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188 Gorfine
Figure 19 A. Outflow tract is removed from the abdominal wall and excised
with electrocautery. B. Reservoir is opened at the site of the old valve. Proximal
bowel is divided 15 cm from the reservoir, and this segment is used to create a
new valve. C. New nipple valve is created from the proximal bowel in the usual
fashion. Cut end of the proximal bowel is anastomosed to the pouch by using
the circular stapler. Stapler is introduced through the pouch opening. When the
anastomosis is complete, the defect in the pouch is closed with a double layer of
running 3-0 absorbable sutures.
Continent Stomas 189
presence of a foreign body, either a silk suture or plastic mesh [47]. The
exception to this general rule occurs in the patient with Crohn’s disease.
These patients are five times more likely to develop a fistula than patients
with colitis or polyposis [33].
An external fistula usually presents with evidence of cutaneous sepsis.
Peristomal cellulitis or subcutaneous abscess will usually precede frank fis-
tulization. Once the tract has been established, leakage of intestinal contents
will ensue. Pouch-cutaneous fistula is an uncommon late complication, oc-
curring in about three per cent of cases [6]. Fiberoptic ileoscopy is often
helpful in establishing the diagnosis, and estimating the chance of non-
operative closure [46]. If the cause of the fistula is a foreign body, the foreign
body must be removed either operatively or endoscopically before the
pouch will heal. If the offending agent (usually a silk suture) can be removed
endoscopically, treatment by continuous pouch intubation and administration
of oral antibiotics for 2–4 weeks usually will produce closure of the defect.
If the foreign body can not be retrieved or the fistula does not close, operative
removal by excision with primary closure of the pouch is indicated.
Late internal fistulae of the nipple valve occur more frequently and are
more troublesome than external fistulas [33]. Leakage of intestinal contents
through the unintubated stoma is the common presentation of this compli-
cation. The size of the fistula and its location along the length of the valve
will determine the degree of incontinence. Leakage is generally greater
when the fistula lies near the base of the valve. The fistula does not affect
ease of reservoir intubation.
Operative revision is indicated when the amount of leakage inconve-
niences the patient. Dozois et al. [24] recommends complete nipple revision
by pouch rotation in all cases of fistula. We have found such revision often
to be unnecessary, especially when the fistula lies at the base of the valve.
However, we agree that if the fistula is not readily accessible or if the
repaired valve is unsuitable for any reason, then creation of a new valve
using the afferent ileum is indicated.
OPERATIVE TECHNIQUE
The pouch is approached through a peristo-
mal incision. The outflow tract is freed circumferentially. The wound is
enlarged by medial and lateral incisions 2 to 3 cm long. The pouch is re-
moved from the abdominal wall and delivered into the wound. The valve
is exposed by opening the pouch along its antimesenteric wall.
The nipple fistula is identified. Any foreign body, if present, is re-
moved. A small rim of normal ileum around the foreign body also is ex-
cised. The nipple is desuscepted to a point a few millimeters beyond the
fistula. This is relatively easy if the fistula is at the base of the nipple. The
edges of the fistula on both ileal walls are freshened, and closed with 3-0,
long-term absorbable sutures. The intussusception is restored with care taken
to avoid overlapping the suture lines. The pouch is closed with a running
190 Gorfine
3-0, long-term absorbable suture. An ileostomy catheter is placed within
the pouch and valvular competence is ascertained.
The outflow tract is brought through the old stoma site. The medial
and lateral incisions in the fascia are repaired with heavy, long-term ab-
sorbable sutures. The skin incisions medial and lateral to the stoma site
are closed with fine nylon. The stoma is matured with 3-0, long-term
absorbable sutures. The catheter is secured to the abdominal wall with a
crosspiece arrangement as described earlier. Gravity drainage is insti-
tuted.
Skin-Level Stenosis Stenosis of the peristomal skin occurs in 8 per-
cent of patients [33]. Patients suffering this complication find insertion of
the ileostomy catheter difficult, painful, and accompanied by modest bleed-
ing. We have found that double Z-plasty of the peristomal skin offers the
most satisfactory long-term results.
OPERATIVE TECHNIQUE
The scar at the mucocutaneous junction is ex-
cised circumferentially. The subcutaneous outflow limb is mobilized com-
pletely to the level of the fascia. Slightly curved, 1.5 cm tangential skin inci-
sions are made at opposite points on the stomal circumference. The skin
edges are undermined through the creation of two rotational flaps. The ileal
walls opposing the skin incisions are divided longitudinally for a distance
of 1.5 centimeters on each side. (Fig. 20A) The skin flaps are rotated into
the groove cut on either side if the ileum. (Fig. 20B) The two Z-plasties
are completed by suturing the full thickness of the ileal wall to the dermis
of the flaps. The revision is completed by fixing the remainder of the ileal
circumference to the skin with 3-0 absorbable sutures. (Fig. 20C)
Prolapse Prolapse of the intact nipple valve is uncommon, occurring
in less than 3% of cases [33]. There seems to be a greater tendency towards
prolapse in patients who have undergone previous nipple revision [25].
Continence is generally maintained between episodes of prolapse.
We have found that prolapse is most often associated with an overly
large fascial stomal defect. Increasing intra-abdominal pressure during exer-
cise or late pregnancy can precipitate nipple extrusion. Reduction can usu-
ally be accomplished by gentle manual pressure. Iced witch-hazel compresses
may be used to reduce stoma edema, facilitating reduction after long-
standing prolapse. Once the valve has been reduced, the reservoir can usu-
ally be intubated without difficulty.
Nonoperative management of nipple valve prolapse usually involves
continuous pouch intubation for 2–4 weeks. A report described “stiffening”
of the outflow tract by transcutaneous electrocauterization and suture. This
technique was successful in three of four cases [48].
Prolapse that occurs during pregnancy is managed best by continuous
intubation after valve reduction [32]. The tube is left in place throughout
labor and delivery. If cesarean section is indicated, the extracorporeal por-
Continent Stomas 191
Figure 10 A. Skin incisions are made on opposing sides of the stoma. Corresponding incisions are
made in the ileum. Skin between a and 1 and d and 3 is mobilized to create two flaps. B. Skin flaps
are rotated into the grooves cut in the ileum; b is brought to a, and 1 is brought to 2; similarly, c is
brought to d. C. New mucocutaneous junction is sewn with interrupted 3-0 absorbably sutures.
192 Gorfine
tion of the catheter is draped laterally with a sterile, adhesive sheet. Midline
incision is usually required. Operative delivery proceeds according to ob-
stetrical principles, exercising care to avoid injury to the reservoir.
Recurring episodes of valve prolapse generally require revisional sur-
gery. Relocation of the reservoir and stoma to a new site, usually the midline
or the left lower quadrant, yields better results than attempts at fascial repair.
OPERATIVE TECHNIQUE
The stoma and outflow tract are mobilized
through a peristomal incision. The incision is extended medially and later-
ally if necessary, and the abdominal cavity is entered. The pouch is care-
fully mobilized from the anterior abdominal wall. If doubt exists concerning
the viability of the outflow tract, creation of a new valve by pouch rotation
is warranted.
The new stoma site is determined by comfortable placement of the
outflow tract. When possible, transrectus placement on the opposite side is
preferable. A circle of skin at the new site is excised. Dissection is contin-
ued into the abdominal cavity. The outflow tract is brought through the new
stoma site, and the reservoir is fixed to the anterior abdominal wall. The
fascia defect at the old stoma site is closed with heavy, long-term absorba-
ble sutures. The wound is covered with sterile towels, and the stoma is ma-
tured with 3-0 absorbable sutures.
Pouchitis The syndrome of reservoir mucosal ileitis or “pouchitis”
has been reported to occur in from 5–43% of patients with a reservoir
ileostomy [4,24,25,33,49]. It presents most characteristically as a change in
the nature and quantity of the ileostomy effluent [50]. High volume (>1000
mL/day), thin, and occasionally bloody, returns are common. Intubation
may become more difficult and catheter induced bleeding may ensue. The
syndrome may also include abdominal cramps or pain, arthralgia, fever,
and malaise [51]. Pouchitis appears to occur almost exclusively in patients
whose initial diagnosis was mucosal ulcerative colitis [24,25,33]. More
than half of the patients who develop pouchitis will present with their first
episode within six months of surgery [52].
The patient presenting with these symptoms for the first time warrants
thorough investigation. A careful history and physical examination are per-
formed. Assay of the ileostomy effluent for enteric pathogens and toxins,
and fiberoptic ileoscopy are also indicated. Typically, ileoscopy reveals muco-
sal edema, friability and granularity [45]. The presence of aphthous ulcer-
ations strongly suggests the possibility of Crohn’s disease [51]. Biopsy may
suggest an alternate diagnosis, or it may show only mild, non-specific in-
flammation or even normal mucosa [53]. Crohn’s disease of the reservoir
and infectious enteritis can mimic pouchitis. Subacute addisonian crisis and
hyperthyroidism have been misdiagnosed as reservoir ileitis [25].
The cause of pouchitis is unknown. Factors implicated as contributory
or causative include pouch stasis, ischemia, altered bacterial flora, bacterial
metabolites, and ileal mucosal metaplasia [54]. None have been proven.
Continent Stomas 193
Resolution of the inflammatory process with treatment by the administra-
tion of antibiotics favors a cause related to the bacterial flora of the pouch.
Pouchitis generally responds quickly to the oral administration of met-
ronidazole [55] or ciprofaxacin. As pouchitis tends to recur in susceptible
individuals [53], each subsequent episode does not require the same investi-
gation as the first. Rather, antibiotic therapy should be started empirically
based on symptoms. Some patients will fail to respond to antibiotic therapy.
In this situation, steroids administered through the catheter or systemically
may be of value [50,56].
Recent reports of the use of concentrated probiotics for the treatment
and prevention of pouchitis in pelvic pouches have been published [56,57].
However, this treatment modality has not been evaluated in the setting of
reservoir ileostomies. Uncommonly, unremitting pouchitis, recalcitrant to
all modes of medical therapy, may prompt the patient to seek removal of
the reservoir [35,50].
CONTINENT COLOSTOMY
Encouraged by the impressive improvement in patient comfort and life style
obtained with the continent ileostomy, investigators have attempted to
achieve similar results with a continent colostomy. Despite intense efforts,
this quest has not been as successful.
A variety of factors has made a reliable, safe, and simple continent
colostomy difficult to achieve. The typical permanent colostomy is fash-
ioned from the end of the sigmoid or descending colon. Colostomy output
is usually semisolid or solid, foul-smelling, and often accompanied by gas.
The nature of colostomy stool, and the differing pattern of motor function
of the colon render useless many of the continence preserving approaches
used with ileostomies. Furthermore, most patients requiring permanent end
colostomy suffer from invasive rectal carcinoma. This disease affects an
older patient population and carries an uncertain prognosis. A continent
colostomy which requires repeated surgical revision or intricate stomal main-
tenance may not be well accepted by these patients.
Irrigation
Colostomy continence achieved by the irrigation technique was introduced
in the 1920s, mainly in response to the dearth of effective pouching systems
available at the time [58]. Colostomy irrigation is essentially an enema
delivered via the stoma. The irrigating fluid stimulates colonic evacuation
in a predictable and reproducible fashion. In many patients, irrigation every
day or every other day is all that is required to keep the stoma free of
leakage between irrigations [59–61]. Between irrigations, a stomal cap or
a gauze pad is all that is worn over the stoma.
194 Gorfine
Indications and Patient Selection
Only left-sided colostomies are amenable to control by this technique.
Right or transverse stomas will generally have an output that is too liquid
to achieve adequate results. Other relative contraindications to irrigation
include parastomal herniation, stomal prolapse, and a predisposition to diar-
rhea related to either the underlying disease process (e.g., inflammatory
bowel disease) or ongoing treatment (e.g., chemotherapy or radiotherapy)
[62]. In general, children and infants are not good candidates because of
increased risk of perforation, and lack of attention span.
Although the contraindications are few, irrigation is not for every-
body. The patient must be generally healthy and possess the manual dexter-
ity and motivation to learn and to apply the technique. Uninterrupted access
to the bathroom for at least 1 hour on irrigation days is also required. Even
under ideal circumstances, all patients will not achieve continence [59–61].
Technique
Irrigation should be performed at approximately the same time of day on
alternate or third days. The patient should be comfortable with the tech-
nique, relaxed, and unhurried. Many patients will choose to irrigate seated
in front of the toilet.
The water bag should be filled with no more than a quart of lukewarm
tap water. Often a pint of water will yield optimum results. The bag should
be suspended at shoulder level within the patient’s view. After air has been
evacuated from the system, the tubing is clamped, and the cone tip is
attached.
The irrigating sleeve is placed around the stoma. The long end of the
sleeve is placed in the toilet. The cone is lubricated and is inserted into the
stoma via the short arm of the sleeve. Gentle pressure allows the tip to
occlude the stoma. The clamp is opened and the water is allowed to slowly
enter the colon. The entire volume is instilled over 3–5 min. The infusion
should be stopped momentarily if cramping occurs.
After infusion, the cone is removed, and the short arm of the sleeve is
clipped. The long arm is left in the toilet until the initial return of water and
stool has ceased. This action will usually take about 15 min. Next, the sleeve
is rinsed clean but left in place. The patient can leave the bathroom or per-
form other tasks if desired. Stool may continue to drain for the next 30–50
min. With time the patient will recognize when the colon is empty. When
there is no further drainage of stool, the sleeve is rinsed and removed. The
peristomal skin is cleaned, and a “security pouch,” cap, or pad is applied.
Results
Irrigation provides colostomy continence in from 30–60% of patients [59–
61]. Patients report improvement in their sense of security and self-
confidence and their ability to function in work and social settings [60,63].
Continent Stomas 195
The time spent on stomal management, and cost of equipment are similar
to those expended by patients who use natural evacuation [60,61]. Neither
age nor diagnosis prevent successful mastery of the technique [64]. Com-
plications are distinctly uncommon [60–62].
Barrier Devices
Despite good results with colostomy irrigation, many patients find the tech-
nique cumbersome and time-consuming. Also, continence is not always
perfect between irrigations. In an effort to provide stomal continence more
easily, various devices have been designed for temporary stomal occlusion.
These methods were intended to provide reliable continence without the
need for irrigation, or at least to improve continence in the interval between
irrigations.
Magnetic Cap
The first of these devices was the magnetic stomal cap [65,66]. This three
part system consisted of an implantable, samarium-cobalt magnetic ring, a
mushroom-shaped cap, and a three layer filter-washer used between the
skin and the cap (Fig. 21). The cap contained a magnetic ring and center
Figure 21 Magnetic stoma cap.
196 Gorfine
pin. The patient centered the washer at the stoma, and occluded the colos-
tomy by inserting the pin in the lumen. The cap was held in place by mag-
netic attraction. The cap was removed when the patient wished to evacuate.
Irrigation was also used as an adjunct in some patients.
Despite early enthusiasm, the magnetic cap yielded disappointing re-
sults. Achievement of continence occurred in only 14–50% of patients [67–
70]. Local infection, erosion of the ring through the skin, and late skin
necrosis were the most common complications. The device is no longer
commercially available.
Balloon Plug
The balloon plug, a device based on the same principle as the magnetic cap
was described in 1984 [71]. This device consisted of an implantable sili-
cone ring and an inflatable silicone balloon. The ring was sutured to the
parietal peritoneum at the stomal aperture. The colon was brought through
the ring and matured at skin level. The stoma was occluded by luminal
insertion and inflation of the balloon. The patient deflated the balloon to
evacuate the bowel.
Although continence was achieved with this device, patient acceptance
was only fair. Complications such as fistula, bowel necrosis, and stomal ero-
sion were also noted. This device is no longer available for clinical use.
Polyurethane Plug
Interest in the use of one- and two-piece, disposable, polyurethane colos-
tomy plug systems resurfaced a number of years ago [72,73]. The device
consists of a polyurethane foam cone which is held in a cylindrical shape
by a polyvinyl alcohol film. The cylinder is inserted into the stoma and
held in place by a flange (two-piece system) or an adhesive/filter base (one
piece system). The moisture in the colon causes the film to desolve, allow-
ing the polyurethane to assume its original conical shape. The cone occludes
the intestinal lumen, preventing leakage of mucus and stool. Gas escapes
though the filter system without noise or odor.
The most recent reports of the use of these devices showed acceptable
levels of continence with most patients reporting no significant odor, noise,
discharge or leakage when the plug was in place [72]. Patient acceptance
of the technique was excellent [72,73]. Most patients with a colostomy in
both studies were concurrently using irrigation techniques. The patients
who were not using irrigation techniques were able to confine bowel move-
ments to evening hours when the plug was not in use. Nonirrigating patients
were also satisfied with the device [72].
Use of the plug appears to be best suited to those patients whose
bowel action can be reliably predicted, either by irrigation or “natural” tech-
nique. Between movements, the plug serves to control odor, noise, mucus
and to minimize fecal leakage. The interval between irrigations can be pro-
Continent Stomas 197
longed in selected patients [73]. These devices are commercially available
from appliance manufacturers.
Other Techniques
Other barrier techniques have been tried with varying degrees of success.
An implantable hydraulic sphincter conferred continence to a small number
of patients [74]. However, infectious complications occurred in half of
those cases. Kock attempted a valve similar to that used in the continent
ileostomy [75]. Emptying the bowel through catheter irrigation was so
time-consuming that the procedure was abandoned after use in five patients.
Achievement of continence of perineal colostomies has been demon-
strated by dynamic graciloplasty [76], colonic smooth-muscle cuff wraps
[77], and artificial anal sphincters [78–80]. These techniques have been
used with variable results in small numbers of highly selected cases. None
of these techniques has gained widespread popularity primarily because
technical complexity and increased morbidity.
SUMMARY
Perfect, simple, and safe stomal continence has yet to be achieved. Ileos-
tomy continence has come closest to this ideal through modifications of
Kock’s technique of reservoir ileostomy. The price of excellent continence
with this method has been a significant rate of complication and reopera-
tion. Acceptable colostomy continence has been achieved through the use
of stomal irrigation. Despite its simplicity and safety, this technique is not
perfectly reliable. Although considerable progress has been made over the
past 30 years, the ideal substitute for the anal sphincter remains elusive.
REFERENCES
1. Kock NG. Historical perspective. In: Dozois RR, ed. Alternatives to Conven-
tional Ileostomy. Chicago: Year Book, 1985:133–145.
2. Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy.
Preliminary observations on a procedure resulting in fecal “continence” in
five ileostomy patients. 1969 [classical article]. Arch Surg 1969; 99:223–231.
3. Kock NG. Continent ileostomy. Prog Surg 1973; 12:180–201.
4. Dozois RR, Kelly KA, Beart RW Jr., Beahrs OH. Improved results with
continent ileostomy. Ann Surg 1980; 192(3):319–324.
5. Failes D. The Kock continent ileostomy: a preliminary report. AustNZJ
Surg 1976; 46(2):125–130.
6. Kock NG, Myrvold HE, Nilsson LO, Philipson, BM. Continent iIleostomy:
the Swedish experience. In: Dozois RR, ed. Alternatives to Conventional
Ileostomy. Chicago: Year Book, 1985:163–175.