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178 Gorfine
Figure 14 Procedure is complete. Stoma, matured flush to skin level, is just
above the pubic hairline. A No. 28 ileostomy catheter has been placed in the pouch
and fixed firmly in place with a rubber collar sutured to the skin.
period, it is imperative that the ileostomy tube remain within the reservoir.
If the catheter slips out, edema of the nipple valve will make reinsertion
difficult. Therefore, utmost care must be exercised during dressing changes
and irrigations to prevent catheter dislodgement.
Bowel function usually returns by the fourth or fifth postoperative
day. Progressive refeeding begins at that time. The diet should exclude
indigestible fruits, nuts, and vegetable material so that plugging of the cath-
eter is avoided.
In the early 1980s patients were kept in the hospital 3 weeks or more
following Kock pouch surgery. This is no longer feasible or necessary.
Most patients with uncomplicated courses can be discharge by the fifth to
seventh postoperative day. Discharged patients go home with the ileostomy
catheter in place. The catheter is occluded with a plastic button beginning
on the fifth or six postoperative day. Evacuation of the pouch by “uncork-
ing” the catheter is performed every hour during the daytime. Gentle pouch
irrigation with a small quantity of saline is performed with each evacuation
to ensure catheter patency. The patient should be cautioned to avoid strain-
ing or pushing to speed evacuation of the reservoir.
At home, the catheter is returned to gravity drainage at night. The
interval between pouch evacuations is progressively lengthened by 15 min
per day over the 2 weeks following discharge. The maximal interval be-
tween evacuations should not exceed 2 hr during this period. A follow-up
appointment is arranged for 2 weeks after discharge. The patient is in-
structed to avoid high-fiber foods until the first postoperative visit.
At the first postoperative visit, usually 3 weeks from surgery, the
wound and stoma are inspected. The catheter is removed from the pouch
Continent Stomas 179
and the patient is taught the technique of pouch intubation. Most patients
master this technique quickly. The catheter should pass into the pouch with-
out difficulty, encountering only minimal resistance at the level of the
valve. Patients are instructed to intubate the pouch every 2 hr while awake
and once during the hours of sleep. This regimen is continued for another
2 weeks. The diet is liberalized to include fruits, nuts, and vegetables in
limited quantities. Another visit is scheduled for 2 weeks later.
At the second postoperative visit 5 weeks from surgery, most patients
report that continence is perfect for feces and gas and that intubations are
uncomplicated. If all is proceeding smoothly, the patient is instructed to
omit the nighttime evacuation. Fiber can gradually be reintroduced into the
diet. The interval between evacuations in increased by
1
⁄
2
-hr increments
every 2–3 weeks. The maximum time between intubations should not ex-
ceed 5 hr. The patient is reminded not to strain while emptying the pouch
and that continuous intubation is recommended during periods of prolonged
coughing or sneezing for the first 6 months.
Functional Results
The vast majority of patients are satisfied with the outcome of their surgery
[27–32]. Although surgical revision of the nipple valve may be required,
ultimately more than 90% of patients are perfectly continent or do not require
the use of an appliance [6,24,25,28,32–34]. Most patients evacuate the
pouch three or four times daily. The stoma is covered with a small dressing
between intubations. The flush stoma does not interfere with clothing or
physical activities [27–32]. Full-term pregnancy and uncomplicated vaginal
delivery are possible in women with continent stomas [35]. Patients whose
standard ileostomies were converted to reservoir ileostomies viewed their
quality of life as substantially better [30,31].
Long-term outcome data for patients who had undergone continent
ileostomy surgery have been collected [28,36]. At a mean interval of 11.4
years (range 1–21 years) from surgery, 60% of patients still had function-
ing reservoir ileostomies, whereas 36% had had their pouches removed
with conversion to standard ileostomies. The indications for pouch removal
included valve dysfunction (42%), refractory pouchitis (23%), multiple fis-
tulas (26%), Crohn’s disease (6%), and “other” indications (16%) (four
patients had two indications). Although in approximately one-third of pa-
tients the pouch had to be removed, 97% of the remaining two-thirds had
a good to excellent outcome [36].
Complications
Creation of a continent ileostomy is associated with a variety of early and
late complications [4,6,24,25,32–34]. Some problems, such as adhesive
180 Gorfine
small bowel obstruction, are not unique to the complex stoma but are com-
mon to all major intra-abdominal procedures. Others are specific to the reser-
voir and valve of the continent ileostomy. Specific complications can be
divided into those occurring in the early postoperative period. Hemorrhage,
pouch leakage, and ischemia of the outflow tract or valve tend to occur
during this time. Most late complications particular to the continent ileos-
tomy involve the nipple valve. These include valve slippage, fistula, and
prolapse. The reservoir itself is prone to a form of mucosal ileitis termed
pouchitis [4,6,24,25,32–34].
Most authors have reported a lowered complication rate as experience
with the procedure and technical modifications have evolved. However, an
overall reoperation rate of 12–66% has been reported in large series [6,24,
33,34]. In more recent studies, the incidence of reoperation is approxi-
mately 15%. This rate is compared to a reported reoperation rate of 18–
23% for large series of standard ileostomies [37,38].
Early Complications
Hemorrhage Hemorrhage from the reservoir is usually noted at approxi-
mately the seventh postoperative day [25]. The indwelling catheter returns
bloody fluid spontaneously or after irrigation. Bleeding is occasionally
brisk, and transfusion may be required. The site of bleeding is most often
one or more of the pouch suture lines.
This complication can usually be managed nonoperatively in the he-
modynamically stable patient. Bleeding will often cease spontaneously if
the pouch can be maintained free of old blood. This state is best achieved
by frequent saline irrigations. The addition of norepinephrine to the irriga-
tion fluid is helpful. Systemic vasopressin has been used successfully in
extreme cases [10,25]. Fiberoptic or rigid ileoscopy should be avoided be-
cause of the risk of perforation. Surgical exploration to control hemorrhage
is almost never required. When laparotomy is necessary, excision of the
pouch and creation of a standard ileostomy is recommended by some [25].
Suture Line Dehiscence Suture-line dehiscence is rare and can usu-
ally be avoided by scrupulous operative technique and careful postoperative
management. This complication occurs in about 2% of cases [6,33]. It pre-
sents with the symptoms and signs of localized or free visceral perforation.
Fluid resuscitation and systemic antibiotics are virtually always indi-
cated [25]. Leakage during the first postoperative week is often poorly con-
tained and frequently leads to generalized peritonitis. In this situation, re-
exploration for drainage and proximal diversion is necessary. Excision of
the reservoir is almost never indicated. Between the second and fourth
weeks, localized abscess and pouch–cutaneous fistula are more common
[25]. This complication usually can be managed without laparotomy.
Fistula The reservoir ileostomy is prone to two distinct types of fis-
tula: internal and external. External fistulas cause an abnormal communica-
Continent Stomas 181
Figure 15 Pouch-cutaneous or external, fistula.
tion between the pouch and the skin (Fig. 15). Internal fistulas traverse
both limbs of the intussuscepted valve, causing communication between the
lumen of the pouch and the lumen of the valve (Fig. 16). Either type of
fistula can appear as an early or late complication.
Early postoperative fistula formation occurs in about 2% of cases
[6,33]. Pouch-cutaneous or external fistulas are somewhat less common
than fistulas involving the nipple valve. An early external fistula tends to
arise from the region of the confluence of the reservoir suture lines near
the base of the nipple valve. Typically it is manifest during the second or
third postoperative week as either a localized peristomal abscess or celluli-
tis. Spontaneous or surgical drainage leads to an enterocutaneous fistula.
This complication is usually managed without laparotomy. Systemic
antibiotics and sump drainage of the reservoir are indicated [25]. A collec-
tion, if present, is drained by incision or percutaneous catheter. In most
Figure 16 Nipple-valve or internal, fistula.
182 Gorfine
instances healing is complete within 2–3 weeks. Total parenteral nutrition
and octreotide are useful therapeutic adjuncts that can speed fistula closure.
Early nipple-valve or internal fistulas also present during the second
or third postoperative week. These fistulas appear to be caused by pressure
necrosis of the tissue under one of the silk sutures placed through the full
thickness of both segments of the intussuscepted valve [25]. Leakage of intes-
tinal contents around the ileostomy catheter is the common presentation.
The magnitude of leakage will depend on the size of the fistulous tract and
its proximity to the base of the valve. Larger tracts nearer the base of the
nipple will cause a greater volume of leakage.
This complication is managed nonoperatively in the immediate post-
operative period. An initial trial of antibiotics and continuous sump drain-
age of the reservoir are warranted. Drainage of intestinal contents around
the catheter is controlled by placing a standard ileostomy appliance around
the intubated stoma. A small percentage of cases of early nipple fistulas
will heal completely within 1–2 weeks without further intervention. Others,
especially those located near the tip of the valve, may shrink to a point at
which continence is only minimally affected when the catheter is removed.
These valve fistulas are best left alone unless the patient is intolerant of the
volume of leakage.
Fistulas that result in symptomatic incontinence and do not close by
4–6 weeks from the initial surgery will usually require operative repair.
These fistulas are then managed in the same fashion as late nipple fistulas.
Ischemia Compromise of the blood supply to the distal portion of
the ileum causes ischemia of the outflow tract, the valve, or both. Compres-
sion or disruption of the intussuscepted mesentery of the nipple valve is
usually the cause. A valve longer than 5 cm, excessive fattiness of the valve
mesentery, and overvigorous suturing or stapling of the valve at its mesen-
teric borders predispose to ischemia by compression [25]. Direct damage
to the vasculature of the valve may occur during removal of mesenteric fat.
Ischemia usually becomes manifest within 48 hr of surgery. Dusky
discoloration of the stoma, bleeding around the catheter, and bloody returns
with irrigation are the hallmarks of poor distal vascularity. Fever and pain
are common, especially with tissue necrosis. Frequent irrigation of the ileos-
tomy catheter, administration of systemic antibiotics, and close observation
are the best early treatments [25]. Ischemia caused by mesenteric edema
may resolve without additional therapy. Progression of the ischemic process
can result in necrosis of the outflow tract, the valve, or both.
Outflow Tract Problems Chronic ischemia of the outflow tract leads
to stenosis of the stomal segment, usually at skin level. Continence is al-
most always maintained. The problem becomes manifest when the patient
begins intubation of the pouch. Progressively increasing difficulty with
catheter insertion is the common presentation. This complication is best
Continent Stomas 183
managed by a 1- to 2-month trial of continuous pouch intubation. The cath-
eter is capped with a plastic button and the reservoir emptied intermittently.
If the problem persists after this period, elective operative repair by double
Z-plasty is recommended.
Ischemic necrosis of the outflow tract causes separation at the muco-
cutaneous junction and ileal “retraction” by dissolution of the distal bowel.
The subcutaneous tissues at the stoma site are exposed, usually resulting in
peristomal cellulitis. Sump suction of the reservoir and administration of
systemic antibiotics are indicated for early management [25]. Healing will
usually occur without immediate surgery, although stricture is almost cer-
tain to follow. Continence is maintained unless the valve is also affected.
Stomal revision can be delayed until the pouch has completely healed,
usually 2–3 months after the initial surgery. The patient can maintain pat-
ency at skin level either by continuous intubation or with an infant pacifier
placed in the stoma site between intubations [25]. Stomal revision by dou-
ble Z-plasty is recommended.
Valve Necrosis Further progression of outflow tract ischemia results
in valve loss by ischemic necrosis. This complication occurs in less than
2% of cases [6,33,34]. The patient will usually experience pain and fever.
Blood clots, necrotic debris, and sutures or staples may return with reser-
voir irrigation. Leakage of intestinal contents around the catheter will occur
as tissue loss results in valve shortening. When valve necrosis is identified,
sump suction of the reservoir and systemic antibiotics should be instituted.
Immediate operation is rarely indicated, as healing, albeit with inconti-
nence, usually occurs spontaneously [25].
Revisional surgery can often be delayed until the pouch has healed
completely [25]. The ileostomy catheter is left in the reservoir throughout
the hospital period and for the 2–3 months following discharge. Leakage is
controlled by the addition of a standard ostomy device fitted around the
intubated stoma. Later, 2–3 months after the initial surgery, the patient is
readmitted to hospital for revision. Creation of a new valve involves “turn-
ing the pouch” [39].
Late Complications
Valve Slippage The most common late postoperative complication of the
Kock ileostomy is desusception or slippage of the nipple valve [4,6,24–28,
33,34]. Early experiences with the procedure were complicated by valve
desusception in from 40–50% of cases [1,6,28,34]. With advances in valve
stabilization techniques and increasing experience, the incidence of desus-
ception has fallen to 3–12% [6,24–26,28,33]. Most of the patients in this
group will require surgical revision of the valve. One-quarter of them will
require a second revision [33].
Considerable effort has been devoted to development of techniques
for improving valve stability. Destruction of the serosa, thinning of the
184 Gorfine
mesentery, and suture or staple fixation of the valve are currently standard
modifications of Kock’s original technique [1,24,40]. Circumferential silk
sutures placed from the pouch to the outflow tract have also contributed to
reduction in the rate of valve slippage.
Additional work has focused on supporting the valve at the junction
of the pouch and the outflow tract. The earliest efforts involved encircled
the base of the valve with a strip of fascia [15] or polypropylene mesh [16,
33,41]. These techniques reduced the incidence of valve slippage but con-
tributed to a much higher rate of fistula formation [18,33]. Substitution of
other synthetic materials—including Mersilene, Teflon, and Gore-Tex—
has also resulted in an unacceptably high incidence of fistula formation (Bauer
et al., 1978, unpublished). Anchoring the valve to the pouch wall with sta-
ples has been suggested as a means of improving stability that is associated
with a lower rate of fistula formation than that seen with synthetic materials
[42].
Replacement of a prosthetic buttress with an ileal collar has gained
popularity over the past 10 years [26]. Published data have shown an inci-
dence of valve slippage of 6.3% and an overall complication rate of 12.8%
occurring from 1–5 years postoperatively [43]. A novel pouch and valve
design was recently described by Kaiser and colleagues [44]. The T pouch
uses a valve mechanism that omits intussusception of the bowel and main-
tains the blood supply to the valve segment. In a small series of patients
followed for 2–18 months, results were fairly good [44]. With greater expe-
rience, and longer follow-up, this technique may prove useful.
Nipple valve dysfunction by desusception is most likely to occur
within the first 2 postoperative years [24,33]. The problem usually begins
with dehiscence of the opposing mesenteries within the intussuscepted
valve [1] (Fig. 17). The nipple desuscepts asymmetrically, causing dispro-
portionate lengthening of the mesenteric wall of the outflow tract. The in-
tact, antimesenteric portion of the valve is pulled toward the longer mesen-
teric wall, angulating the valve mechanism (Fig. 18). Asymmetr ical “unrolling”
of the valve initially causes difficulty with intubation. Further desusception
leads to valve shortening and incontinence.
Progressive desusception with resulting angulation often leads to com-
plete inability to intubate the pouch. Therefore intestinal obstruction is a
common emergency presentation [6,24]. Initial management is directed at
relieving obstructive symptoms. Pouch intubation can be accomplished by
fiberoptic or rigid ileoscopy using a pediatric gastroscope or an 11-mm rigid
sigmoidoscope [45,46]. A guidewire or the shaft of a long cotton-tipped
swab is left in the pouch and the endoscope is removed. An ileostomy
catheter is threaded over the guide and taped in place.
At the first episode of valve dysfunction, a trial of prolonged reservoir
intubation is warranted. This trial often stabilizes the valve, allowing it to
become fixed in the new position. The patient is instructed to leave the
Continent Stomas 185
Figure 17 Nipple desusception begins at the site of the opposing mesenteries.
catheter taped in place for 2–3 weeks. The end of the catheter is occluded
with a plastic button, which is removed to empty the pouch. At the end of
this period, intubation resumes as before. If difficulty in intubation persists,
surgical revision is indicated.
OPERATIVE TECHNIQUE
A standard antibiotic preparation is adminis-
tered before surgery. Valve revision is usually possible through a circum-
stomal incision. The outflow tract is dissected free of the skin, subcutaneous
tissue, and fascia. Medial and lateral extensions of the peristomal incision
in the skin and fascia may be necessary for pouch mobilization. The reser-
voir is carefully removed from the abdominal wall and delivered through
the surgical wound.
Vale Repair The partially desuscepted valve often can be reintussus-
cepted by gentle inward pressure. If successful reduction can be achieved,
it is not necessary to open the reservoir. The intussusception is maintained
by suturing the pouch to the outflow tract as in a gastric fundoplication.
The ileostomy catheter should be inserted into the reservoir prior to place-
ment of these sutures so that the outflow tract is not narrowed. Four or five
sutures of 3-0 silk will usually suffice.
Alternatively, a bladeless linear stapler can be used to secure the valve
to the anterior pouch wall. One blade of the stapler is passed through the
Figure 18 Progressive desusception of the valve causes angulation of the valve
and outflow tract.
186
Continent Stomas 187
stoma and the other is passed along the side the pouch. The instrument is
mated and care is exercised to see that no intervening bowel loops are within
the jaws of the instrument. The stapler if fired, opened, and removed.
Once the valve has been stabilized, the outflow tract is matured in the
usual fashion at the old abdominal wall site. The ileostomy catheter is fixed
in place with a rubber crosspiece as already described. If there is any ques-
tion about the adequacy of the valve, it should be inspected by opening the
pouch along its anterior wall. If a new valve is necessary, valve reconstruc-
tion by pouch “turnaround” is performed.
Vale Reconstruction The 20-cm length of small bowel immediately
proximal to the pouch is mobilized. Remnants of the outflow tract and valve
are excised from the intact pouch with electrocautery (Fig. 19A). The pouch
is opened from this point for another 10 cm along its antimesenteric aspect.
The new valve is created by orthograde intussusception of the proxi-
mal inflow tract. The afferent ileum is transected with electrocautery 15 cm
from its junction with the reservoir (Fig. 19B). The proximal 10 cm of the
inflow tract is prepared for intussusception by removing the mesenteric fat,
abrading the serosal surface, and placing silk sutures as previously de-
scribed. A Babcock clamp is passed into the inflow tract, grasping the ileum
about 5 cm from the reservoir. The bowel is intussuscepted and fixed by
sutures and staples as for the original procedure. The catheter is inserted
into the pouch, and a collar of pouch is sewn to the new outflow limb with
3-0 silk sutures.
The reservoir is rotated 90 degrees on its axis, which brings the new
outflow tract to an anterolateral position. The cut end of the proximal ileum
is anastomosed to the pouch at a convenient location using the circular
stapling instrument. The reservoir walls are reapproximated and closed with
two layers of running 2-0 long-term absorbable suture (Fig. 19C). The af-
ferent limb is occluded with a noncrushing intestinal clamp, and the ileos-
tomy tube is inserted through the new valve. The pouch is tested for conti-
nence by insufflating air and removing the catheter.
Four 3-0 silk sutures are placed from the pouch to the parietal perito-
neum near the stomal aperture prior to exteriorizing the new outflow tract.
The outflow tract is then brought through the old stomal opening in the
abdominal wall and the fixation sutures are tied. A closed suction drain is
placed in the right gutter lateral to the pouch. The drain end is brought out
at a distance from the stoma. The fascia medial and lateral to the stomal
opening is reapproximated with heavy long-term absorbable suture. The
outflow tract is trimmed flush with the skin, and the stoma is matured with
3-0 long-term absorbable sutures. The ileostomy catheter is left in the reser-
voir and connected to dependent drainage.
Fistula On average, most late fistulas will occur within 2 years from
the time of the initial surgery [34]. Nearly all late fistulas are related to the