Continent ileostomy in the pediatric patient

Continent Ileostomy in the Pediatric Patient By I. M. Gelernt,

J. J. Bauer, and I. Kreel

T

HE PEDIATRIC PATIENT with ulcerative colitis (a surgically curable disease) is frequently permitted to suffer the ravages of the disease and its treatment for an unjustifiable duration. Studies’** demonstrating that ulcerative colitis in children has an even more ominous prognosis than in adults are well known to pediatricians; yet we continue to see children with continuous delayed development of secondary sex debility, severe growth retardation, characteristics, interference with emotional maturation, and, occasionally, disseminated colonic malignancy. The reluctance of pediatrician, patient, and patient’s family to accept the need for a permanent. continuously worn appliance despite the very tolerable life it permits is well known to all. Nils Kock’s3.4 introduction of a continent ileostomy has helped to overcome much of the reluctance of the patient, the family, and the pediatrician to elect surgery. The psychologic, social, and sexual barriers that the conventional ileostomy suggested have been largely removed with the continent ileostomy that requires no appliance, and the proper focus is placed on eradicating this crippling disease. CASE

MATERIAL

The 10 patients in this study (Table I) had ulcerative colitis. The ages ranged from I.! to 18 yr. There were 3 males and 7 females. Six patients had the reservoir continent ileostomies constructed at the time of total protocolectomy. All were receiving large doses of corticosteroids at the time of surgery. One patient had an abdominoperineal resection and a reservoir ileostomy 4 yr following a subtotal colectomy and ileal- rectal anastomosis. One patient had an abdominoperineal resection of the rectum and conversion of a standard ileostomy 8 mo following subtotal colectomy. Two patients had revision of standard ileostomies, one for psychosocial indications, the other for repeated episodes of retraction and prolapse, having already had several failed revisions of her ileostomy. TECHNIQUE The procedure for constructing a continent ileostomy is the same when performed as a secondary procedure or in conjunction with a total proctocolectomy. The procedure is described with the surgeon on the patient’s left. Forty centimeters of terminal ileum is used to create the reservoir. nipple valve. and outflow tract: IO cm of the most terminal ileum (slightly more if there is a very thick panniculus) is left untouched. to be used to form the valve and outflow tract. The remaining 30 cm of ileum is folded m a U-shaped pattern with the outflow tract facing cephalad. The two 15-cm limbs are joined with a running absorbable suture along their antimesenteric borders (Fig. 1A). These limbs of the ileum are then incised along the suture line, extending the incision 2 to 3 cm more proximal than the suture line, on the afferent limb. This facilitates separation of the aKerent (inflow) and efferent (outflow) limbs when the reservoir is closed. The cut margins of the U-shaped limbs are then

From the Department Presented Raton.

before

Fla., April

29-Ma,v

Address for reprint of Medicine,

qf Surgery,

the 7th Annual

Sinai School

oJ’Medicine.

of the American

Pediatric

New York, Surgical

N. Y.

Association.

Boc,a

I, 1976.

requests:

I. M. Gelernl,

M.D..

Department

rtf Surgery.

The Mount

Sinai

School

New York. N. Y. 10029.

‘C, 1976 Grunc~ & Straiton.

Journo/

The Mounr Meeting

of Pediafrk

Surgery,

inc.

Vol. 11, No. 5 (October),

1976

773

774

GELERNT,

BAUER,

AND KREEL

Table 1. Patient Material Number Patients 6

Procedure

Total proctocolectomy,

Steroids

Indications

6

Failure of medical therapy

0

Premalignont changes (1). continued

0

Repeated prolapse and retraction (l),

continent ileostomy 2

Abdominoperineol resection, continent ileostomy

2

Revision of standard

disease rectum (1)

ileostomy

psychosocial (1)

by a continuous absorbable suture, constituting an inner layer for the first suture line (Fig. 1B). The most terminal portion of the ileum is then intussuscepted in a retrograde fashion to form a 3.5- to 4-cm nipple (Fig. 1C). When one is satisfied that the nipple intussuscepts easily, it is reduced, and the serosa of that portion of the ileum is abraded with a fine orthopedic rasp and then scored with cautery (Fig. 1D). Two rows of four 2-O silk seromuscular sutures are placed so as to plicate both mesenteric edges of the ileum (Fig. 2A). When tied, the mesenteric edges of the ileum will have been fixed in a retrograde intussuscepted fashion (Fig. 2B). The remainder of the intussusception is then carried out, and a series of 12 to 16 2-O silk approximated

sutures are placed circumferentially at right angles to the long axis of the nipple, through both intestinal walls. A large-bore catheter should be placed in the nipple valve during the suture placement to prevent inadvertent occlusion of the lumen by suturing the bowel at the opposite side. The intestinal plate is then closed apex to apex as demonstrated in Figure ZC, with two layers of a running absorbable suture material (Fig. 2D). The reservoir is then folded into the leaves of the mesentery so that only the original suture line is visible. The valve function is then tested by occluding the inflow portion of the ileum, introducing a catheter into the reservoir, filling it with air, and removing the catheter. There should be no escape of air when the catheter is removed. The catheter is again introduced and the air escapes. A button of skin is then excised in the right lower quadrant. The site is determined by choosing the site where the reservoir will fit best while resting on the pelvic peritoneum. The stoma will usually exit best just above the pubic hair line and will be concealed by undergarments. A cruciate incision is made in the rectus fascia, and the muscle is divided bluntly in the direction of its fibers; an incision is made in the posterior fascia and peritoneum. In order to facilitate proper fixation of the pouch, the posterior aspect of the reservoir immediately behind the outflow tract is sutured to the inferior aspect of the peritoneal defect before the outflow tract is brought through the abdominal wall (Fig. 3A). Silk sutures are used. After the pouch has been securely

\

’

Fig. 1. (A) Initial suture line of reservoir. (8) Ileum incised. (C) Nipple valve. (D) Scoring of serosa.

CONTINENT ILEOSTOMY

Fig.

2.

(A)

Fixation

of

mesenteric edge. (B) Mesenteric edge intussuscepted. (C) Initial suture to close reservoir. (D) Reservoir completed.

fastened

wall, and wall with amputated Charriere) eral times. tion. All

to the lateral parietes (Fig. 3B). the outflow tract is brought through the abdominal the remainder of the pouch about the outflow tract is securely sutured to the abdominal 2-O silk. The entire outflow tract must lie within the body wall. The outflow tract is then at skin level. The ileostomy catheter (A.B. Medina, Kungsbacka. Sweden, No. 2X is inserted into the pouch. It must traverse the canal easily and should be tested sevThe stoma is matured, and the catheter is placed in the reservoir in a dependent posiof the openings of the ileostomy catheter must lie within the pouch. The catheter is

sutured securely to the skin (Fig. 3C). Soft rubber drains are placed in the lateral gutter and exit via a lateral stab wound. The space lateral to the pouch is closed by suturing the cut margin of mesentery of the ileum to the lateral parietes. The ileostomy catheter is connected to a bedside bag via a wide-bore tube, and the wound is closed.

POSTOPERATIVE

MANAGEMENT

The catheter is left to gravity drainage for 14 days. It is irrigated frequently to ensure patency. On the 14th day the catheter is corked for 1 hr intervals and left to gravity drainage at night, The duration of corking of the catheter is grad-

Fig. 3. (A&B) Fixation of posterior aspect of reservoir. (C) Reservoir with ileostomy catheter.

776

GELERNT,

EAUER,

AND KREEL

ually increased, and by the 20th postoperative day the catheter is removed and the patient is trained in its use. For several weeks the patient empties the reservoir frequently, slowly increasing the times between emptying. Each patient is taught how to irrigate the pouch in the event that it is ever needed. In several months the reservoir is emptied only two to four times per day. RESULTS

There have been no deaths. All 10 patients are back at school. Nine patients wear only a small dressing or bandage and empty their reservoir two to four times per day. Emptying time is approximately 3 to 4 min. One patient is partially incontinent and wears an appliance when away from home for extended periods. Early postoperative complications included a perforated gastric ulcer in a patient receiving large doses of corticosteroids for many years and a high jejunal obstruction secondary to an adhesive band to the anterior abdominal wall. One patient was incontinent of gas and a minimum amount of stool for approximately 2 wk following extubation of the reservoir because of a pinpoint fistula in the nipple valve. This healed without treatment, and the patient is now continent. One patient developed a skin stricture that was repaired by a small Z-plasty. All patients have returned to full activity and are essentially on unrestricted diets. DISCUSSION

The results in this small group of pediatric patients suggest that in the properly chosen patient the continent ileostomy is far superior to the standard ileostomy with a continuously worn appliance. The complications attributable directly to the reservoir ileostomy have been small, and other complications (i.e., the perforated ulcer and small bowel obstruction) are similar to those seen in total proctocolectomy alone.5s6 Acceptance of the reservoir ileostomy has been rightfully slow in coming. Early reports 7- 11 contained only fair results. This was in part due to inclusion of several different modifications within the same paper. Also, the details of operative and postoperative management did not take into account predictable postoperative complications. The procedure as we have described it has been used successfully on our service in a large number of adults as well as in this group of pediatric patients. The failure of the reservoirs constructed without valves requires no further discussion. Several of the patients described in the literature did not have secure fixation or any fixation of the pouch to the abdominal wall. This makes intubation of the reservoir very difficult and requires the use of small-caliber flexible tubes. These patients will spend inordinate amounts of time emptying the reservoir and will frequently require irrigations. It is well known to surgeons and pediatricians that to reduce an intussusception one must exert some force on the lead portion of the intussusception. A distended reservoir exerts just such a force on the nipple valve. For this reason we have kept the reservoir intubated for a considerably longer duration than other

CONTINENT

authors,

777

ILEOSTOMY

and then we insist on very frequent

emptying

of the pouch

for several

weeks into the postoperative period. This permits firm serosal bonding of the nipple valve before it is exposed to a considerable head of pressure. Earlier techniques did not adequately secure the mesenteric aspect of ileum used for the nipple valve, It is in this portion of the valve that reduction of the intussusception first occurs, and plication of the mesentery was the one step of the procedure not completely performed in our patient that is incontinent. Contraindications to performing a continent ileostomy are severe debility, emergency surgery, local or systemic sepsis, subtotal colectomy, granulomatous colitis, and an unreliable patient. The reservoir construction adds approximately 60 to 90 min to the procedure, and there are multiple long suture lines. It should be reserved for the elective situation and not performed during colectomy for massive hemorrhage, toxic dilatation, or peritonitis. Steroids alone do not represent a contraindication to this procedure. as has been suggested by Kock.3 Six of our 10 patients had been receiving steroids for many months prior to proctocolectomy and pouch construction. Patients who are severely debilitated or hypoproteinemic should have the procedure staged and should have the reservoir constructed when the patient is better prepared. One patient, a young boy, had toxic dilatation of the colon and acute pancreatitis, probably secondary to massive steroid dosage, with a severe chemical peritonitis. It would have been foolhardy in this situation to construct a reservoir with the obvious risks involved. It is troublesome that many of the patients who have been referred to us have been too ill for us to perform the procedure in one stage. unjustifiable in granuloThe high recurrence rate”-14 makes the procedure matous colitis. Patients who might otherwise require only a minimal resection would possibly require sacrifice of the 40 cm of ileum used to construct the ileostomy reservoir and outflow tract, with more surgery a likely possibility in the future. Is there an appropriate age for the construction of a continent ileostomy? The surgeon must know the patient well and decide if the child is intellectually and psychologically capable of intubating the reservoir. The patient must be cooperative and reliable, for unlike an incontinent ileostomy, serious harm can befall the patient who fails to care for his continent ileostomy properly. The youngest patient in our series was 12 yr old, and at present we do not see this procedure being performed in children prior to puberty. The continent ileostomy still requires an abdominal stoma; thus it does not represent a panacea for the patient having a proctocolectomy. However, there has been no question on the part of any of the people (nurses, physicians, social workers, psychologists, and parents) dealing with these children that acceptance of this procedure is significantly better than with the standard type of ileostomy. The pediatrician and gastroenterologist have found parents and patients much more accepting of the need for proctocolectomy when the spectre of a lifelong appliance has been removed. Our own observations strongly support the feelbetter with a continent ings of Kock Is that the quality of life is significantly ileostomv.

GELERNT,

778

BAUER,

AND

KREEL

SUMMARY

Continent ileostomies have been performed in 10 juvenile patients. The operative technique and postoperative management are described. Nine patients wear only small dressings to cover the stoma. One patient is partially incontinent and frequently wears an appliance. Criteria for patient selection and contraindications are discussed. ACKNOWLEDGMENT The authors provided

wish to thank

Professor

N. I. Kock

for his encouragement

and for the help that he

when this study was begun.

REFERENCES I. Korelitz 91, Gribitz D: Prognosis of ulcerative colitis with onset in childhood. II. Steroid era. Ann Intern Med 57:592, 1962 2. Schneider KM, Becker JM, Korelitz BI, et al: The surgical treatment of ulcerative colitis in childhood. A study of 38 cases. J Pediatr Surg 3: 12, 1968 3. Kock NC: Ileostomy without external appliance. Ann Surg 173:545, 1971 4. Kock NC: Continent ileostomy. Prog Surg 12:180, 1973 5. Watts JM, DeDombal FT, Goligher JC: Early results of surgery for ulcerative colitis. Br J Surg 53: 1005, 1966 6. Scott HW Jr. Wimberly JE, Shull HJ, et al: Single stage proctocolectomy for severe ulcerative colitis. Comparison with less extensive procedures. Am J Surg I l9:87, 1970 7. Beahrs OH, Adson MA: lleal pouch with ileostomy rather than ileostomy alone. Am J Surg 125: 154, 1973 8. Beahrs OH, Kelly KA, Adson MA, et al: Ileostomy with ileal reservoir rather than ileostomy alone. Ann Surg 179:634, 1974 9. Goligher JC. Lintott D: Experience with 26 reservoir ileostomies. Br J Surg 62:893, 1975

IO. Beahrs OH: Use of ileal reservoir ing

proctocolectomy.

Surg

Gynecol

followObstet

141:363. 1975

I I. Madigan

MR:

The

continent

ileostomy

and the ileal bladder.

Ann

R Coil

Surg 5S:Q.

1976 12. Korelitz BI, Present DH, Alpert LI, et al: Recurrent ileitis after ileostomy and colectomy for granulomatous colitis. N Engl J Med 287: I IO, 1972 13. Korelitz BI, Janowitz HD: Controversy on recurrent ileitis after ileostomy and colectomy for granulomatous ogy 65498. 1973

colitis.

Gastroenterol-

14. Steinberg DM, Allan RN, Brooke BT, et al: Sequalae of colectomy and ileostomy: Comparison between Crohn’s colitis and ulcerative colitis. Gastroenterology 68:33. 1975 15. Kock NC, Darle N, Kewenter J, et al: The quality of life after proctocolectomy and ileostomy. A study of patients with conventional ileostomies converted to continent ileostomies. Dis Colon Rectum 17:287, 1974

Discussion S.

Schuster (Boston): Both patients did not have previous ileostomies. and they heard about the continent ileostomy. They are essentially totally continent. They would like to organize a national organization for continent ileostomies. One of the problems that we have had is that both patients on occasion may have difficulty in getting the catheters in. I am not certain exactly why that is. T. Boles (Columbia~: Dr. Thomas Morse had a patient 16 yr of age who had a Koch pouch operation, and she did well for about 6 mo. During this time she was free of symptoms, was continent, and went to school daily with no problems. At the end of about 6 mo she developed periodic abdominal pain and bleeding. The pouch was endoscoped, showing the inside of it to be markedly ulcerated and inflamed, and the pouch was removed. Prior to the Koch procedure the diagnosis was thought definitely to be ulcerative colitis. However, the removed pouch. 6 or 8 mo later, was

CONTINENT

ILEOSTOMY

779

shown to have Crohn’s

disease. With any question

of granulomatous

disease the procedure

ob-

viously should not be done.

I

A. Shaw (Chadormvillei: have a preexistent pouch

without

disturbing

B. Othersen 1. Gelemr diagnosis.

and a reservoir men.

Penrose

above

drains

from

the pouch. the

pubic lateral

although

problem

that

intubating

their

nipple.

so that

of the

abdominal

wall;

new direction the pouch returned

was lifted to its previous

must

a problem

the stoma

line.

The

a patient

Gelernt

not

how

be done

because

patients

he keeps the stool

in patients

one cannot

a standard

will

all are taught has provided There

the outflow

will

with

always

ileostomy

who the

liquid

granuloma-

be certain

should

site

difficulty

a very

is a rare

of the

be performed,

thick

some concern are several

output.

patient

This

shifts

but

who

will

straight:

for

this:

and

was weii demonstrated

by the growing

uterus.

exit

for

a fluid

with

prune

occasionally

some (I)

the

patients

partial

(3) the pouch

position,

on the abdo-

an

the

effluent or apple have

to

necessary.

is the difficulty

reasons

lower

provides

in maintaining

how to do this if it becomes

is no longer

out of the pelvis

considerably

ileostomy

is little

have It

the pouch

the catheter.

be placed

previous

There

is achieved.

position.

to ask Dr

the procedure

to the pouch.

(3) occasionally

for

he is able to form

at a later date.

hair

pouches.

for inserting

like

as to the diagnosis,

consistency

the pouch.

just

ileostomy.

Occasionally

proper

The only have

the

his technique

or whether

ileostomy.

can present

is any doubt

lying

juice irrigate

agree that

a standard

he modified

it all down

accumulating.

can be constructed

revising

just

from

of course,

If there

When

I

(&sing): This,

he takes

I would

solid material

tous colitis.

like to ask how

the cutaneous

(Charleston):

and prevents

would

ileostomy-whether

coming

patient

loose

must

in a pregnant

Following

occasionally

deintussusception from

the

be taught patient

the delivery,

a

when

the pouch