HISTORY OF ILEOSTOMY OPTIONS
The history of ostomy surgery that has led to continence preserving operations began in 1913, when the first ileostomy was performed for Ulcerative Colitis. However, it only bypassed the colon and did not successfully treat the underlying disease. Subsequently, surgeons developed techniques for removal of the diseased large intestine (colon and rectum), but the ileostomy stoma was a major problem. There were no appliances and consequently patients with an ileostomy could usually not leave their home. In 1941 a new technique was devised by Dr. Lester Dragstedt, Chairman of Surgery at the University of Chicago. He devised a stoma involving placing a skin graft onto the ileostomy segment hanging out of the skin to permit the irritating waste (effluent) to pass into a collecting container strapped around the waist. Quality of life was significantly impaired. Finally, in 1952 Dr. Brian Brooke at the University of Birmingham in England published his ileostomy technique in the Lancet. It involved a simple technique of turning the end of the intestine over on itself and suturing the edge to the skin. At about the same time, published in 1953, Dr. Rupert Turnbull of the Cleveland Clinic described a very similar technique of ileostomy creation. Dr. Turnbull also discovered the use of Karaya as a skin protectant and co-designed the first appliance for ostomy patients. Through Dr. Turnbull’s efforts, the Nursing specialty of Enterostomal Therapy was initiated. (The “ET nurse” has become the Wound, Ostomy and Continence nurse with the specialty now known as WOCN.)
The Brooke ileostomy allows most patients to lead a normal life. A patient with an ideal ileostomy stoma will change the appliance once every 4-7 days, will be unlimited in activities as diverse as sky diving and scuba diving, and will make a good emotional adjustment to living with an external appliance including intimate and sexual activity. Such a patient will be able to live a long and happy life with their ileostomy. However, wearing an external appliance continuously (since the small intestine is a continuous flow system) is not ideal. Not everyone has an optimal outcome, either physically or emotionally. In addition, there is an 11% incidence (1 in 10 chance) of requiring a surgical revision for hernia, prolapse, retraction, stricture, and other issues.
In 1969 Dr. Nils Kock, a surgeon in Sweden, performed the first intestinal internal pouch. This ileal reservoir or “Kock Pouch” as it came to be called, was not satisfactory until 1972 when he added a valve made of the person’s own intestine. This became the continence mechanism. For the very first time a patient with an ileostomy stoma could now have complete control over the discharge of their intestinal waste. There now was truly a “continent ileostomy”. The initial failure rate of the operation, due to slipping of the valve and fistula, was 40%. This led to the disenchantment of most surgeons and gastroenterologists with the Kock pouch. Despite this, there have been a number of General and Colorectal Surgeons who have devoted themselves over the years to improving outcomes with the continent ileostomy. Current textbooks of Surgery include references to variations in technique, including the Barnett modification of the Kock pouch. The Barnett version of the Kock pouch is the BCIR or Barnett Continent Intestinal Reservoir. It involves the use of an intestinal collar that wraps around the outer aspect of the pouch-valve junction, tightening as the pouch becomes filled, thereby helping to diminish the likelihood of a slipped valve. Other techniques include variations in stapling and suturing of the valve, creation of a folded or linear pouch, and changing the direction of the nipple valve. The people who are candidates for a continent ileostomy include patients who have difficulty or dissatisfaction with their conventional Brooke ileostomy, patients who are not able to have the primary continence-preserving procedure known primarily as the ileoanal J pouch, patients who have had a J pouch procedure with an unsatisfactory outcome, and patients who choose this option over the Brooke ileostomy and the ileoanal pouch procedure. The continent ileostomy is sometimes chosen based on occupational needs, as the ability to defer evacuation for the longest time without any possibility of soiling oneself comes with the continent ileostomy rather than the ileoanal pouch. No waste or gas escapes from the stoma of a continent ileostomy until the patient inserts a tube into the internal pouch allowing the waste to flow into the toilet receptacle. This is done 2-5 times daily, is painless, and takes only a few minutes. Most patients eat whatever they like, but roughage can clog the catheter taking more time to evacuate the pouch. The stoma is low on the abdominal wall and flush with the skin as it is not designed for an external appliance like a Brooke ileostomy. The stoma must be covered with a small patch or bandaid to absorb mucous.
In 1977 surgeons for the first time created an internal pouch from the small intestine and sutured it to the lower rectum or anal canal. This allowed someone who has undergone removal of their large intestine for Ulcerative Colitis or Familial Adenomatous Polyposis to evacuate waste the normal way, without any supplies, catheters or equipment. Continence is achieved by the intact neuromuscular sphincter mechanisms of the anal canal. This operation is known as the Ileal Pouch Anal Anastomosis or IPAA, the ileoanal pouch, the J (or S or W) Pouch, or the Pull-Through. These terms are all used synonymously to refer to Restorative Proctocolectomy. The operation involves removal of the entire colon and most of the rectum. Variations in technique affect outcome, such as whether the lining of the rectum is removed (rectal mucosectomy) or the lowest portion of the rectum is used in the “double stapling” technique. The latter offers better outcomes with regard to stool frequency and continence. Ideally, a patient with a J pouch with evacuate 4-5 times a day, will be able to defer evacuation for at least 45 minutes from the first urge, and will have no incontinence either daytime or at night. Patients with an unacceptable outcome and quality of life can be candidates for a continent ileostomy (Kock type pouch) or a Brooke ileostomy. Leaving some of the lower rectum has an associated risk of recurrent inflammation or cancer, so that annual endoscopy is needed in both ulcerative colitis and polyposis patients.
It is very interesting that studies of long-term outcomes and patient satisfaction for all three of the options reveal very similar results. Approximately 90% of people with a Brooke ileostomy, Kock pouch continent ileostomy, and the ileoanal J pouch report being very satisfied with their life and would recommend their procedure to others.
DURABILITY AND CUMULATIVE SUCCESS RATE
People with a Brooke ileostomy can and do live to advanced age. The incidence of stoma revision during a patient’s lifetime is 11%. Many revisions are minor procedures, but some include relocation of the stoma to the other side of the abdomen and repairs of hernia, sometimes extensive and requiring mesh reconstruction of the abdominal wall. Patients 60 years of age or older tolerate ileostomy well, but as mental capacity and physical dexterity diminish, care of the stoma can be a problem. Compared to younger patients, there are no differences in occupational limitations or restrictions of activity. A caregiver can readily empty the appliance as well as change the faceplate when needed if the patient becomes incompetent.
The long term failure rate of the IPAA (ileoanal J pouch) in most studies is in the range of 10% or less over 20 years. Failure involves take down of the pouch. These patients usually have a history of pelvic infection, and symptoms can include incomplete evacuation, frequent stools, incontinence, and pain. Pouchitis is a concern with any pouch operation, and is reported to occur in up to 50% of patients 5-15 years after initial surgery. Up to 50% of patients with a J pouch require one or more reoperations for postoperative complications.
The continent ileostomy (Kock pouch) failure rate has been reported to be as low as 20% of patients after 30 years. That means that 80% of patients will have satisfactory long-term function of their pouch for up to 30 years (the time period studied). Of those 80% of patients, 97% reported good to excellent outcomes. The reoperation rate in large studies is approximately 20%, including both major and minor revisions.
BENEFITS OF THE BCIR CONTINENT ILEOSTOMY
The Barnett Continent Ileostomy gives patients the ultimate in freedom and control. Unlike the conventional ileostomy where an external pouch (ostomy appliance) must be worn constantly, the BCIR needs only a small covering over the stoma to absorb mucous. Unlike the ileoanal J pouch, with the BCIR there is never any urgency to evacuate, and therefore emptying the internal pouch can be done when and where it is convenient. Your body no longer controls you, instead you have control over this most basic of bodily functions – elimination of digestive waste.
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About the Author:
Dr. Schiller is a specialist in General Surgery, practicing in Los Angeles, California. He graduated from the Albert Einstein College of Medicine in the Bronx, NY and did his Surgical Residency at UCLA Medical Center. He has been a Fellow of the American College of Surgeons his entire career. Since 1989 he has specialized in the Barnett Continent Intestinal Reservoir (BCIR) – the Barnett version of the Kock Pouch. He has created hundreds of new BCIR pouches, revised many Kock pouches that have malfunctioned, and preserved a continence option for many patients with a failed ileoanal J pouch.