Keywords

Indications

There are three well -established configurations for construction of a continent ileostomy: Kock pouch (1969), Barnett continent intestinal reservoir (BCIR , 1984), and T-pouch (2002). Each features an ileal pouch reservoir with a valve mechanism created to prevent leakage of accumulating stool. It is offered to select patients after proctocolectomy for ulcerative colitis or FAP as a salvage alternative to an ileal J-pouch anal anastomosis or end ileostomy. Despite a notorious revision rate, these constructs offer the potential for improved quality of life, “continence,” and avoidance of a cumbersome external appliance.

Continent ileostomies are increasingly rare, and due to the required expertise, performed by only a few specialized centers. Nonetheless, patients with existing continent ileostomies may present to general surgeons. It is important to have a baseline understanding of the function, possible complications, and solutions to avert a catastrophe. This chapter describes these strategies for management of complications related to existing continent ileostomies.

Evaluation and Preparation

  • Review the patient’s history, diagnosis, and functional aspects. Oftentimes, however, that information and respective records are not available when the continent ileostomy had been created decades earlier.

  • Recognize acute problems that necessitate immediate action (Table 52.1).

  • Characterize chronic problems to plan appropriate workup (Table 52.2).

  • Attempt a gentle intubation to allow drainage of at least some gas/stool using any available catheter of any size.

  • Provide fluid resuscitation and electrolyte replacement if unable to tolerate oral intake.

  • Identify signs of sepsis and administer antibiotics.

Table 52.1 Acute complications: Assessment and immediate management
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Table 52.2 Chronic problems : Workup and management planning
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Pitfalls and Danger Points

  • Inability to intubate/drain a continent ileostomy: Recognize that this is functionally a complete bowel obstruction. Emergency intervention is required to decompress before bowel ischemia and perforation occur.

  • Placement of a nasogastric tube as a sole intervention is insufficient but may supplement decompression of the pouch and bowel.

  • Valve slippage may result in a tortuous access segment: Forceful blind intubation may traumatize or even perforate the valve segment or the pouch.

  • Abdominal exploration: Patients with continent ileostomy frequently have extensive adhesions. They also have a severely altered anatomy and counterintuitive blood supply to bowel segments that together, increase the risk for enterotomies, bowel loss, and short bowel syndrome.

  • Cancer risk: Patients with inflammatory bowel disease or hereditary cancer syndromes such as FAP are at increased risk to develop cancer in the small bowel including the pouch. This must be considered in the differential diagnosis of a bowel obstruction.

Operative Strategy

Quickly determine whether the patient’s situation reflects an acute emergency that necessitates an urgent intervention, or whether a chronic management problem exists. As long as stool can be drained from the pouch, there is usually no acute emergency. It may be the case that intermittent intubation must be interrupted. An indwelling tube can be left in place to enable continuous drainage, or can be intermittently clamped and drained. Do not hesitate to contact a center with experience in managing continent ileostomies and their complications.

Difficult Stoma Intubation

The most common causes for difficult intubation are a desintussucepted valve with a tortuous course of the access segment, chronic stricturing (at the skin level stoma or the valve itself), or acute traumatization from failed intubations with worsening edematous swelling. An excessively full pouch can also result in kinking of the valve segment or the afferent bowel, which may induce a vicious circle of overload and dysfunction.

The absolute priority is to establish access and successful decompression of the pouch, which should be achieved before other any other steps or imaging. If a tube with a soft tip cannot be easily inserted, pouch intubation under direct visualization is required. Depending on the circumstances, that may be possible on the spot (bedside, clinic) or require an interventional suite (operating room, GI, or fluoroscopy suite).

Management During Non-related Surgeries or Incapacitation

To manage patients who are temporarily incapacitated and unable to perform intubations for more than 4–6 hours (e.g., during anesthesia for a non-related surgery, or due to mental or physical factors), an indwelling tube should be placed and secured to a gravity draining bag, until the ability to intermittently intubate is restored. During that period the output needs to be carefully monitored and the tube may need to be flushed to maintain patency.

Considerations for Unrelated Abdominal Surgery

Patients with a functional continent ileostomy may need an abdominal surgery that is entirely unrelated to their pouch (e.g., cholecystectomy, gynecological, and urological). In such cases, anticipation is the best protection. Imaging should be reviewed to determine the position and strategize about safest access routes. Extensive adhesions are common and may preclude minimally invasive procedures.

For minor/short procedures, it is sufficient to instruct the patient to intubate and empty the pouch immediately before and after surgery. For longer or complex surgeries, it is advisable to place an indwelling soft ileostomy tube that is connected to a draining bag and excluded from the surgical field underneath the sterile draping. In addition to providing continuous drainage, the tube facilitates palpation and identification of the pouch during the operation. If necessary, the pouch can be filled with water to further clarify the anatomy. Postoperatively the tube is left in place and monitored for regular output until the patient is again capable to resume self-intubations.

Acute Pouch Surgery

Pouch revision is a complex procedure and should not be considered without respective experience. Approach acute problems with a pouch that necessitate a nonelective abdominal intervention, by the following strategies (individually or in combination):

  1. 1.

    Repair acute injury and establish proper pouch drain position and function.

  2. 2.

    Proximal diversion with loop ileostomy.

  3. 3.

    Pouch excision and creation of end ileostomy.

Unless specifically consented for, the decision to perform a definitive pouch removal should be approached with caution. A true pouch revision during an emergency is discouraged, and whenever possible revision surgery should be deferred until the patient and the tissues are in optimal condition to minimize the postsurgical morbidity.

Chronic Pouch Dysfunction

Non-emergent problems with a continent ileostomy warrant a proper workup leading to a thorough decision-making process about the options and expectations. When confronted with chronic pouch issues, establish temporary measures to mitigate the symptoms and refer the patient to a center with experience in continent ileostomy surgery.

Documentation Basics

Coding for surgical procedures is complex. Consult the most recent edition of the AMA’s Current Procedural Terminology book for details (see references at the end). In general, it is important to document:

  • Findings and indications

  • Bowel viability

  • Absence of twisted efferent segment or small bowel mesentery

  • Pouchoscopy—adequacy of views/preparation, ease of scope insertion, length and configuration of valve segment, mucosal appearance, abnormal findings, and any biopsies performed

Operative Technique

Endoscopic Pouch Decompression

First examine the abdomen and visualize the skin-level ostomy. A digital exam is almost always inappropriate. Instead, use a small catheter or a Q-tip to gently “palpate” the valve segment and get an idea about the direction for the intubation. Assess the diameter of the opening and decide which instrument to use. Sedation in most circumstances is not necessary.

  1. A.

    Narrow rigid sigmoidoscopy: This instrument can often be advanced to the pouch reservoir and facilitate preliminary decompression. However, the narrow sigmoidoscope is too small to accommodate passage of an adequate size indwelling tube (24-30F), and a standard thin guide wire is too soft to serve as a reliable help. Therefore, you must first slide in a smaller tube that fits through the lumen of the rigid scope and then advance the desired tube over the first one. Take precaution not to inadvertently push the smaller tube further into the pouch where it may become a lost foreign body. A conventional guide wire may be pushed through the plastic at the end of the small catheter and looped to create a handle for added security. The larger tube can now be slid over the small tube+guidewire loop until the reservoir is reached. Withdraw the small tube and verify appropriate pouch drainage from the larger tube. Secure it in place and connect it to a catheter bag to gravity drainage.

  2. B.

    Flexible endoscope: Select the appropriate size of instrument. A very slim 5–6 mm scope can usually be inserted but does not allow for appropriate drainage. Hence, using lots of lubricant, slide a larger drainage tube with an open end tip as a sheath over the flexible part before accessing the pouch. Then insert the sheathed instrument into the ileostomy and advance it under direct visualization and with the minimum necessary insufflation. Once you reach the pouch, gently advance the tube into the reservoir and remove the scope. Stool should immediately start to drain. Repeated water irrigations may be necessary to flush the openings . Secure the drain in place and connect it to a catheter bag to gravity drainage.

Pouchoscopy

When performing a flexible pouchoscopy for diagnostic reasons rather than therapeutic pouch decompression (see above), use the largest flexible instrument that fits through the skin level stoma. Oftentimes, that is the pediatric endoscope. Sedation and analgesia are not routinely administered, but may be optional per patient request.

Insert the endoscope into the skin-level stoma and slowly advance under direct visualization, utilizing fluid irrigation or insufflation as necessary, until the pouch reservoir is visualized. Use irrigation as needed to remove residual stool and inspect for any mucosal abnormalities. Identify the afferent limb and attempt to follow it for 20 cm. Retroflex in the pouch reservoir to visualize the valve segment. Be sure to describe the intestinal mucosa, any abnormal findings, as well as the length and structure of the valve segment. Routinely take biopsies from the afferent limb and the pouch reservoir, or from any suspected pathology. Avoid biopsying the valve segment. Suck out as much air as possible as the scope is withdrawn.

Pouch Revision

A more detailed explanation of the technical aspects of pouch revision surgery is beyond the scope of this chapter.

Postoperative Care

  • Diet: Restart immediately if no obstruction, otherwise as soon as return of bowel function

  • Catheter management: Monitor and record output every 6 hours. Irrigate the catheter twice daily with 30 cc of tap water: Instillation and withdrawal should have not resistance.

  • Antibiotics: Only for specific therapeutic indication.

Complications

  • Bowel/pouch perforation

  • Enterotomies

  • Trauma to valve segment or pouch

  • Abscess formation

  • Enterocutaneous fistula formation