Clinical aspects of continent ileostomies

Abstract

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached the height of its popularity soon after its introduction in 1969, but subsequently was supplanted by ileal pouch-anal anastomosis (IPAA), an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for IPAA or for whom IPAA or end ileostomy have failed. Complication rates that initially were high have decreased during the past three decades following the steady introduction of technical improvements.

Keywords: Continent ileostomy; Kock pouch; review; technique.

Figure 1

Continent ileostomy. (A) Three limbs of small bowel are measured and the bowel wall is sutured together. (B) After opening the bowel along the dotted lines in (A), the edges are sewn together to form a two-layered closure. (C) A valve is created by intussuscepting the efferent limb into the pouch and fixing it in place with a linear noncutting stapler. (Inset: staples in place on valve.) (D) The valve is attached to the pouch side-wall with the linear noncutting stapler. A cross-section of the finished pouch is shown. (E) After closure of the last suture line, the pouch is attached to the abdominal wall and a catheter is inserted to keep the pouch decompressed during healing.

Figure 2

Barnet Continent Ileostomy Reservoir (BCIR). (A) Two limbs of small intestine are sewn together and opened. (B) The afferent limb is intussuscepted to form a valve and the valve is stapled and stapled to the side of the reservoir. (C) The pouch is folded back and sutured closed. Insert shows cross-section of pouch. (D) Completed BCIR. The afferent limb of bowel has been divided and reattached to the apex of the pouch and the efferent limb is wrapped around the valve to form a collar.

Figure 3

T pouch. (A) Seromuscular sutures approximate the back wall of the pouch and fix the valve segment to the pouch through mesenteric windows. (B) The bowel is opened. (C) Edges of the bowel are closed over the valve segment. (D) The reservoir is folded in half and closed.