a careful suturing, with clots accumulating in the pouch blocking the draining catheter. Too
little attention has been directed to the importance of the
postoperative wide-bore (28Fr) catheter drainage. With
strict irrigation routines and the use of a proper draining
system, this complication should in most cases be possible to manage conservatively.
The importance of a defunctioning ileostomy for reduc-
ing the early morbidity rate, or at least minimizing the consequences of any complication developing during the early
postoperative phase, may be controversial; however, such a
safety measure should probably be recommended for the
beginners before experience has been gained.
Late Complications
Key Concept : Despite surgical experience , improvements in
technique , and strict routines in the postoperative care , sliding or prolapse of the nipple valve , or a nipple valve fi stula ,
may develop resulting in incontinence and a need for surgical intervention .
Late complications typically manifest in predictable
ways, and most involve problems with the nipple valve itself.
In this section we will walk you through how to approach
these often diffi cult situations.
Sliding of the Nipple Valve and Its Correction
Key Concept : Nipple valve sliding presents with problems
with pouch intubation . While temporizing measures are possible , this most often requires formal operative revision .
Intubation diffi culties of the reservoir and/or leakage of
gas and faeces are symptoms indicating nipple valve sliding
(Fig. 10.3 ). Confi rmation of a defect valve can be done by
using a fl exible endoscope. In this context it should be mentioned that patients may sometimes present acutely with an
over-distended reservoir due to inability to insert the catheter. The problem can be solved by using a small-size rigid
sigmoidoscope (i.e. children’s sigmoidoscope), by which it
is possible to follow the typically angulated course into the
reservoir under direct vision. An indwelling catheter can
then be passed through the sigmoidoscope and left in place.
Revisional surgery through a formal laparotomy is required
for reestablishment of continence in most cases, however. The
surgical approach to be employed depends on the precise fi ndings at laparotomy. The stoma and outlet is fi rst dissected free
and the reservoir mobilized into the wound. After opening the
pouch, it may occasionally be possible to de-invaginate the
intussusception simply by careful dissection and separation of
layers of the nipple valve. Provided that the segment is suffi ciently long, a nipple valve is reconstructed and fi xed in position according to established technique. In most cases,
however, the outlet segment is damaged by the dissection or
insuffi cient in length and has therefore to be sacrifi ced. A new
nipple valve and outlet has to be constructed, a procedure that
can be done by two different techniques.
The most common technique is to sever the entrance conduit 15–20 cm from the reservoir. After peritoneal stripping
and “defattening” of mesentery of the segment that is still
attached to the pouch, the new nipple valve is fashioned and
stabilized according to the stapling techniques described. The
reservoir is then rotated to enable the new outlet to be passed
through the abdominal channel, allowing a new stoma to be
formed (Fig. 10.7 ). Special attention should be directed to the
fi rm anchoring of the pouch to the abdominal wall. The channel through the abdominal wall should either be narrowed to
fi t the outlet properly, or when not possible, a new trephine
wound should be created at another site of the abdominal wall.
Another alternative procedure for construction of a new
pouch exit conduit and nipple valve is to isolate a 15–20 cm
segment of the ileum at a convenient level above the reservoir and interpose the segment between the reservoir and the
abdominal wall (Fig. 10.8 ).
Prolapse of Nipple Valve
Key Concept : Prolapse is typically from the abdominal wall passage becoming too wide and normally requires surgical revision .
Although a prolapse can often be temporarily restored
manually, surgical revision by laparotomy will be required
for lasting cure. It should be mentioned that prolapse of the
nipple valve occurring during pregnancy can be easily
reduced manually and mostly resumes to normal after
delivery. A common underlying cause of the prolapse is that
the channel through the abdominal wall has become too wide.
The stoma and exit conduit should therefore be dissected free
with complete mobilization of the reservoir. The channel
should be narrowed by suturing the rectus muscle and the fascia, allowing the exit conduit to fi t snugly. An alternative is to
select another site for the ileostomy and create a new trephine
wound through intact abdominal wall. Anchoring the nipple
valve by stapling it to the wall of the reservoir has contributed
greatly to prevent nipple valve dislocation (Fig. 10.5 ).
Parastomal Hernia
Parastomal hernia is rare but should be treated according to
up-to-date techniques in the same way as any parastomal hernia. Because of the high recurrence rate after suture repair, the
use of mesh in parastomal hernia repair is preferred [ 30 ].
Fistula Through the Nipple Valve
Key Concept : Internal fi stulas are revised via laparotomy ,
and external fi stulas are managed locally .
Fistulas may be external or internal bypassing the nipple
valve (Fig. 10.9 ). The reported complication rate is about
25 % [ 17 , 22 ], but reoperations may be successful [ 31 ]. The
position of the fi stula is mostly at the base of the nipple
valve. Formerly silk sutures and/or synthetic material
10 Continent Ileostomy
163
a
b
cd
Fig. 10.7 Reconstruction of the nipple valve on the efferent loop and rotating the reservoir. ( a ) Line of dissection and resection along the efferent
limb. ( b ) Recreating the nipple valve. ( c ) Rotation of the pouch in the direction of the arrows. ( d ) Completed reservoir
(Marlex or Mersilene ® mesh) used to stabilize the intussusception was a frequent underlying cause. As most authors
have advised against the use of these products, the complication has now become rare. When a fi stula appears today, suspicion of Crohn’s disease arises.
While external fi stulas should be best depicted by fi stu-
more reliable option to deal with the problem is to resect the
nipple valve with its outlet and to construct a new outlet as
described for nipple valve sliding (Figs. 10.7 and 10.8 ). In
cases with complicated fi stula systems often turning out to
be Crohn’s disease, pouch excision and construction of a
conventional ileostomy is often the best solution.
lography, internal fi stulas are diagnosed by endoscopy.
Repair of the external fi stulas may be accomplished by local
sutures after excision of its edges sometimes without a formal laparotomy. Internal fi stulas through the nipple valve
require laparotomy, however. Although desintussusception
of the nipple valve and repair by excision of the fi stula and
reconstruction of the valve on the same intestinal segment
may well be tried, such a repair is mostly unsuccessful. A
Miscellaneous
Perforation of the reservoir a very rare complication which
might be caused by too vigorous insertion of the catheter or
by penetration of a sharp food object such as a fi shbone. The
closure of a perforation—particularly when associated with
peritonitis—should be protected by a defunctioning loop
ileostomy. Volvulus of the reservoir has been reported, but
164
a
a
L. Hultén and H.E. Myrvold
b
b
c
Fig. 10.8 Reconstruction of the nipple valve by interposition of a new
outlet segment between the reservoir and the abdominal wall. ( a ) Line
of dissection along nipple valve and afferent limb. ( b ) Resection of the
original nipple and construction of new segment (C-D) for the nipple
(arrows demonstrate rotation). ( c ) Completed reconstruction
should not occur if the fi xation of the reservoir is performed
according to current principles. Fibrosis of the tip of the nipple
valve is another complication that may require dilatation and
occasionally reconstruction. Skin stricture around the stoma is
also common but is easily dealt with by local revision.
Recurrent Nipple Valve Complications
Key Concept : Nipple valve dysfunction can be successfully
revised , even after one or more previous revisions .
Fig. 10.9 Enterocutaneous fi stula and fi stula through nipple valve. ( a )
Enterocutaneous fi stula. ( b ) Fistula through the nipple valve
The policy in our institution has always been to recommend the patient to have revisional surgery to re-establish
continence in cases of nipple dysfunction. Only occasionally
would there be a need for removing the pouch due to any of
these complications. An association between the number of
revisions and conversion to conventional ileostomy has been
suggested, but has so far not been confi rmed [ 15 , 32 , 33 ].
It must in this context be emphasized that surgical revision of nipple dysfunction, although requiring another laparotomy, is in fact not necessarily a major undertaking. Even
if such a reconstruction is again followed by sliding or any
other defect of the nipple valve function, a further operation
for restoration of continence is mostly justifi ed and will be
successful eventually [ 34 ]. It appears also from our experi-
ence—amounting to 40–50 years clinical practice—that
10 Continent Ileostomy
165
Fig. 10.10 Endoscopic view of acute pouchitis
once a patient has experienced the benefi t of a continent ileostomy, such a patient usually insists on a further revision
(even if it may be the third or fourth in order) and refuses to
have the reservoir removed [ 35 ].
Ileitis (Pouchitis)
Key Concept : Similar to IPAA , continent ileostomies may
develop pouchitis . Management is typically medical , though
severe cases may require diversion or excision .
In patients with continent ileostomy, approximately onethird of the patients may experience episodes of pouchitis
[ 14 , 31 , 33 , 36 ]. The cause of this unspecifi c infl ammatory
reaction that sometimes develops in the reservoir and/or the
afferent intestinal loop is still obscure [ 36 , 37 ]. It may be
mild or asymptomatic, apparent at endoscopy as reddened
oedematous mucosa (Fig. 10.10 ). In more severe cases, the
patients suffer from colicky abdominal pain and diarrhoea
with liquid, bloodstained faeces. It is often readily reversed
by oral antibiotics (metronidazole or ciprofl oxacin), although
continuous drainage may be required in severe cases. A loop
ileostomy may occasionally be justifi ed as an alternative
measure, when other treatment has failed, and before removal
of the pouch is decided. It has been suggested that the process is bacterial in origin. However, since the condition
appears to be connected almost exclusively to patients
operated upon for ulcerative colitis, and particularly to those
suffering from primary sclerosing cholangitis, the reaction
pattern is more likely to be inherent in the original disease.
As compared to the other complications that can all be
managed surgically, pouchitis is therefore considered a particularly distressing and ominous complication. When looked
upon in a longer perspective, however, such fears appear to be
unfounded. Although the overall failure rate of the Kock
pouch may approach 10–15 %, pouchitis appears only occasionally to be the reason for pouch excision. Moreover, there
is a general impression that the episodes of pouchitis become
milder or may even disappear with the passage of time.
Epithelial Dysplasia and Cancer Risk
Key Concept : The development of dysplasia and cancer in
the pouch is rare for most patients ; however , adenomas in
the setting of FAP are more common requiring surveillance .
Sporadic reports of dysplasia and occasional adenocarcinomas in the ileal pouch mucosa have been published [
thus demonstrating the arrival of a further complication of the
ileal pouch as another model of the multistep progression
theory of cancer, taking normal mucosa through the stages of
infl ammation, dysplasia, and eventually carcinoma. Most
reports suggest that dysplastic transformation in pelvic
pouches is a rare phenomenon, and therefore, the risk of further progression to cancer should be small [ 39 ]. Others [ 40 ]
claim the opposite view. Common to these studies is that the
follow-up observation period is relatively short and casts
doubts as to the reliability of these statements. The long-term
results presented recently from a study on patients with a continent ileostomy are more reliable and reassuring. Considering
an observation time of an average of 30 years and the comparatively large series of patients kept under close supervision, the incidence of mucosal dysplasia in the ileal pouch
mucosa proved to be low, and no case of carcinoma or highgrade dysplasia was observed [ 41 , 42 ]. Surveillance intervals
should be left to the discretion of the provider.
38 ],
Ileal Pouch Adenomas in Patients Operated for with Familial Adenomatous Polyposis (FAP)
The apparent ability of small bowel adenomas to develop
many years after colectomy for familial polyposis may be
a different problem in patients with a continent ileostomy
[ 43 – 45 ]. Thus adenomas with the potential to progress to
adenocarcinomas can develop even in the mucosa of the continent ileostomy. The risk of developing one or more adenomas over a 10-year period has been calculated to be about
35 %, and patients with adenomas appear also more likely to
have duodenal and ampullary adenomas [ 46 ]. Regular endo-
scopic surveillance of FAP patients with a Kock pouch is
therefore recommended at a frequency similar to that of
upper gastrointestinal endoscopy. In general, most guidelines recommend every 3–5 years for upper endoscopy and
every 1–2 years for IPAA patients.
166
L. Hultén and H.E. Myrvold
Pouch Removal
Key Concept : Disease - specifi c , anatomic , and functional
problems may occasionally lead to pouch excision .
Persistent leakage after numerous nipple valve revisions,
unsuccessful fi stula operations, intractable pouchitis, and
Crohn’s disease are the common indications for pouch
removal. Removal rate is currently reported below 10 %
[ 6 , 14 , 17 , 20 – 24 ]. When the continent ileostomy fails, the
pouch is usually excised and a conventional ileostomy established. Although a pouch constructed on a new ileal segment
may well be possible, such a procedure is risky and usually
not recommended as metabolic disturbances will inevitably
occur and may lead to a short bowel syndrome eventually.
Criteria of Selection
Key Concept : Although the prevalence of continent ileostomies is decreasing , there remains well - defi ned cohort of
patients for which this pouch may be useful .
The main indications for a continent ileostomy are ulcerative colitis and familiar polyposis, but the procedure has
also been used in patients with multiple colorectal carcinomas, aganglionosis coli, coloanal incontinence, and severe
constipation. In patients with Crohn’s disease, the operation
has been marred by a very high rate of immediate and late
complications, and most surgeons therefore consider Crohn’s
disease a contraindication [
cases (such as those undergoing proctocolectomy for Crohn’s
colitis without involvement of the distal ileum and diseasefree for at least 5 years and still not accepting their conventional ileostomy), the procedure may still be justifi ed and is
often successful [ 48 , 49 ]. In patients with familial adenoma-
tous polyposis, the development of desmoids should be considered, as their occurrence will interfere with construction
of a continent ileostomy.
Obese patients can often be a technical problem, as the
mesenteric fat content may interfere with both the folding
procedure and the valve construction. It is also often argued
that the patient’s manual skill will inevitably be reduced with
ageing and might interfere with the evacuation routines, but
in fact, these daily routines are less demanding than those
used for the management of a conventional ileostomy.
Provided that the patient is mentally fi t, older age should
therefore not be a contraindication to the Kock pouch.
47 ]. However, in highly selected
Concluding Remarks
It appears reasonable to assume that anyone with a keen
interest in colorectal surgery should be able to adopt the continent ileostomy technique in its present fashion and put it
into practice with a good prospect of success. Complications
will initially inevitably occur, requiring reintervention before
the ideal functional stage is reached.
Experience and surgical skill are needed to improve the
success rate, but competence is also required for proper management of the complications. A suffi ciently large patient
fl ow is of prime importance to achieve and maintain expertise in these respects, and the continent ileostomy should
therefore be done in specialized surgical units where a team
of surgeons must be prepared to accept a long-term commitment of these patients.
Since the advent of the pelvic pouch procedure, there are
today even fewer advocates for the continent ileostomy. This
is very unfortunate, as the technique has still a defi nite place
in surgery [ 50 ]. There may be patients with a conventional
ileostomy who may wish to undergo a conversion to a continent ileostomy due to ileostomy problems, or there may be
patients who are considered unsuitable for a restorative proctocolectomy. Moreover, it appears that the excision rate for
pelvic pouches increases with the passage of time [ 51 , 52 ]
and a failing pelvic pouch may be used for conversion to a
continent ileostomy rather than being excised [ 53 – 57 ].
Therefore it is of our opinion that surgeons in specialty clinics offering patients a pelvic pouch should also be conversant and facile with the continent ileostomy technique.
The Continent Ileostomy: Its Place in the Future
Key Concept : In addition to primary construction following
proctocolectomy , a continent ileostomy may be considered in
carefully informed and strongly motivated patients with a
failed ileal pouch - anal anastomosis .
The pelvic pouch procedure has become the chief method
today for curative treatment of ulcerative colitis and familial
polyposis. The failure rate after construction of a pelvic
pouch in patients with ulcerative colitis (UC) varies. While
Tulchinsky et al. [ 27 ] reported a failure rate of 9 % in 635
patients, with an average follow-up of 3 years, Korsgen and
colleagues [ 58 ] reported a 19 % failure rate in 154 patients.
Interestingly, most of the pouch failures seem to occur late
postoperatively. Pelvic sepsis, poor function, pouchitis, and
overlooked Crohn’s disease (in that order) seem to be the
main reasons for failures. The failure rate when calculated
and expressed in crude fi gures is often unreliable, and actuarial methods should be a more correct statistical method to
determine this cumulative risk. A life table calculation based
on fi gures presented so far would imply that the cumulative
risk for pelvic pouch failure in a UC patient is about 10–15 %
over 10 years [ 14 , 28 , 59 , 60 ] and 30–40 % in patients who
develop septic complications [
long-term results imply that the ileoanal pouch may not be
the panacea it was initially thought to be.
28 , 52 ]. Time will tell, but the