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108 N. Parekh and D.L. Seidner
1 year or more. More frequently, hyperglycemia or abdominal distention and constipation are seen with short-term use
of high doses of octreotide. General guidelines call for the
use of octreotide in non-septic, non-obstructed patients with
ECFs unresponsive to 7 days of conservative treatment [
20,
26 ] . Octreotide should be discontinued after 2–3 weeks of
treatment if there is no response, and long-term use should
be routinely reevaluated for development of biliary tract
abnormalities.
Fibrin Glue
Fibrin glue has been shown to lead to a more rapid closure of
low-volume-output ECFs in a small randomized controlled
trial. In 13 patients who had failed medical therapy after
2–4 weeks of fi stula formation, those patients treated with
fi brin glue experienced ECF closure within 4 days, while
patients continuing conservative medical management closed
after 1–2 weeks [ 64 ] . The ECFs in these patients were in a
variety of locations including the stomach, small bowel, and
colon. In a small case series of patients with chronic, highoutput ECFs following surgical repair of gastroduodenal ulcers
due to peptic ulcer disease, fi brin glue was shown to reduce
ECFs draining as much as 500–1,000 mL each day [ 65 ] . These
results suggest that in a select group of patients, fi brin glue
may be useful in closing ECFs without surgical intervention.
Conclusion
Medical management of the high-output enterostomy or ECF
is largely based on a working knowledge of the anatomy and
physiology of the remaining GI tract. Nutrition and pharmacotherapy is tailored to treat patients with varying bowel
lengths in continuity. Fistuloclysis has been shown to be a
successful way to enterally feed patients with at least 100–
120 cm of small bowel distal to the ECF. When GI losses
remain exceptionally high despite optimal dietary and pharmacologic intervention, patients will often require intravenous nutrient and/or fl uid support until further surgery can
safely be performed. Further research is needed to investigate the role of probiotics and soluble fi bers in improving
sodium and fl uid balance in patients with high-output
enterostomies or ECFs.
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Intestinal Stomas and the Biliary Tree
Michael D. Johnson and John Fung
9
The use of intestinal stomas in hepatobiliary surgery has traditionally been limited to use in hepatolithiasis and refractory biliary strictures. Surgical management of complex bile
duct pathology often involves bile duct exploration followed
by creation of a Roux-en-Y hepaticojejunostomy. The Roux
limb acts as a defunctionalized conduit that maintains fl ow
of bile into the intestine. When there are no residual stones or
a stricture has been successfully bypassed, this can represent
a defi nitive operation by itself. However, there are often more
proximal intrahepatic strictures and stones requiring repeated
therapy sessions. A Roux-en-Y reconstruction precludes
easy endoscopic access to the biliary tree.
Hepaticocutaneous jejunostomy has been used in situations that require permanent, easy access to the biliary tree
(Figs. 9.1 and 9.2 ). Many variations have been employed in
Asia where hepatolithiasis is much more prevalent compared
to North America. The Roux limb is left long, such that the
end can be brought out as an intestinal stoma, or left closed
but secured subcutaneously and marked with metal clips
for later percutaneous access. Fan et al. reported a series of
41 patients undergoing hepaticocutaneous jejunostomy for
hepatolithiasis. Sixty-six percent underwent postoperative
choledochoscopy for recurrent symptoms anywhere from
1 to 15 times [
pared to choledochoscopy performed through a T-tube tract.
Drawbacks to this technique include inconvenience to the
1 ] . Patient comfort was much better com-
patient related to the presence of a stoma and development of
Roux limb varices in patients with longstanding liver disease
and portal hypertension. The latter have potential to cause
dangerous variceal bleeding. Alternatives to a hepaticocutaneous jejunostomy include a classic Roux limb construction
and simultaneous duodenojejunostomy or jejunal interposition between the duodenum and biliary tree. Both of these
maintain endoscopic access to the biliary tree via the duodenum [
2, 3 ] .
M. D. Johnson (*)
The Nebraska Medical Center ,
Surgical Services of the Great Plains, P.C. , Omaha , NE , USA
e-mail: mdj2003@yahoo.com
J. Fung
Digestive Disease Institute, Transplant Center, Cleveland Clinic
Lerner College of Medicine , Cleveland Clinic Foundation ,
Cleveland , OH , USA
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_9, © Springer Science+Business Media, LLC 2012
Fig. 9.1 Roux-en-Y hepaticojejunostomy with hepatocutaneous stoma
for access to biliary tree (Illustration © CCF)
111
112 M.D. Johnson and J. Fung
Fig. 9.2 Roux-en-Y access limb to left segmental bile ducts with
hepaticocutaneous stoma (Illustration © CCF)
References
1. Fan ST, Mok F, Zheng SS, et al. Appraisal of hepaticocutaneous
jejunostomy in the management of hepatolithiasis. Am J Surg.
1993;165(3):332–5.
2. Ramesh H, Prakash K, Kuruvilla K, et al. Biliary access loops for
intrahepatic stones: results of jejunoduodenal anastomosis. ANZ J
Surg. 2003;73:306–12.
3. Cunha JEM, Herman P, Machado MCC, et al. A new biliary access
technique for the long-term endoscopic management of intrahepatic
stones. J Hepatobiliary Pancreat Surg. 2002;9:261–4.
Continent Ileostomy
Ravi Pokala Kiran and Victor W. Fazio
1 0
Introduction
The ileoanal pouch (IPAA) is the procedure of choice in
patients requiring proctocolectomy, as it provides control of
colitis or polyposis but maintains normal per anal defecation.
For certain groups of patients, however, IPAA may not be
technically feasible or advisable. Expectations of poor functional outcomes due to sphincter compromise, risk of perianal sepsis in patients with preexisting perianal disease, and
patients with cancer of the lower rectum where an adequate
oncologic resection may not be achieved with a restorative
proctocolectomy are examples of such circumstances.
Further, some patients who develop pouch failure may not be
candidates for a redo pouch procedure, or this may not be
technically feasible. These patients face a permanent end
ileostomy and may want to consider the merits of a continent
ileostomy as an alternative [
ileostomy is technically challenging and may be associated
with a variety of complications, its advantages over an end
ileostomy include continence for feces and fl atus, better body
image, and improved quality of life (QOL) [ 4– 8 ] .
1– 3 ] . Although the continent
Historical Perspective
The continent ileostomy was developed by Nils Kock in
1969 [ 9 ] based on previous reports by Tasker who fi rst
described the use of detubularized parts of the bowel for urinary diversion. A nipple valve was subsequently designed by
adding an intussuscepted length of ileum as an efferent limb.
R. P. Kiran (*)
Department of Colorectal Surgery , Digestive Disease Institute,
Cleveland Clinic Foundation , Cleveland , OH , USA
e-mail: kiranp@ccf.org
V. W. Fazio
Department of Colorectal Surgery , Digestive Diseases Institute,
Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University, Cleveland Clinic Foundation , Cleveland , OH , USA
e-mail: faziov@ccf.org
Over the years, the continent ileostomy has shown itself
to be prone to several complications, mostly related to the
nipple valve. Numerous modifi cations have been made to
circumvent these problems, but there continues to be a high
incidence of pouch revision and excision.
Indications
The most common indication for the procedure is removal of
the large intestine for ulcerative colitis and indeterminate colitis in patients who are not candidates for IPAA, or when the
creation of an IPAA may be technically impossible due to diffi culties with reach of the pouch to the anal canal. Some
patients with an ileostomy are unable to cope with the demands
of life with an external appliance, while others suffer complications of a conventional ileostomy including hernia, fi stula,
prolapse, recession, and leakage resistant to revisional surgery.
In addition, some patients seek conversion of an end ileostomy
to a continent ileostomy to circumvent psychological, social,
and sexual problems associated with the wearing of an external appliance. In patients who experience failure of IPAA, and
a redo IPAA is not possible, due consideration may be given to
a continent ileostomy. In this case, the IPAA can be modifi ed
for use as a continent ileostomy pouch, offering the additional
advantage of preservation of small bowel since pouch excision
would otherwise have been performed.
In recent times, the procedure has been extended for use
in a select group of patients with cancer of the colon and
rectum, Crohn’s disease confi ned to the large bowel and
perineum, and patients with colonic inertia. In these situations, careful consideration is given to the relative risk of
recurrence of disease, its effect on function of the pouch and
small bowel, survival of the patient, and the risk of development of a short bowel syndrome were the patient to develop
failure of the K-pouch, thus, requiring subsequent excision
of the pouch. Patients in whom these risks are considered to
be minimal, the procedure may be offered after due and thorough discussion of the potential risks involved.
V.W. Fazio et al. (eds.), Atlas of Intestinal Stomas,
DOI 10.1007/978-0-387-78851-7_10, © Springer Science+Business Media, LLC 2012
113
114 R.P. Kiran and V.W. Fazio
Fig. 10.1 Double-folded reservoir in the shape of a “U” as described by Nils Kock (Illustration © CCF)
Contraindications
It is crucial that patients understand the importance of timely
catheterization of the continent ileostomy when full since
the reservoir will not drain itself spontaneously. Patients
need to have on their person at all times the drainage tube
required to empty the pouch. Thus, patients lacking adequate mental competence required to master intubation are
not candidates for the procedure. Obesity is a relative contraindication owing to several factors. In addition to the
technical diffi culty associated with delivery of the exit conduit through a thick abdominal wall, a foreshortened fatty
mesentery may preclude creation of an adequate nipple
valve and predispose to valve slippage. Patients with marginal small-bowel length and those who are deemed to be at
a higher risk of failure of the continent ileostomy due to
recrudescent Crohn’s disease or desmoid disease in FAP are
at risk of developing short bowel syndrome due to the potential loss of 50 cm of small-bowel length that is utilized in the
creation of a continent ileostomy.
Original Surgical Technique
The continent ileostomy was originally designed by Nils
Kock based on the two fundamental principles of creation of
a low-pressure reservoir by detubularization of the bowel
and use of intermittent catheterization to empty the reservoir.
The double-folded reservoir, which was created by splitting
a segment of ileum longitudinally at its antimesenteric border and folding it in the shape of a “U”, was a modifi cation
of the original J-pouch design of Tasker (Fig. 10.1 ). The two
limbs of the “U” were sutured together, and the pouch formed
by a second fold. The double-folded design circumvented
the problem of high pressures that developed at large volumes in the original J-pouch design. The reservoir initially
had an opening at its corner through which it was emptied.
Subsequently, a segment of intestine was interposed between
the pouch and the skin. Since several patients suffered incontinence, an intussuscepting outlet (“nipple”) was subsequently added to the design to prevent leakage (Fig.
The pouch was subsequently modifi ed by Fazio to a 3-limb
10.2 ).
11510 Continent Ileostomy
Fig. 10.2 Addition of an intussuscepting outlet (“nipple”) to prevent leakage (Illustration © CCF)
the nipple valve. The commonest portion of the valve that
predisposes to dessusception is the mesenteric aspect, where
one limb of the nipple valve tends to slip on the other.
Although various modifi cations have been described to prevent slippage, the complication rate continues to remain
high. The modifi cations that have been described include the
use of a sling made of fascia, marlex, or prolene to support
the base of the nipple [ 10, 11 ] ; anchorage of the nipple valve
to the pouch wall by sutures [ 12 ] ; peritoneal stripping and
mesenteric fat excision [ 12 ] ; scarifi cation of the serosa [ 13 ]
(Figs. 10.3 and 10.4 ); and staple stabilization of the nipple
14– 16 ] . Barnett described a modifi cation of the proce-
valve [
dure designed to stabilize the base of the nipple valve using
a segment of the efferent limb to form a living collar [
(Fig. 10.5 ). Stapler fi xation of the nipple to the pouch wall
and biomechanical stabilization have also been described
[ 18, 19 ] . Unfortunately, the stabilizing procedures themselves can lead to complications [ 20 ] .
Fig. 10.3 Excision of mesenteric fat to reduce valve slippage
(Illustration © CCF)
Complications
17 ]
S-shape made of three 12–15-cm limbs of small bowel and a
nipple segment that is created by intussuscepting the penultimate 12 cm into itself, followed by the last 8 cm forming the
exit conduit and ileostomy segment.
There is, however, a high complication rate associated
with the original design, the commonest being slippage of
The different modifi cations have reduced the complication
19, 21 ] , but there continues to be a diverse spectrum of
rate [
complications associated with the Kock pouch (Table
10.1 ).
Early complications that have been described include anastomotic leak, necrosis of the nipple valve, fi stula, pouchitis,
wound sepsis, dehiscence, and intestinal obstruction. Late
116 R.P. Kiran and V.W. Fazio
Fig. 10.4 Scarifi cation of the serosa to reduce nipple valve slippage (Illustration © CCF)
complications include pouchitis, inability to intubate,
incontinence, peristomal sepsis, fi stula, anemia, stomal sepsis,
parastomal hernia, redundant stoma, and skin level stricture.
Current Technique
The operative technique currently practiced at the Cleveland
Clinic Foundation has gradually evolved based on increasing
experience with the procedure. The procedure involves the
construction of an ileal reservoir from three 12–15-cm loops
of terminal ileum using a hand-suture technique. The terminal
20 cm of the ileum are used to create the nipple valve and the
exit conduit, with 12 cm devoted to the valve, and 8 cm devoted
to the exit conduit and stoma. Thus, by intussuscepting the
12-cm segment of the efferent limb, a 6-cm nipple is created.
After identifying and freeing the terminal ileum, the termi-
nal 20 cm of the small bowel and the 3 12–15-cm length segments
are measured and marked with stay sutures (Fig. 10.6a, b ).
Seromuscular sutures are placed to appose adjacent loops of
bowel forming the S-pouch (Fig. 10.7 ). An enterotomy is
made on adjacent limbs of the pouch (Fig. 10.8a, b ), and
mucosal approximation of the back wall of the pouch is completed (Fig. 10.9a, b ). The 12-cm segment of ileum adjacent to
the pouch is then intussuscepted on itself to form a nipple
valve (Fig. 10.10a–c ). Prior to this, the thickness of the mesen-
tery supplying this segment of ileum is reduced by the application of coagulation current to the fat between the vasa recta.
Using the transverse stapler, two parallel rows of staples
are then placed on the inner aspect of the nipple valve on
either side of the folded mesentery of the intussuscepted segment (Fig. 10.11a, b ). The fundus of the pouch is then sewn
onto the base of the exit conduit to strengthen the intussusception. These “fundoplication-like” sutures help stabilize
the valve, maintaining an adequate length of nipple valve
intussuscepted into the pouch. Since these sutures could
11710 Continent Ileostomy
Fig. 10.5 Stabilization of the nipple valve with the use of a segment of the efferent limb to form a living collar (Illustration © CCF)
potentially jeopardize the blood supply to the pouch/nipple
Table 10.1 Late complications of the Kock pouch
I. Abnormalities of Continence-Providing Valve and Efferent Ileal
Segment
Sliding
Eversion
Detachment of the reservoir from the abdominal wall
Sliding hernia
Valve-shunting fi stulas
II. Abnormalities of the Reservoir
Pouchitis
Relapse of Crohn’s disease
Fistulas: internal or external
III. Abnormalities of the Afferent Ileal Segment
Ileitis
Stenosis and dilatation
Antirefl ux valve
Miscellaneous: stenosis resulting from misalignment between the
afferent ileal segment and the reservoir.
valve (exit conduit), these are used selectively when the
blood supply is felt to be good, and additional fi xation sutures
are felt necessary for maintaining the conformation of the
nipple valve in relation to the pouch.
Closure of the anterior wall of the pouch is then commenced, starting from the apex of the pouch at its junction
with the base of the nipple. Some of these sutures deliberately include a portion of the nipple valve in order to appose
the nipple wall to the suture line. When the apex of the nipple
has been reached, the transverse stapler is inserted into the
lumen of the nipple valve, and the device deployed to form a
row of staples that overlap the previously placed suture line
(Fig. 10.12a–c ) and providing additional fi xation of the nip-
ple valve to the pouch.
Closure of the anterior wall of the pouch is then completed
and the pouch tested for integrity and continence (Fig.
The exit conduit is brought through the abdominal wall and
10.13a–c ).
118 R.P. Kiran and V.W. Fazio
Fig. 10.6 Operative
photograph ( a ) and illustration
( b ). The terminal 19–20 cm of
the small bowel and the three
12–15 cm length segments are
measured and marked with stay
sutures (Illustration © CCF)
7cm
12cm
12−15cm
a
Fig. 10.7 Seromuscular sutures are placed to appose adjacent loops of
bowel forming the S-pouch
anchoring sutures placed to secure the pouch to the inside of
the abdominal wall. The lateral para-ileostomy space is obliterated and a drainage catheter secured safely in the pouch
before the abdomen is closed (Fig. 10.14a, b ).
Postoperative Care
The drainage catheter is left in the pouch for 4 weeks to
allow complete healing of the pouch. The tube is connected
to a drainage bag that is strapped to the patient’s leg. The
b
tube is irrigated with 30 mL of saline every 2–3 h postoperatively (Table 10.2 ). After the return of bowel activity, the
frequency of irrigation is reduced to twice daily. The
patients are normally discharged 5–7 days after surgery and
scheduled for the fi rst outpatient visit at 3 weeks. At that
time, the pouch is tested, and intermittent catheterization
begins at two hourly intervals, with a gradual reduction to a
frequency of intubation as required by the patient within
the subsequent 4 weeks (Table 10.3 ). Routine follow-up is
scheduled at 3 months from the discharge day and at yearly
intervals thereafter.
Conversion of the Ileoanal Pouch to Continent Ileostomy
The pouch is mobilized, disconnected, and detached from
the anal anastomosis by either an abdominal or combined
abdomino-anal approach. When a decision is made to preserve the entire, or a portion of, the pelvic pouch prior to
the performance of the continent ileostomy, the mobilized
pouch is disconnected from the proximal bowel segment to
achieve pouch rotation, and a nipple valve about 6 cm long
created by intussuscepting the afferent limb of the pelvic
pouch into itself. A pouchotomy is created through which
the transverse stapler is introduced and the valve stabilized
with three fi rings of the stapler, the last one including the
anterior pouch wall as previously described. Thus, in such
cases, a two-loop continent ileostomy is created. When the