ABBREVIATIONS
BCIR
Barnett Continent Intestinal Reservoir
CD
Crohn’s disease
CI
continent ileostomy
IPAA
ileal pouch-anal anastomosis
QoL
quality of life
INTRODUCTION
The continent ileostomy (CI) was developed by Nils Kock in 1969. It is currently performed in patients who are not candidates for an ileal pouch-anal anastomosis (IPAA) or when the creation of an IPAA may be technically impossible due to difficulties with reach of the pouch to the anal canal. Some patients with an ileostomy may prefer conversion to a continent ileostomy to improve quality of life (QoL) or to circumvent problems with an ileostomy or its pouching. An IPAA can also be converted to a continent ileostomy when there are problems with the pouch. The continence mechanism for the pouch is established by a nipple valve created by an intussuscepted length of the ileum. Patient satisfaction with the K-pouch is high, reflecting the general aversion to an end ileostomy and the preference of the patients for the procedure over the other options. There may also be some financial advantages with the continent ileostomy for patients, since it does away with the need for stoma-pouching supplies. The continent ileostomy is, however, prone to several complications, mostly related to the nipple valve. Numerous modifications 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, indeterminate colitis, and some other conditions limited to the large intestine where a proctocolectomy was performed or intended. More recently, the procedure has been extended for use in a select group of patients with cancer of the colon and rectum, patients with Crohn’s disease (CD) confined 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 CD, functional problems (constipation), and the effect of the continent mechanism on the function of the pouch and small bowel, survival of the patient, and the risk of development of a short bowel syndrome, if a pouch excision is eventually needed. K-pouch may be performed as a salvage operative for selective patients who fail ileal pouch-anal anastomosis, such as those with pouch vaginal fistula but healthy pouch body and prepouch ileum. ,
Surgical Technique of Continent Ileostomy (K-Pouch) Creation
After the removal of the colon and rectum or laparotomy with lysis of adhesions when the patient has already had a proctocolectomy with an end ileostomy, an S-pouch about 15 cm long is created using 45 cm of the small bowel, leaving the terminal 15 to 20 cm intact. The S-pouch is created by suturing the three limbs of the small bowel in two layers using an inner layer of continuous #3–0 Vicryl suture and an outer layer of interrupted #3–0 Ethibond suture. The most distal 15 to 20 cm of the small bowel is then used to create the exit conduit and associated nipple valve. The mesentery of the small bowel is carefully de-fatted and abraded to facilitate adhesions. The portion of the small bowel closest to the pouch is then intussuscepted into the pouch and a 5-cm nipple valve is created with two loads of a noncutting stapler. A third application of the stapler includes the pouch wall via the partially closed anterior pouch suture line. The anterior pouch incision is completed in two layers with #3–0 Vicryl suture and # 3–0 Ethibond suture in an interrupted fashion. The pouch is tested for ease of intubation and continence. A trephine fascial aperture is created low in the waistline and the exit conduit is brought out and matured to the skin with interrupted #3–0 Vicryl sutures. The pouch is secured to the abdominal wall using two interrupted #0 Vicryl sutures. The pouch is once again tested for ease of intubation and continence. A Marlen tube is secured to the skin with a tripod stitch using #1 silk suture. The pouch is left empty with continuous intubation for 3 weeks during which it is intermittently irrigated. After 3 weeks, the indwelling tube is removed with the pouch intubated frequently for a further 3 weeks after which intubation is usually only needed two to three times over 24 hours ( Fig. 39.1 ).
Anatomy of the K-Pouch
The landmarks of a K-pouch consist of small ileostomy at the skin level ( Fig. 39.2A ), exit conduit ( Fig. 39.2B ), nipple valve ( Fig. 39.2C and D ), pouch body, pouch inlet ( Fig. 39.2E ), and prepouch ileum.
COMPLICATIONS
The most troublesome complication associated with the K-pouch that necessitates reoperation is nipple valve slippage. There are several other associated complications also. Early complications, some of which are associated with any colorectal, intestinal, or stomal operation, include anastomotic leak, intra-abdominal abscess, wound sepsis, dehiscence, and intestinal obstruction while those specific to the continent ileostomy procedure include pouch bleeding, necrosis of the nipple valve, pouchitis, fistula, and valve slippage. The late complications are listed in the table. In addition to slippage of the nipple valve, these include pouchitis, inability to intubate, incontinence, peristomal sepsis, fistula, anemia, stomal sepsis, parastomal hernia, redundant stoma, and skin-level stricture ( Table 39.1 ). Pouchoscopy plays a key role in the diagnosis and management of structural and inflammatory complications. ,
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