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444 G.G. Delaini, G. Colucci, M. Fontana, F. Nifosì
As a result, as many as 3.5-9% of patients who
undergo total proctocolectomy and IPAA are found
to develop recurrent Crohn’s disease in the ileal
pouch [55, 56] so that, in retrospect, these individu-
als presumably had surgery for Crohn’s disease
involving the colonrather than for UC.
In general, patients with Crohn’s disease are not
usually offered IPAA because recurrence, refractory
fistulase, abscesses and strictures, extraintestinal
manifestation and the high morbidity in these
patients [57, 58,] may lead to a higher incidence of
pouch failure. Neoplastic transformation of the
pelvic pouch has also been reported, particularly in
patients with chronic pouchitis.
Moreover, when total proctocolectomy is required
for patients with intractableCrohn’s colitis (i.e. gran-
ulomatous colitis), some surgeons advocate an IPAA
in select casesto avoid the need for a permanent end
ileostomy [59, 60].
However, surgery for Crohn’s disease is only a
temporary intervention in most cases because of the
high rate of recurrencet: the reported prevalence of
radiographic or endoscopic recurrence of Crohn’s
disease in the small bowel at or nearsurgical anasto-
moses is as high as 18-55% at 5 years and 40-76% at
10 years [61].
Most colorectal surgeons therefore do not recom-
mend an IPAA for Crohn’scolitis because of the high
risk of developing recurrent Crohn’s disease in the
ileal pouch and the high morbidity in these patients
[62-66].
Nevertheless the secondary diagnosis of Crohn’s
disease after IPAA is associated with protracted free-
dom from clinically evident Crohn’s disease, low
pouch-loss rate and good functional outcome. Such
results can only be improved by the continued devel-
opment of medical strategies for long-term suppres-
sion of Crohn’s disease. These data support a
prospective evaluation of IPAA in selected patients
with Crohn’s disease. [62-64].
Despite the fact that a diagnosis of Crohn’s disease
is currently considered a contraindication for an
IPAA, some patients with secondary diagnosis of
Crohn’s disease have good functional outcome and
quality of life after restorative proctocolectomy. [65,
66].
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Introduction
Over the second half of the last century, proctocolec-
tomy in regards to terminal ileostomy has played an
important role in the management of inflammatory
diseases affecting the colon and rectum. For a long
time it has been considered the gold-standard opera-
tion and all the results of alternative procedures have
been compared with it. Before the era of restorative
proctocolectomy, the possibility of removing all the
diseased tissue in a one-stage procedure while avoid-
ing the risk of cancer made this technique very suc-
cessful. However, although this procedure has a low
rate of morbidity and mortality and allows the
patients an early return to normal activities [1], there
are some important drawbacks that have spurred
surgeons on to develop restorative proctocolectomy.
First of all, the patients perceive the ileostomy as an
unnatural condition which impairs their relation-
ships and social life. Although modern stoma care
allows an easier management of the stoma appliance,
the unpredictable faecal and noisy gaseous discharge
may be of such an extent that they restrict patient
activities to the point of becoming a psychological
barrier. Sexual complaints of the patients depend on
both the functional and psychological impairment.
Permanent impotence is rare with the intersphinteric
technique and some authors have reported no per-
manent male dysfunction, either partial or complete,
when using a perimuscular rectal excision during the
proctocolectomy [2]. Women often complain of vagi-
nal discharge and dyspareunia because of the per-
ineal scar. However, psychological lability and the
perception of the self-image are the factors that
mainly affect sexual intercourse and the relationship
of the patient. Moreover, some bladder dysfunctions
may occur [3] and the perineal wound healing may
take a long time, particularly in patients with unde-
tected Crohn’s disease [4]. Finally, the cost of the
management of the ileostomy should be considered.
Indications
The choice of the ideal surgical procedure for treat-
ing these patients is based upon the following con-
siderations:
– the need of definitive treatment with a one-stage
procedure that allows a complete removal of the
diseased tissue and avoids the risk of cancer.
– The possibility of restoring the anatomy as well as
the bowel function and the faecal continence.
– The outcome and the complications of different
surgical procedures.
– The patient’s skills in managing the new condition
and coping with the possible complications.
– And, above all, the possibility of improving the
quality of life of the patient, which implies the
evaluation of multiple functional and psychologi-
cal factors.
Nowadays, restorative proctocolectomy is certain-
ly the gold-standard technique for treating patients
with ulcerative colitis or familial adenomatous poly-
posis [5, 6]. Nevertheless, there are still a few patients
in which the proctocolectomy along with definitive
ileostomy may be considered a good indication. The
proctocolectomy with perineal excision and defini-
tive ileostomy may be an indication of necessity in
patients presenting with cancer or severe dysplasia of
the very low rectum or anus [7]. In these cases, the
choice of this surgical procedure should be based on
the tumour stage and the need for radiotherapy. In
other cases, the indications are more controversial
and are still being debated. Provided that all the alter-
natives are discussed with the patient, the decision of
the surgeon should be drawn from a sort of balance
between the factors mentioned above. In elderly
patients with a longstanding disease and a weak
sphincter, a one-stage procedure with definitive
ileostomy could be beneficial and better accepted by
the patient. Similarly, all the patients with sphincter
damage, particularly women with post-obstetric neu-
The Place of Proctocolectomy with Ileostomy in the Era
of Restorative Proctocolectomy
Giovanni Romano, Francesco Bianco, Vittorio D’Onofrio
448 G. Romano, F. Bianco, V. D’Onofrio
ropathic sphincter trauma, might be good candidates
for a definitive ileostomy. In these patients, the exci-
sion of the rectum to the level of the perineal muscles
and the removal of the diseased anal mucosa could
lead to disappointing results in terms of continence
with much more discomfort and distress symptoms
for the patient than a well-managed ileostomy. All
the patients should be correctly informed about the
outcome and the possible complications after
restorative proctocolectomy such as diarrhoea, noc-
turnal soiling and recurrent pouchitis, so that
patients who refuse to take these risks can be candi-
dates for a proctocolectomy with a definitive ileosto-
my. Other patients are too psychologically weak and
unstable to cope with the uncertainties of the out-
come of a restorative procedure or are not available
to attend the strict follow-up that is mandatory when
an ileal pouch-anal anastomosis has been performed
[8]. Furthermore, the definitive ileostomy, as salvage
surgery, constitutes the last option for patients who
previously underwent a restorative proctocolectomy
in which the ileal pelvic pouch had to be removed [9].
The emergency operations are a particular problem.
In patients with a previously detected severe inflam-
matory anorectal involvement, continuous bleeding
from the ultra-low rectum or a perforation at this site
may occasionally constitute an indication for a radi-
cal proctocolectomy without anastomotic recon-
struction. Nevertheless, some authors suggest that
even in these cases the rectum should be mobilised at
the level of the levator ani and transected at the
anorectal junction so that a pelvic pouch might be
subsequently performed [4]. However, it should be
stressed that, recently, many authors have reported
that, in emergency, the primary procedure is more
frequently a total colectomy with an ileostomy. They
suggest that in these circumstances the surgeon
should do a minimal intervention, and subsequently
the patient may undergo a restorative proctectomy
or an ileo-rectal anastomosis [10]. Emergency opera-
tions certainly have more complications such as a
higher risk of fistula and pelvic nerve damage, and in
these cases the surgeon’s experience plays an impor-
tant role in the choice of surgical options [11].
The surgeon and the stoma care nurse should
arrange a pre-operative meeting with the patients
whenever an elective procedure is performed. In
order to make the right choice, the patient and the
partner have to be aware of the alternative proce-
dures such as restorative proctocolectomy with an
ileal pelvic pouch and total colectomy with ileo-rectal
anastomosis. The procedures have to be carefully
described to the patients with particular attention to
technical details, drawings and literature data. More-
over, they should be correctly informed about the
quality of life and the possible implications of these
operations. Particularly, some aspects of both the
procedures have to be discussed such as complica-
tions, continence, soiling, diarrhoea, dietary restric-
tions, social restrictions and the necessity of long-
term follow-up. The patient should be reassured that
a stoma care unit is always available for all his needs.
However, above all, the information given to the
patients must be as objective as possible since,
patients potentially unsuitable for the restorative
operation may be persuaded by the excessive enthu-
siasm of the surgeons for the pouch procedure [8].
Once a decision to perform a definitive ileostomy
has been taken, the surgeon is requested to make a
second choice: whether or not to perform a continent
reservoir ileostomy according to a modified Kock
technique instead of a conventional Brooke ileosto-
my [12, 13]. Nowadays, the Kock ileostomy is rarely
used as the primary treatment for ulcerative colitis or
familial adenomatous polyposis due to the other
alternative surgical options that are available and the
surgical and metabolic complications associated with
the reservoir ileostomy [14]. Nevertheless, besides
the above-mentioned indications for conventional
ileostomy, patients who have a poorly functioning
ileoanal pouch and who are unsatisfied with their
continence and quality of life, may be suitable for a
conversion to a continent reservoir ileostomy [9, 15].
Similarly, the continent reservoir may be proposed to
a limited cohort of selected and strongly motivated
patients who have previously had a terminal conven-
tional ileostomy. However, it is necessary to stress
that there is an important learning curve for this
operation and, just because nowadays the indications
are rare, only a few centres have acquired sufficient
experience with the procedure.
Even in this case, a detailed description of the pro-
cedure and its aims should be given to the patient,
since a failure of the reservoir exposes the patient to
the risk of a reoperation, a further loss of 50–60 cm of
the ileum along with consequent metabolic derange-
ment and, finally, the need for wearing a convention-
al appliance for the stoma. Therefore, it is obvious
that the possibility of evaluating whether or not the
procedure will be successful depends on a clear and
objective definition of the aims of the reservoir
ileostomy. Some authors have described these aims
as the possibility of achieving a pouch completely
continent to the gas and faeces with a capacity of
800–1 000 ml. This pouch should be emptied by a
catheter no more than two or three times a day, with-
out the urgency of draining at night, and the
catheterisation should take no longer than 15 min.
The exit conduit of the stoma should be invisible
under the clothes and there should be no need of
wearing a stoma bag as the mucous discharge should
be minimal and there is complete control achieved by
The Place of Proctocolectomy with Ileostomy in the Era of Restorative Proctocolectoymy 449
the application of a disposable dressing over the
stoma. Finally, there should be no restrictions of food
intake, sexual activities, work or any other social
functions [8].
A careful selection of these patients is of para-
mount importance. A psychological assessment
should be made in order to verify the real motivation
of the patient and the psychological profile, thus
excluding psychologically unstable patients who are
seeking attention. The social environment should be
evaluated as well as the physical skill of the patient to
manage the pouch. Some patients have been
described as having badly managed and perforated
the pouch during catheterisation, others, with psy-
chological lability, manipulate and deteriorate the
pouch themselves; likewise, the elderly patients
should not be considered for this procedure. Patients
with pathological and psychological dietary distur-
bances such as the alcoholic, the anorexic, the bulim-
ic, the obese and the very thin should be excluded.
Particular attention should be paid to the patients
who have previously undergone abdominal surgery,
because the presence of thick adhesions may be a
contraindication. Moreover, previous small-bowel
resections, gastrectomy or pancreatic insufficiency
are criteria for exclusion since in these cases there is
an increased risk of electrolyte deficiency and meta-
bolic complications. Finally, the emergency opera-
tion may be considered a contraindication for this
procedure.
In 1997, Williams reported ten cases of Kock
pouch construction. Four patients had a primary
conventional proctocolectomy with a Kock pouch for
ulcerative colitis with good long-term results. Six
patients who had previously undergone restorative
proctocolectomy for ulcerative colitis were converted
to reservoir ileostomy. Among these latter, the reser-
voir was successful in four patients and failed in two:
one due to sepsis and one due to obesity [8].
Although many authors consider a diagnosis of
Crohn’s disease as an absolute contraindication for a
Kock pouch construction, this particular topic is still
being debated [16]. In most of the reported cases, the
patients with Crohn’s disease who had a reservoir
ileostomy as the primary operation, had a diagnosis
of ulcerative colitis at the time of the first operation
and, only subsequently, was the underlying diagnosis
of Crohn’s disease confirmed. In these patients, the
diagnosis is usually achieved by the histological
examination of the colon specimen in the early post-
operative period or, later—via the analysis of the
removed ileal pouch as a consequence of complica-
tions. In these latter cases, the histological examina-
tion of the colon, at the time of the first operation,
has features similar to those of the ulcerative colitis,
but the subsequent pouch complications reveals
Crohn’s disease. Some of these patients with Crohn’s
disease develop complications in the early post-oper-
ative period such as sepsis, fistula, bleeding and poor
functional results requiring pouch excision; others,
after years of good functional results, begin to have
the typical symptoms of pouchitis. These patients
complain of abdominal pain, fever, diarrhoea with
high volume of fluid discharge and loss of elec-
trolytes, bleeding, obstruction and difficult catheter-
isation. Frequently, they are classified as having
chronic pouchitis and only the endoscopic biopsy
allows the correct diagnosis of the underlying
Crohn’s disease. In these recurrent forms of Crohn’s
disease, medical treatment rarely achieves good
results and, often, the patients end up with the
removal of the pouch and a conventional ileostomy.
Myrvold and Kock, in their important study that was
a milestone in this specific area, reported only 27% of
complications out of a total of 52 patients with
Crohn’s disease who underwent a reservoir ileosto-
my. The same incidence of complications was found
in patients operated on for ulcerative colitis or famil-
ial adenomatous polyposis [17]. Other authors
reported similar results in a small subset of patients
with Crohn’s disease. These authors suggested that
patients with Crohn’s disease confined to the colon
and no evidence of disease to the small bowel, after a
minimum follow-up of 5 years might be candidates
for a reservoir ileostomy. Similarly patients with
indeterminate colitis without evidence of disease to
the ileum might be suitable for the Kock ileostomy
[18]. On the contrary, Handelsman reported four
pouch excisions out of eight patients operated on
with Crohn’s disease compared to only two pouch
excisions in 87 patients with ulcerative colitis, so that
he concluded that the suspicion of Crohn’s disease is
a contraindication to continent reservoir ileostomy.
Management, Outcome and Complications
The management of a conventional Brooke ileosto-
my is quite easy, both for the surgeon and the patient.
As soon as possible, the patient is allowed to drink to
easily achieve a correct balance of fluid intake.
Beginning in the early post-operative period, a stoma
care nurse should instruct the patient and his partner
to empty and change the bag and to apply the flange.
Although the rehabilitation mainly depends on
patient motivation, the availability of a stoma care
unit greatly helps the patient. They have to be
informed about the correct volume of fluid intake,
the need of wound dressing until complete healing is
achieved and the risk of intestinal obstruction due to
stoma impairment or post-operative adhesions.
Mortality is related to the proctocolectomy and
450 G. Romano, F. Bianco, V. D’Onofrio
ranges between 2 and 3%, but for emergency proce-
dures, a mortality of 23% has been reported. A
depression may occur in the first period probably
due to the new perception of the self-image and to
the suspension of steroids medication. The most fre-
quent complications in the early post-operative peri-
od are perineal sepsis and bleeding from the perineal
wound, which are conservatively treated; a persistent
sepsis or bleeding from the abdomen or the pelvis
may require a second laparotomy. The loss of a large
volume of fluid and electrolytes through the ileosto-
my may represent a serious problem, particularly in
the first days after the post-operative ileus has
resolved; therefore, it may be necessary to continue
intravenous infusion to replace fluid loss. In some
cases, chronic ileostomy diarrhoea occurs and the
patients need to increase the volume of fluid and
electrolyte intake. As the follow-up lengthens, an
increased incidence of urolithiasis is reported, prob-
ably related to the extent of bowel excision. As in all,
the patient who undergoes a bowel resection, an
intestinal obstruction due to adhesions may compli-
cate the early and late post-operative course; it must
be remarked that this occurrence may be disastrous
for these patients since a reoperation may lead to a
further loss of bowel.
What is more difficult, is the management of a
reservoir ileostomy in the early and late post-opera-
tive periods; however, the selected patients are usual-
ly very strongly motivated to actively cope with the
new condition. At the end of the operation, and as
long as the ileus has completely resolved, a perma-
nent catheter is placed in the reservoir in order to
drain the pouch and avoid disruption, leakage and
nipple valve desusception. Subsequently, the catheter
is periodically occluded and the time of drainage is
progressively reduced. Some irrigation may be neces-
sary to avoid faeces and food particles obstructing
the catheter both in the early post-operative period,
when the patient starts eating, and then at the time
when the pouch is functioning. After a few weeks, the
patient becomes aware of the necessity of emptying
the reservoir and, usually, this manoeuvre is easily
accomplished three or four times a day. Besides the
complications already mentioned as being associated
with any ileostomy and major laparotomy, there are
a few others that are specific to a stoma reservoir
construction. Some patients complain of continuous
abdominal bloating and pain and others need to
spend too much time in frequent catheterisations
and irrigations to wash out the pouch from smelly
particulate contents. These complaints are likely to
be more frequent in patients with slow small-bowel
transit. Accordingly, some authors consider that
patients having a chronic constipation with a slow
bowel transit, for which a conventional total procto-
colectomy has been indicated as the last option,
should have a Brooke ileostomy rather than a reser-
voir ileostomy [8, 19]. In the past years, valve slip-
page was reported as the most common complica-
tion, up to 44% of incidence, but this problem has
been almost completely solved by using stapling
machines. More important complications are the
ischaemia or the fistula of a part of the ileostomy
such as the exit conduit, the nipple valve or, at worst,
the pouch. The fistula may be a consequence of an
ischaemic tract, a suture line dehiscence or a perfora-
tion subsequent to catheterisation. Obviously, the
most serious complication is the leakage in the
abdomen of bowel contents particularly from the
pouch since, if the fistula is not immediately recog-
nised, the life of the patient may be threatened. In
such circumstances, salvage surgery is mandatory. In
case of a simple slippage of the valve, a new nipple
valve can be refashioned [20]. When the valve or the
exit conduit are ischaemic with a possible fistula, or
the bowel tract is not sufficient, a reconstruction pro-
cedure is needed such as a rotational procedure or an
interposed loop, in which a new bowel segment is
adopted for the new valve and conduit. However, in
the worst cases, the pouch cannot be saved. In these
circumstances the reservoir must be entirely
removed, and a completely new pouch ileostomy
may be performed or, in some cases, a conversion to
a Brooke ileostomy. Failes reported a 21% of reoper-
ation rate and most of the revisions were undertaken
within 1 year from the first operation [21]. In order
to improve the functional results and reduce the
early and late complications, over the last years a
series of novel techniques for performing a continent
ileostomy have been described such as the Barnett
reservoir, the T pouch, and the ileocecal valve-pre-
serving ileostomy [14, 22, 23, 24]. These new proce-
dures are reported as improving the continence and
the quality of life of the patients. However, although
the preliminary reports are encouraging, a long-term
follow-up is not yet available for correctly comparing
the results.
The incidence of pouchitis has been reported to
range between 4 and 40% in patients with a Kock
reservoir for ulcerative colitis [25, 26]. The diagnosis
is based on the typical above-mentioned symptoms
and on an endoscopic biopsy that reveals diffuse
bleeding inflammation and/or a villous atrophy.
However, the histological features are often non-spe-
cific and may hide Crohn’s disease. It is likely that
this pouchitis rate is higher in patients who under-
went the same operation for Crohn’s disease than in
those with ulcerative colitis, and much lower in
patients operated on for familial adenomatous poly-
posis; besides, the more the follow-up lengthens, the
more the incidence of pouchitis increases. In 1993,
The Place of Proctocolectomy with Ileostomy in the Era of Restorative Proctocolectoymy 451
the group from Göteborg University compared the
pouchitis rate after a long-lasting follow-up of
patients with a Kock reservoir to that of patients with
a pelvic reservoir. Pouchitis was found to be more
frequent in the pelvic pouches as it occurred in 34%
of the Kock procedures and 51% of the pelvic pouch-
es; and in 64 and 76% of the cases there was only a
single episode or a slight and short form of disease
[26]. Nevertheless, patients with a Kock reservoir
more frequently developed a chronic form of pouch-
itis than those with a pelvic pouch: 18 vs. 6%. Pouch-
itis is likely to be due to a bacterial overgrowth and a
delayed small-bowel transit, and thus in most of the
cases it quickly responds to conservative treatment
with metronidazole and pouch catheterisation. Some
metabolic disturbances such as fluid and electrolyte
deficiencies, megaloblastic anaemia due to the deple-
tion of vitamin B
12
, fat or bile-salt malabsorption, as
well as villous atrophy, may occur both in patients
with pouchitis and those with a normal functioning
reservoir. Moreover, the same metabolic complica-
tions have been found in patients with a convention-
al Brooke ileostomy, so it is likely that these metabol-
ic imbalances depend on the volume of the ileostomy
output, regardless of the type of ileostomy.
Many authors have reported a better quality of life
in patients who underwent a restorative proctocolec-
tomy than those who underwent a conventional
proctocolectomy with ileostomy [5, 6]. In 1991, in
order to assess whether the improvement of the qual-
ity of life in patients with restorative proctocolecto-
my was due to the absence of a stoma or to a better
faecal continence, Kohler and Pemberton examined
functional and performance activities in 406 patients
with Brooke ileostomies (stoma present, inconti-
nent), 313 with Kock pouches (stoma present, conti-
nent), and 298 with ileal pouch-anal anastomoses
(stoma absent, continent). All the patients had been
operated on for ulcerative colitis or familial adeno-
matous polyposis. Patients with ileal pouch-anal
anastomoses had fewer restrictions in sports and sex-
ual activities than those with Kock pouch, whereas
those with Kock pouches, in turn, had fewer restric-
tions in these activities but more restrictions in trav-
el than those with Brooke ileostomies. Performance
in the categories of family, work and social life were
similar between the groups. They concluded that
both the presence of a stoma and faecal incontinence
impair the quality of life after proctectomy, so there-
fore the ileal pouch-anal anastomosis allows the best
quality of life [6]. On the contrary, more recently,
some other authors reached more controversial con-
clusions. Mikkola evaluated the clinical differences
between conventional and restorative proctocolecto-
my among 240 patients, the reoperation rate was 38
and 36% respectively; but as major complications
were more frequent in the pouch group, he therefore
concluded that ulcerative colitis can safely be man-
aged with either conventional or restorative procto-
colectomy, and more remarkable, in most cases the
patient’s preference should dictate the choice of pro-
cedure [27]. Likewise, in 2003, Camilleri-Brennan
[28] analysed morbidity and quality of life in two
matched groups of patients who underwent a
restorative proctocolectomy or a conventional proc-
tocolectomy with a Brooke ileostomy. The restorative
proctocolectomy was found to be associated with a
significantly better perception of body image than a
permanent stoma, although the quality of life in gen-
eral was similar in both groups and the patients with
the pelvic pouch had more long-term complications
than patients with ileostomy: 52.6 vs. 26.3% respec-
tively. Therefore, because of the higher complication
rate and the relatively small advantage in terms of
quality of life associated with the restorative procto-
colectomy, patients should be thoroughly advised
before agreeing to this operation [28]. Moreover,
conventional ileostomy usually represents the ulti-
mate procedure after unsuccessful salvage surgery
for patients who have experienced the failure of an
ileal anal-pouch. As an alternative, the group from
Göteborg University converted 13 patients with a
failed previous restorative proctocolectomy to a con-
tinent ileostomy with reservoir. Subsequent revision-
al surgery was required in eight patients but, after a
follow-up of 6 years, ten patients with intact ileosto-
my were fully continent and none had to use a stoma
appliance. Provided that this operation should cer-
tainly be done in specialised units, it may be consid-
ered as an alternative salvage surgery to the Brooke
ileostomy in motivated patients [29].
Closing Remarks
Although in the era of restorative proctocolectomy it
is hard to accept that a reservoir ileostomy may be a
satisfactory alternative to the ileal anal-pouch, it can-
not be denied that, recently, many have reported
rewarding results with the continent ileostomy even
after a long-term follow-up. In 2004, Berndtsson et al.
analysed data from 68 patients operated on with con-
tinent ileostomy between 1967 and 1974 to assess the
long-term pouch durability and the health-related
quality of life. The median follow-up was 31 years.
The majority of patients reported good physical con-
dition and satisfactory pouch function. Patients emp-
tied the pouch a median of four times every day and
65% of patients had at least one post-operative revi-
sion to restore continence. The quality of life scores
were compared to those of a control group. Seventy-
eight percent of the patients rated their overall health
452 G. Romano, F. Bianco, V. D’Onofrio
as good, very good or excellent and the scores were
comparable to the reference values [30]. Likewise, in
2005, Castillo reported a retrospective study in which
the results of 24 patients operated on with a modified
Kock pouch between 1993 and 2003 were evaluated.
The median follow-up was 66 months. The underly-
ing disease was ulcerative colitis in 71% of the
patients, 20 patients had already been operated on:
13 patients were converted from a Brooke ileostomy
to a continent ileostomy and 7 patients were operat-
ed on for a failure of a previous ileal anal-pouch.
Revisional operations were performed in 58% of
patients. The failure rate with reconversion to con-
ventional ileostomy was only 8.3%, and 90% of the
patients were satisfied with the continent pouch [31].
Although a high rate of reoperations may be need-
ed to restore continence, continent ileostomy has
good durability, satisfactory pouch function or qual-
ity of life, which are, in most cases, similar to that of
the normal population. Therefore, the results report-
ed make this procedure a viable option for patients
with a previous restorative proctocolectomy that has
failed, or whenever a restorative proctocolectomy is
not likely to be advisable for the reasons discussed
above. However, the patients must be carefully
selected and before performing a reservoir ileostomy,
they should always be advised of the high risk of revi-
sional operations. Moreover, despite the high reoper-
ation rate, most patients are reported to be pleased
with continent ileostomy and, even in the case of
reservoir failure or dysfunction, when they are asked
to choose, most of them prefer to cope with revision
operations rather than manage a conventional
ileostomy for their entire lifetime [8].
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