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Kock Pouch, Barnett Continent Intestinal Reservoir, and Diverted Pouch
Chapter 38
Kock Pouch, Barnett Continent Intestinal Reservoir, and Diverted Pouch Min Chen, MD, PhD⁎, Bo Shen, MD† ⁎
Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China, †Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
ABBREVIATIONS BCIR Barnett Continent Intestinal Reservoir BMI body mass index CARP chronic antibiotic-refractory pouchitis CD Crohn’s disease CMV cytomegalovirus CRP C-reactive protein FAP familial adenomatous polyposis IBD inflammatory bowel disease IPAA ileal pouch-anal anastomosis NSAID non-steroidal anti-inflammatory drugs QOL quality of life SCFA short chain fatty acids UC ulcerative colitis
INTRODUCTION Patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) may undergo total abdominal colectomy with a continent ileostomy instead of end ileostomy or pelvic pouch. There are two forms of continent ileostomy, namely Kock pouch and Barnett Continent Intestinal Reservoir (BCIR). The main structure of Kock pouch is an intra-abdominal pouch with a nipple valve, which can preserve the continence. BCIR is a variant of the Kock pouch where a loop of small bowel is wrapped around the pouch outlet to augment continence of ileostomy. During the construction of ileal pouch-anal anastomosis (IPAA), temporary fecal diversion is often needed as part of the staged restorative proctocolectomy. Some pouches will be permanently diverted if pouch failure occurs due to refractory pouchitis or Crohn’s disease (CD) of the pouch. In this chapter, we will also discuss the complications of diverted pouch, such as diversion pouchitis, diverted pouch stricture, and neoplasia.
KOCK POUCH Kock pouch, which was also named continent ileostomy, was first devised by Nils Kock in 1969 [1]. It was then overtaken by IPAA in the 1980s, which has an advantage of preserving the natural route of defecation. However, the Kock pouch remains to be a valuable choice for selected patients who are not candidate for IPAA or for those patients who have failed IPAA. It provided the patients substantial benefits over traditional ileostomy of not having to use an external appliance. The Kock pouch surgery is a complicated procedure, with the creation of a nipple valve being the most challenging part. The nipple valve of Kock pouch is constructed by retrograde intussusception of the efferent limb into the pouch body and stabilized by the application of three or four rows of staples. The fundus of the pouch is sewn onto the base of the exit conduit to strengthen the intussusception. The pouch is then closed and tested for integrity and continence. The exit conduit is Pouchitis and Ileal Pouch Disorders. https://doi.org/10.1016/B978-0-12-809402-0.00038-1 © 2019 Elsevier Inc. All rights reserved.
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brought through the abdominal wall and the anchoring sutures are completed by being inserted through the posterior rectus sheath and sutured. The lateral para-ileostomy space is closed and a catheter is then installed for continuous postoperative drainage. The drainage catheter is left in the lumen of pouch body for approximately 4 weeks to allow for complete healing of all suture or staple lines. Patients are normally scheduled for the first outpatient visit at several weeks postoperatively, to have their pouches tested. The anatomy and landmarks of the Kock pouch are illustrated in Figs. 1 and 2. The main components of a Kock pouch include the nipple valve, pouch body, pouch inlet, and afferent limb.
Indications and Contraindications The indication for Kock pouch includes patients who are not candidates for pelvic ileal pouches; those who failed pelvic pouches; or those who are not satisfied with conventional ileostomy. IPAA, either J- or S-pouches, preserves the natural route of defecation and is the standard surgical treatment modality for patients with UC or FAP. However, pelvic J pouch procedure is not suitable for patient with either poor anal sphincter function or involvement of the anal canal by malignancy. In addition, the IPAA is associated with a significant rate of complications, which may eventually result in pouch failure in 10%–15% of patients [2]. A conversion of a failed J ileal pouch to a continent ileostomy in highly selected patients, using old, functioned J-pouch body, or constructing with a new segment of small bowel. In a historical cohort study from Cleveland Clinic, the investigators identified 64 patients with Kock pouches which were constructed as a rescue procedure for failed J-pouches. The most common underlying diagnoses were UC (N = 44, 68.8%) and CD with perianal disease only (N = 13, 20.3%). The previous pelvic pouch was used in 16 (25%) patients. During a median follow-up of 5 years, the rate of Kock pouch dysfunction was 50% and the rate of complication rate was 60.9%, and the revision rate was 45.3%. However, the retention rate of Kock pouches was 95.3% with a median pouch survival of 4.2 (range, 1–19) years [3] (Fig. 3). Finally, convertion of a conventional end ileostomy to a continent ileostomy may be “earned” by those who are concerned their body image or have difficulties in external appliance.
FIG. 1 Anatomy of a healthy Kock pouch. (A) Valve opening on skin; (B) lumen of the nipple valve; (C) intact nipple valve on endoscopic retroflex view; and (D) afferent limb proximal to the pouch inlet.
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FIG. 2 Anatomy of Kock pouch on cross-sectional imaging. (A and B) Pouch body and nipple valve (green arrow).
FIG. 3 Conversion of J-pouch to Kock pouch. (A) Perianal disease with J-pouch; (B) normal pouch body and afferent limb of the J-pouch; (C) intact nipple valve of a Kock pouch converted from the failed J-pouch with a diagnosis of Crohn’s disease; and (D) normal body and afferent limb of the Kock pouch.
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Contradictions for the construction of the continent ileostomy are CD, limited small bowel reserve, obesity, and significant comorbidities. Handelsman et al. [4] evaluated 95 patients who underwent Kock pouch surgery for inflammatory bowel disease (IBD) and found that all 8 patients (100%) with a precotocolectomy diagnosis of CD or indeterminate colitis suffered from serious complications. In contrast, the majority of remaining 87 patients with preoperative diagnosis of UC did well with the surgery and only 17 (20%) had complications, with 6 having readily corrected complications. The construction of a de novo Kock pouch requires a 50–70 cm segment of the small intestine. Patients with anticipated risk for Kock pouch failure should not have the surgery. In addition, Kock pouch surgery should not be offered to those with a limited small bowel length due to previous surgery of bowel resection or diseased small bowel. Obese patients are not candidates for continent ileostomy, as excessive cutaneous and mesenteric fat increases the risk of complications of the valve.
Disorders of Nipple Valve of the Kock Pouch The Kock pouch surgery is a complex procedure with a high rate of complications. The majority of complication of Kock pouch is associated with the nipple valve, including valve slippage, prolapse, stricture, and fistula formation. Other complications including pouchitis, strictures at the pouch inlet or afferent limb, CD of the pouch, and pouch bezoars have also been reported. A healthy Kock pouch is largely dependent on the structure and function of the nipple valve. On the other hand, the nipple valve disorders, such as slippage, prolapse, stricture, and fistula formation are the most frequently encountered complications (Fig. 4). Denoya et al. [5] reviewed 31 patients who developed complications after having a normal Kock pouch for >10 years and found 26 (83.9%) patients with nipple valve slippage. Nipple valve slippage can be partial or total. The partial slippage makes intubation difficult or impossible, while total valve slippage can lead to pouch incontinence. Obesity or excessive weight gain is a common risk factor for nipple valve slippage (Fig. 5). Obesity or weight gain can cause fat deposition in both mesentery of the intussuscepted ileum and abdominal wall, which may act to dessuscept and weaken the
FIG. 4 Dysfunctional nipple valve of a Kock pouch. (A) Prolapsed valve; (B) ulcerated, angulated, and strictured valve due to repeat intubation; and (C) enterocutaneous fistula with internal opening at the base of the nipple valve.
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FIG. 5 Weight gain and partial valve slippage in a patient with the Kock pouch. (A) Persistent weight gain; (B) retracted opening of the valve due to obesity (green arrow); (C) long, intact valve 2 years prior; and (D) partially slippage of the valve.
valve. Nessjar et al. [6] found a 1.8-folds higher rate of valve slippage for every 5-point increase in body mass index (BMI). Therefore, the avoidance of weight gain has been a key to maintain an intact pouch valve. The stricture of Kock pouch may occur at the skin level, the nipple valve, pouch inlet, or afferent limb. The causes of skin-level stricture include too small skin opening, tissue contraction, ischemia, infection, valve retraction, and repeated trauma. The causes of non-skin-level Kock pouch strictures include CD of the pouch, surgery-related ischemia, inappropriate techniques of catheter intubation, or the use of nonsteroidal anti-inflammatory drug (NSAID). A slipped or strictured valve may cause difficulty in catheter intubation and symptom of bowel obstruction. Patient may try to place a Foley catheter to relieve obstruction. If available, urgent endoscopic intubation should be attempted to suction air and fecal contents in the pouch reservoir, followed by placement of a guide wire. Subsequently, a drainage catheter can be inserted into the pouch over the guide wire to provide longer-term drainage and to bridge more definitive therapy. Surgical stomaplasty or revision of the stoma is the main stay for the treatment of slipped nipple valve. In contrast, endoscopic treatment may be attempted first for the treatment of nipple valve stricture before surgical intervention. Endoscopic treatment modalities for nipple valve stricture include balloon dilation (Fig. 6), electroincision with stricturotomy with needle knife or isolated-tip knife (Fig. 7), and even polypectomy (Fig. 8). In the past decades, endoscopic therapy, especially needle knife stricturotomy has emerged as a valid alternative to surgery for the management of strictures in patients with Kock pouches. Our previous study of 16 consecutive patients in the Kock pouch, including 10 patients having 10 nipple valve strictures (33.3%), 12 having 12 pouch inlet strictures (40.0%), and 4 having 8 afferent limb strictures (26.7%). A total of 60 sessions of endoscopic therapy (balloon dilation and/or endoscopic stricturotomy) were performed in the 16 patients for the treatment of 90 Kock pouch strictures. During a median follow-up of 32 months (interquartile range: 12–64-months), none of the 16 patients required surgical intervention. The study showed that endoscopic therapy in treating Kock pouch strictures was feasible, effective, and safe [7]. Surgical modalities in the treatment of Kock pouch strictures include revision of the valve (Fig. 9), strictureplasty, small bowel resection/reanastomosis, and pouch excision. Although surgical therapy is effective, it is associated with significant risk for the development of postoperative complications and recurrent strictures [8]. In addition, surgical revision of Kock
FIG. 6 Nipple valve stricture at skin level. (A) Tight stricture at the skin level; (B) balloon dilation of the stricture; (C) the stricture after dilation; and (D) slipped valve.
FIG. 7 Nipple valve stricture at skin level. (A) Tight stricture at the skin level; (B) needle knife electroincision of the stricture; and (C and D) the stricture after the therapy.
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FIG. 8 Nipple valve stricture. (A) The stricture with polypoid lesions;and (B) snare “polypectomy.”
FIG. 9 Nipple valve stricture at skin level with surgical revision. (A) Before treatment; and (B) after surgical revision of the valve.
pouch stricture is technically challenging due to the complex anatomy, as well as concern about iatrogenic injury to the pouch body and adjacent visceral organs [9]. The valve prolapse occurs when the fascia defect around the efferent loop is too large (Fig. 4A). It is less common than valve slippage or stricture. Denoya et al. [5] reviewed 31 patients undergoing pouch revision who had a normal pouch for >10 years, 26 (83.9%) of them had valve slippage, while 3 (9.7%) had a prolapsed valve. In another study, Nessar et al. [6] followed 330 patients undergoing Kock pouch surgery at Cleveland Clinic, 20 (6.1%) had a prolapsed valve, while 98 (29.7%) had a valve slippage. Valve prolapse may be managed by surgical revision or repair of fascia. Fistula of the Kock pouch can develop at the nipple valve, pouch body, or the distal small bowel. The main phenotype is enterocutaneous fistula, originated from the base of nipple valve (Fig. 4C), which is believed to result from mechanical or ischemic factors. The nipple valve area, including skin, subcutaneous fat, muscle, and fascia is prone to ischemic injury. Surgical technique problems, such as sutures being placed through the walls of the valve and tied too tightly, erosion of prosthetic materials, tension of mesentery, or improper placement of nonabsorbable mesh. In the past, a Marlex or Mersilene mesh was used in patients with Kock pouches as a sling to stabilize the valve or as a fundal wrap to prevent valve prolapse. However, this technique has been shown to increase the risk or formation of fistula and was then abandoned in the 1980s. Kock pouch-related fistula can be also caused by CD of the pouch. The fistula (mainly enterocutaneous fistula) often originates from a diseased afferent limb with downstream stricture. The treatment of CD-related fistula requires multidisciplinary approach, with medical, endoscopic, and surgical therapy.
Pouchitis of the Kock Pouch The reported cumulative frequency of pouchitis in patients with Kock pouches or Kock pouchitis varies from 10% to 30% [10–12]. From our Pouch Center at Cleveland Clinic, we evaluated 36 patients with continent ileostomies (33 Kock pouches
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and 3 BCIRs), 45 patients with-S pouches and 215-J pouches. We found that the rates of chronic antibiotic-refractory pouchitis (CARP) in the Kock pouch, S-pouch, and J-pouch were 8.3%, 0%, and 13.0%, respectively. The patients with Kock pouches have a lower risk for CARP than those with J-pouches [13]. In our clinical practice, we have noticed that Kock is characterized by asymmetric inflammation in the pouch body, with the most common locations being in the pouch inlet area, the area close to nipple valve, or surface of the valve (Fig. 10). We speculate that ischemia may be a main contributor to Kock pouchitis. Patients with pouchitis usually present with watery and foul smelling intestinal discharge, requiring more frequent catheter intubation. The patients may present with fever, nausea, abdominal pain. The pouchitis of patient with Kock pouch are mostly mild and transient, and usually response to antibiotics. We have also used topical mesalamines and corticosteroids to treat antibiotic-refractory Kock pouchitis. However, patients with severe or persistent Kock pouchitis are at risk for dehydration or even acute renal failure.
CD of the Kock Pouch CD can occur in patients with Kock pouches. Of 36 patients with continent ileostomies (33 Kock pouches and 3 BCIRs), 45 patients with S-pouches, and 215 J-pouches, the cumulative frequency of CD of the pouch was 25.0%, 24.4%, and 18.6%, respectively (P = .51) [13]. There is no consensus on the diagnostic criteria. The diagnosis of CD of the Kock pouch is often based on endoscopic histopathological, and radiographic features of the pouch or perioperative findings. CD of the Kock pouch may have patchy distribution of inflammation or ulceration of the pouch body, afferent limb, stricture or fistula, or transmural inflammation (on cross-sectional imaging or postoperative histopathology) (Fig. 11). Some patients may have noncaseating granulomas on biopsy of the pouch body or afferent limb. The postoperative histopathology CD of the pouch also includes fat wrapping of the small bowel, enlarged mesenteric lymph nodes, dense adherence, stricture, fistula, and abscess. In most cases of CD of the Kock pouch, the afferent limb is involved, with
FIG. 10 Patterns of Kock pouchitis. (A) Patchy inflammation and ulcers; (B) ulcers and nodularity along the suture line and on the valve; (C) diffuse inflammation; and (D) normal afferent limb.
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FIG. 11 Crohn’s disease of the Kock pouch. (A) Inlet stricture and ulcers; and (B) tight stricture with ulcerations at the afferent limb.
inflammation, stricture, or entero-enteric fistula, or enterocutaneous fistula. CD of the pouch, including that in the Kock pouch, has been a main cause of pouch failure. In one study including 330 patients with Kock pouches, the pouch excision rate in patients with CD of the pouch was much higher than those without CD of the pouch: 26% (11/42) versus 13.9% (40/288), respectively [6]. There are no published data on the medical management of CD of the Kock pouch. We believe that aggressive medical treatment with mono or combo (with immunomodulators)—biological agents are necessary in the majority of patients, as surgical excision of the pouch is not ideal or preferred option with a risk of loss of a long segment of valuable small bowel. Antibiotic therapy may provide additional benefits. CD-associated strictures may be treated with endoscopic balloon dilation or stricturotomy (Fig. 12).
FIG. 12 Pouch inlet strictures. (A and B) Endoscopic balloon dilation; and (C and D) endoscopic needle knife stricturotomy.
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Pouch Bezoars The formation and retention of foreign body and bezoars are unique complications of a Kock pouch (Fig. 13). The bezoars can be detected by cross-sectional imaging or pouchoscopy (Fig. 14). Capsule endoscopy has been used for the evaluation of small bowel disease in patients with ileal pouches, including those with Kock pouches [14]. Therefore, patients with Kock pouches undergoing capsule endoscopy should be prepared for pouchoscopy for the retrieval of retained capsule (Fig. 13A). Jarvinen et al. [15] evaluated the complications in 76 patients with Kock pouches after a following-up of 9 years, they found that the incidence of bezoars was 9.2% (7/76). The majority of patients with bezoars can be treated with endoscopy. Our group has reported a case with nipple valve stricture and large pill bezoars in the Kock pouch body. The dietary supplement pills taken by patients were undissolved and retained in the pouch reservoir, forming bezoars. The nipple valve stricture was dilated with balloon and the retained pills were then retrieved endoscopically in a piecemeal fashion [16]. Subsequently, we reported patients with ileal pouch bezoars, including 5 (0.4%) of the 1390 patients with J-pouch and 7 (13.0%) of 54 with continent ileostomy (P < .001). Of the 12 patients, 6 (50.0%) had phytobezoars; 4 (33.3%) had lithobezoars; 1 (8.3%) had pharmabezoar; and remaining 1 (8.3%) had a retained-Jackson-Pratt drain. Ten patients (83.3%) were symptomatic, including 7 (58.3%) who presented with symptoms of partial bowel obstructive. Eleven patients (91.7%) were initially managed with endoscopic treatment. The endoscopic tools included basket (N = 9, 81.8%), RothNet® (N = 6, 54.5%), mechanical lithotripsy (N = 3, 27.3%), tripod (N = 2, 18.2%) and snares (N = 2, 18.2%). After a median number of 1 (1–3) endoscopic therapies, bezoars were successfully removed in seven patients (63.6%). Surgical intervention was needed in the remaining five patients (41.7%) [17]. We found that endoscopic mechanical lithotripsy for lithobezoar has not been effective (Fig. 14C). For large lithobezoars, we have successfully performed ultrasound and laser lithotripsy of Kock pouch bezoars in operative room with a team of gastroenterologists and urologists (Figs. 15 and 16).
FIG. 13 Foreign bodies and bezoars in Kock pouches. (A) Retained endoscopy capsule; (B) lithobezoar; (C) pharmacobezoar; and (D) phytobezoars.
FIG. 14 Kock pouch bezoar. (A and B) A calcified bezoar at the afferent limb of the pouch and (C) attempted and failed endoscopic mechanical lithotripsy.
FIG. 15 Kock pouch bezoar. (A) Setting at operating room with gastroenterology and urology teams; (B) laser lithotripter unit; and (C) probe-based lithotripter in action.
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FIG. 16 Kock pouch bezoar. (A) Ultrasound lithotripsy in action; (B) a large calcified bezoar (lithobezoar) in the pouch body; and (C) fragmented bezoar.
Risk of Pouch Neoplasia The development of carcinoma can be a concern in patients with restorative proctocolectomy. The risk of dysplasia or carcinoma in patients with Kock pouches appears to be rare, with only one case reported in the literature to date [18]. This is a 39-year-old male patient with a long history of UC. He was found to have a large adenocarcinoma involving the intussusception valve after having a Kock pouch for 17 years [18]. Therefore, routine surveillance for pouch neoplasia is not recommended in patients with Kock pouches, unless the patient has a diagnosis of colitis-associated colorectal neoplasia before colectomy.
Long-Term Prognosis of Patients With Kock Pouches Patients with Kock pouches may have comparable quality of life (QOL) with those having IPAA [19]. However, a number of the patients with Kock pouches would need repeated revision surgery to treat the complications and maintain a functional pouch. Some may eventually have pouch excision due to refractory pouch disorders. For example, a small study of 11 patients with Kock pouches showed 5(45.5%) patients developed complications after a median follow-up of 7 years: two had pouch fistulas resulting in pouch excision; two had valve slippage and enterocutaneous fistula leading to pouch revision, and the remaining one had pouchitis [20]. In a study of 50 patients with Kock pouches, Wasmuth et al. [21] found that, 28 (56%) patients needed pouch revision and four (8%) patients required pouch excision, after a mean follow-up of 12 years. In a study of 330 patients from Cleveland Clinic by Nessar et al. [6], the 10- and 20-year pouch survivals were 87% and 77%, respectively, with a median follow-up of 11 years. They also found that the QOL measurements for patients with Kock pouches were higher on all scales than those with initial Kock pouch failure and then reverted to a Brooke ileostomy [6]. Despite the high rate of pouch revision, most patients with Kock pouches can maintain a functional pouch and have high QOL scores.
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BARNETT CONTINENT INTESTINAL RESEARVOIR The Kock pouch is associated with a high complication rate of valve slippage. Many surgical techniques have been modified over the years to solve this problem. In 1979, Spencer and Barnett [22,23] began to modify the Kock pouch with an attempt to decrease the complication of valve slippage. Barnett noted that intussusceptions often develop in a forward, isoperistaltic direction, and the weakest point of the valve is on the mesenteric side where intussusception produces a large bulk of fatty mesentery that prevented the two walls of the valve from firmly attaching to each other. They used an afferent limb of small bowel to construct a nipple valve by isoperistaltic intussusceptions, and then added this intestinal segment around the exit conduit to control valve slippage. The “living intestinal collar” supports the mesenteric side of the valve where slippage is initiated. It is believed that the intestinal collar of BCIR may help to reduce the incidence of valve slippage and fistula formation. The following is a brief technical description of the BCIR procedure. Approximately 60–65 cm of distal ileum is used during the procedures. This includes 8–10 cm for the collar, 15 cm doubled on itself to construct the pouch itself, 12 cm for the isoperistaltic valve, and 5–10 cm for the access segment to the outside. Limbs of the pouch are then doubled back on themselves and sutured with a double layer carried onto the anterior aspect of the pouch. The valve and access segment are measured and the bowel is divided proximal to this measurement. The valve segment is then intussuscepted on itself, making an isoperistaltic valve of 5 cm in length. An intestinal collar is brought through a defect in the mesentery and sutured tightly around the base of the valve. There are two main differences between the Kock pouch and BCIR: the valve and the pouch body. The Kock pouch uses an antiperistaltic valve that is held by surgical staples, while the BCIR uses an isoperistaltic valve that is held by surgical staple and a “living intestinal collar.” The other difference between the Kock pouch and BCIR is the pouch orientation. The Kock pouch is globular in orientation, which gives the pouch a naturally weak trifurcated suture line, while the BCIR uses a side-to-side orientation to eliminate the trifurcated suture line. The main structural components of BCIR include the valve, intestinal collar, pouch body, pouch inlet, and afferent limb (Figs. 17 and 18A).
FIG. 17 Anatomy of Barnett Continent Intestinal Reservoir (BCIR) pouch. (A and B) Intestinal collar-enhanced valve (green arrows); (C) endoscopic view of the valve—a pinched area from the intestinal collar (yellow arrow); and (D) lumen of BCIR body.
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FIG. 18 Healthy and diseased BCIR pouches. (A) Intact valve with an intestinal collar (green arrow); (B) stricture in the valve treated with endoscopic needle knife electroincision; (C) diffuse pouchitis; and (D) food bezoar in the lumen of the pouch.
Whether the construction of a BCIR helps to reduce the complication rate of valve slippage is controversial. Barnett et al. [24] published results on 16 consecutive isoperistaltic valve continent ileostomy reservoirs or BCIR, none of which necessitated reoperation for valve slippage within 3 years of follow-up. However, Nessar et al. [6] found that the rate of slipped valve for the subgroup of patients with isoperistaltic valve (23.7%) was similar to those in the anisoperistaltic group (25%). The authors believed that it is the physiological forces that work against the valve stabilization. Therefore, whether the valve is isoperistaltic or anisoperistaltic, the slippage may occur. In summary, BCIR is a complicated pouch to construct. Consequently, BCIR has not been popular since its introduction. Pouchitis, strictures in the valve, inlet or afferent limb, fistula, and bezoars can also occur in patients with BCIR (Fig. 18). Endoscopy is the main tool for the diagnosis. It is important to be familiar with the anatomy and landmarks of BCIR, particularly structure of intestinal collar.
DIVERTED POUCH When the pouch is separated from the fecal stream, it is called diverted pouch. Staged IPAA requires pouches to be temporally diverted, to promote the maturation of staple or suture lines. Temporary fecal diversion may be a part of pouch redo surgery or treatment for refractory pouch disorders, such as CD of the pouch and pouch-vaginal fistula. Permanent fecal diversion is performed in patients with pouch failure or a given-up pouch, for various causes, ranging from refractory pouchitis to CD of the pouch. Both temporarily diverted pouch and permanent diverted pouch can develop fecal diversionassociated adverse sequalae.
Diversion Pouchitis The patients may develop diversion pouchitis in the presence of proximal fecal diversion. The etiology of diversion pouchitis remains unclear. It is believed that the lack of short-chain fatty acids (SCFA) and other luminal nutrients in enterocyte or interference with their metabolism by alterations in gut flora may have a role [25,26].
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The diagnosis of diversion pouchitis is not straightforward. The diagnosis of diversion pouchitis should be considered if the patient with diverted pouch presents with cramping abdominal pain with a mucoid or bloody discharge. No specific pathogens have been identified in the development of diversion pouchitis. However, stool testing for specific enteric pathogens, such as cytomegalovirus (CMV), Clostridium difficile, Campylobacter species, and Escherichia coli 0157:H7, is recommended to exclude infectious etiology. Evaluation of albumin, erythrocyte sedimentation rate, and C-reactive protein (CRP) are also needed to assess disease activity. The endoscopic features of diversion pouchitis include erythema, extreme friability, edema, and granularity. In more severe cases, patients may have ulcers, filiform polyps, and stricture (Fig. 19A and B). Histopathological features are not diagnostic, but biopsies of the pouch are necessary to exclude other etiologies. The most common histopathological features of diversion pouchitis include expanded lymphoid aggregates and inflammation in the lamina propria with lymphocytes and plasma cells [27,28]. Although crypt architecture is usually preserved in mucosa of patients with diversion pouchitis, features which mimic IBD, including crypt distortion and basal lymphoplasmacytosis, may be seen [29–31]. The diversion pouchitis can be managed by surgical reanastomosis and medical therapy. Surgical reanastomosis is the first-line treatment in symptomatic patients with diversion pouchitis. In patients who have no contradiction for surgical reanastomosis, we recommend to restore the intestinal continuity as early as possible, which is an effective method to relieve the symptoms [32]. Medical therapy should only be reserved for symptomatic patients who are not candidates for surgery or in whom diversion pouchitis cannot be distinguished from active distal IBD. The diversion pouchitis can be managed by SCFA enemas, topical mesalamines, and topical glucocorticosteroids. Patients whose pouches were diverted for reasons other than UC seem to respond more consistently to SCFA enemas. In patients with underlying UC, we have used SCFA enemas in combination with topical mesalamines. The use of topical glucocorticosteroids should be limited to patients with diversion pouchitis who do not respond to or only partially respond to 2–4 weeks of therapy with SCFA enemas and topical mesalamines. A new approach with a combined probiotic and fiber supplement to generate “natural SCFA” has been investigated (Chapter 43).
FIG. 19 Diverted pouch. (A) Diversion pouchitis with friable mucosa; (B) distal pouch pinhole web-like stricture; (C) endoscopy stricturotomy over a guide wire; and (D) copious fluid collection in the lumen of the diverted pouch, which was suctioned.
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Distal Pouch Stricture Inflammation or long-term nonuse can lead to mild-to-severe stricture of the diverted pouch. Fecal diversion is performed in patients during staged IPAA or as a treatment of refractory pouch disorders. Endoscopic evaluation of a diverted ileal pouch should be performed to ensure that there is no stricture or leak before closing the stoma. Periodic endoscopic evaluation of a permanently diverted pouch is needed for diagnosis, treatment, and surveillance purpose. Common locations of pouch strictures are at the pouch outlet or anastomosis and the pouch inlet (Fig. 19B). The location, length, number, degree, and traversability of stricture should be documented. The majority of pouch strictures in diverted pouch can be safely managed endoscopically along with topical medical therapy. The main endoscopic modalities to treat diverted pouch stricture is balloon dilation and needle knife stricturotomy (Fig. 19C and D) [33]. Alternatively, the strictures can be dilated with a bougie. Unfortunately, most of the patients with periodic treatment. Definitive therapy for stricture and diversion inflammation in a diverted pouch is reestablishment of bowel continuity, if possible; or pouch excision. Pouch excision can be complicated with stump leak, perineal hernia, and small bowel obstruction. In patients who are not eligible to have stoma closure, we need balance risks and benefits of periodic endoscopic or bougie treatment of stricture as well as diversion pouchitis versus pouch excision.
Neoplasia in Diverted Pouch The risk of dysplasia or cancer in the diverted pouch appears to be low in patients with diverted pouch in the absence of a history of IBD. To date, only two cases of carcinoma in the diverted pouch were reported in the literature and both were patients with a long history of UC. One patients developed carcinoma from residual rectal mucosa [34], and the other one developed carcinoma from diverted ileal pouch body [35]. Nonetheless, surveillance for carcinoma in diverted pouch is still recommended especially for the patients who have underlying disease associated with an increased risk for carcinoma, such as a long history of IBD, family history of colon cancer, and presence precolectomy diagnosis of colitis-associated neoplasia.
Surgical Excision of Diseased Diverted Pouch Clinicians and patients with diseased diverted pouches may face a difficult decision on whether to keep the pouch permanently in situ or to excise the pouch. There has been concern on postoperative complications of pouch excision. In a study from Cleveland Clinic, the investigators identified 110 patients in their Pouch Registry undergoing pouch excision, of whom 48% of patients had CD. Persistent perineal sinus occurred in 40% patients and delayed perineal healing occurred in 51% of patients. The risk for persistent perineal sinus or delayed perineal healing was comparable between CD and non-CD patients. In addition, 4 of 15 (26.7%) patients with sphincter-preserving closure developed persistent perineal sinus [36]. In a separate study of 147 patients undergoing pouch excision from Mayo Clinic, 46 patients had the surgery for sepsis (31%) and 37 for CD (25%). Eighty-four (57%) patients experienced short-term (<30 days) postoperative complications; the most common one being surgical site infection (N = 32; 21%); and 55 (37%) patients had long-term complications (>30 days postoperatively), the most common one being return to the operating room (N = 19; 13%) largely due to perineal wounds [37]. The Cleveland Clinic team further performed a study of 136 patients with pouch failure who underwent either pouch left in situ (N = 31) or pouch excision (N = 105). In a median follow-up of 9.9 years, QOL scores were better in patients in the pouch excision group than those with pouch left in situ. Anal pain and seepage with pad use were the predominant concerns of patients in the pouch left in situ group. Despite technical difficulty, the investigators recommended pouch excision over leaving pouch in situ [38].
SUMMARY AND RECOMMENDATIONS While it spares function of the anal sphincter, the construction of a Kock pouch or BCIR is a complex procedure and requires a great technical expertise. Poor constructed continent ileostomy or change in body habitus, especially significant weight gain, can be associated with various mechanical complications. Inflammatory disorders of the continent ileostomy can also occur. Complications of the Kock pouch include nipple valve slippage, prolapse, fistula, pouchitis, pouch stricture, CD of the pouch, and pouch bezoars. Some of the complications, such as pouchitis, CD of the pouch, pouch stricture, and pouch bezoars can be managed by medical or endoscopic therapy. However, the majority of patients who developed mechanical complications of the Kock pouch or BCIR would need surgical intervention, including nipple valve revision. A majority of patients with Kock pouches or BCIR are able to maintain functional pouches and report of having a high QOL.
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Temporary fecal diversion is often needed as a part of the staged restorative proctocolectomy or as an adjunct treatment for refractory pouch disorders. Permanent fecal diversion with an ileostomy may be required for patients with pouch failure. All diverted pouches, especially permanent ones can develop diversion pouchitis. In symptomatic patients with diversion pouchitis, restoring intestinal continuity with surgical reanastomosis is the first-line treatment. The topical antiinflammatory therapy can be used for patients who are not candidates for surgery. Distal stricture is common in a long-term diverted pouch. It can be managed by endoscopic balloon dilation or endoscopic stricturotomy. In addition, diverted pouch may carry a risk for neoplasia, which requires endoscopic surveillance.
REFERENCES [1] Kock NG. Intra-abdominal “reservoir” in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal “continence” in five ileostomy patients. Arch Surg 1969;99:223–31. [2] Tulchinsky H, Hawley PR, Nicholls J. Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 2003;238:229–34. [3] Lian L, Fazio VW, Remzi FH, Shen B, Dietz D, Kiran RP. Outcomes for patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis. Dis Colon Rectum 2009;52:1409–14. [4] Handelsman JC, Gottlieb LM, Hamilton SR. Crohn’s disease as a contraindication to Kock pouch (continent ileostomy). Dis Colon Rectum 1993;36:840–3. [5] Denoya PI, Schluender SJ, Bub DS, Gorfine SR, Bauer JJ. Delayed Kock pouch nipple valve failure: is revision indicated. Dis Colon Rectum 2008;51:1544–7. [6] Nessar G, Fazio VW, Tekkis P, et al. Long-term outcome and quality of life after continent ileostomy. Dis Colon Rectum 2006;49:336–44. [7] Chen M, Shen B. Endoscopic therapy for Kock pouch strictures in patients with inflammatory bowel disease. Gastrointest Endosc 2014;80:353–9. [8] Lepisto AH, Jarvinen HJ. Durability of Kock continent ileostomy. Dis Colon Rectum 2003;46:925–8. [9] Kock NG. Present status of the continent ileostomy: surgical revision of the malfunctioning ileostomy. Dis Colon Rectum 1976;19:200–6. [10] Litle VR, Barbour S, Schrock TR, Welton ML. The continent ileostomy: long-term durability and patient satisfaction. J Gastrointest Surg 1999;3:625–32. [11] Berndtsson IE, Lindholm E, Oresland T, Hulten L. Health-related quality of life and pouch function in continent ileostomy patients: a 30-year perspective. Dis Colon Rectum 2004;47:2131–7. [12] Castillo E, Thomassie LM, Whitlow CB, Margolin DA, Malcolm J, Beck DE. Continent ileostomy: current experience. Dis Colon Rectum 2005;48:1263–8. [13] Mukewar S, Wu X, Lopez R, Shen B. Comparison of long-term outcomes of S and J pouches and continent ileostomies in ulcerative colitis patients with restorative proctocolectomy-experience in subspecialty pouch center. J Crohns Colitis 2014;8:1227–36. [14] Shen B, Remzi FH, Santisi J, Lashner BA, Brzezinski A, Fazio VW. Application of wireless capsule endoscopy for the evaluation of iron deficiency anemia in patients with ileal pouches. J Clin Gastroenterol 2008;42:897–902. [15] Jarvinen HJ, Makitie A, Sivula A. Long-term results of continent ileostomy. Int J Colorectal Dis 1986;1:40–3. [16] Lian L, Fazio V, Shen B. Endoscopic treatment for pill bezoars after continent ileostomy. Dig Liver Dis 2009;41:e26–8. [17] Wu X, Ashburn J, Shen B. Frequency, manifestations and management of bezoars in ileal pouches. Dig Endosc 2015;27:596–602. [18] Cox CL, Butts DR, Roberts MP, Wessels RA, Bailey HR. Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case. Dis Colon Rectum 1997;40:500–3. [19] Hoekstra LT, de Zwart F, Guijt M, Bakx R, Gerhards MF. Morbidity and quality of life after continent ileostomy in the Netherlands. Colorectal Dis 2009;11:719–25. [20] Wasmuth HH, Trano G, Wibe A, Endreseth BH, Rydning A, Myrvold HE. Failed pelvic pouch substituted by continent ileostomy. Colorectal Dis 2010;12:e109–13. [21] Wasmuth HH, Svinsas M, Trano G, et al. Surgical load and long-term outcome for patients with Kock continent ileostomy. Colorectal Dis 2007;9:713–7. [22] Spencer MM, Barnett WO. The continent ileal reservoir (Kock pouch): a new approach. J Enterostomal Ther 1982;9:8–13. [23] Barnett WO. Continent intestinal reservoir. South Med J 1987;80:1262–5. [24] Barnett WO. Improving the continent ileostomy. J Miss State Med Assoc 1983;24:31–4. [25] Harig JM, Soergel KH, Komorowski RA, Wood CM. Treatment of diversion colitis with short-chain-fatty acid irrigation. N Engl J Med 1989;320:23–8. [26] Roediger WE. The starved colon—diminished mucosal nutrition, diminished absorption, and colitis. Dis Colon Rectum 1990;33:858–62. [27] Glotzer DJ, Glick ME, Goldman H. Proctitis and colitis following diversion of the fecal stream. Gastroenterology 1981;80:438–41. [28] Haque S, Eisen RN, West AB. The morphologic features of diversion colitis: studies of a pediatric population with no other disease of the intestinal mucosa. Hum Pathol 1993;24:211–9. [29] Ma CK, Gottlieb C, Haas PA. Diversion colitis: a clinicopathologic study of 21 cases. Hum Pathol 1990;21:429–36. [30] Komorowski RA. Histologic spectrum of diversion colitis. Am J Surg Pathol 1990;14:548–54. [31] Whelan RL, Abramson D, Kim DS, Hashmi HF. Diversion colitis. A prospective study. Surg Endosc 1994;8:19–24. [32] Roe AM, Warren BF, Brodribb AJ, Brown C. Diversion colitis and involution of the defunctioned anorectum. Gut 1993;34:382–5. [33] Sinh P, Shen B. Endoscopic evaluation of surgically altered bowel in patients with inflammatory bowel diseases. Inflamm Bowel Dis 2015;21:1459–71.
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[34] Puthu D, Rajan N, Rao R, Rao L, Venugopal P. Carcinoma of the rectal pouch following restorative proctocolectomy. Report of a case. Dis Colon Rectum 1992;35:257–60. [35] Iwama T, Kamikawa J, Higuchi T, et al. Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case. Dis Colon Rectum 2000;43:101–4. [36] Nisar PJ, Turina M, Lavery IC, Kiran RP. Perineal wound healing following ileoanal pouch excision. J Gastrointest Surg 2014;18:200–7. [37] Lightner AL, Dattani S, Dozois EJ, Moncrief SB, Pemberton JH, Mathis KL. Pouch excision: indications and outcomes. Colorectal Dis 2017;19:912–6. [38] Kiran RP, Kirat HT, Rottoli M, Xhaja X, Remzi FH, Fazio VW. Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision. Dis Colon Rectum 2012;55:4–9.
Kock Pouch, Barnett Continent Intestinal Reservoir, and Diverted Pouch Min Chen, MD, PhD⁎, Bo Shen, MD† ⁎
Department of Gastroenterology, Zhongnan Hospital of Wuhan University, Wuhan, China, †Center for Inflammatory Bowel Diseases, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, United States
ABBREVIATIONS BCIR Barnett Continent Intestinal Reservoir BMI body mass index CARP chronic antibiotic-refractory pouchitis CD Crohn’s disease CMV cytomegalovirus CRP C-reactive protein FAP familial adenomatous polyposis IBD inflammatory bowel disease IPAA ileal pouch-anal anastomosis NSAID non-steroidal anti-inflammatory drugs QOL quality of life SCFA short chain fatty acids UC ulcerative colitis
INTRODUCTION Patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) may undergo total abdominal colectomy with a continent ileostomy instead of end ileostomy or pelvic pouch. There are two forms of continent ileostomy, namely Kock pouch and Barnett Continent Intestinal Reservoir (BCIR). The main structure of Kock pouch is an intra-abdominal pouch with a nipple valve, which can preserve the continence. BCIR is a variant of the Kock pouch where a loop of small bowel is wrapped around the pouch outlet to augment continence of ileostomy. During the construction of ileal pouch-anal anastomosis (IPAA), temporary fecal diversion is often needed as part of the staged restorative proctocolectomy. Some pouches will be permanently diverted if pouch failure occurs due to refractory pouchitis or Crohn’s disease (CD) of the pouch. In this chapter, we will also discuss the complications of diverted pouch, such as diversion pouchitis, diverted pouch stricture, and neoplasia.
KOCK POUCH Kock pouch, which was also named continent ileostomy, was first devised by Nils Kock in 1969 [1]. It was then overtaken by IPAA in the 1980s, which has an advantage of preserving the natural route of defecation. However, the Kock pouch remains to be a valuable choice for selected patients who are not candidate for IPAA or for those patients who have failed IPAA. It provided the patients substantial benefits over traditional ileostomy of not having to use an external appliance. The Kock pouch surgery is a complicated procedure, with the creation of a nipple valve being the most challenging part. The nipple valve of Kock pouch is constructed by retrograde intussusception of the efferent limb into the pouch body and stabilized by the application of three or four rows of staples. The fundus of the pouch is sewn onto the base of the exit conduit to strengthen the intussusception. The pouch is then closed and tested for integrity and continence. The exit conduit is Pouchitis and Ileal Pouch Disorders. https://doi.org/10.1016/B978-0-12-809402-0.00038-1 © 2019 Elsevier Inc. All rights reserved.
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brought through the abdominal wall and the anchoring sutures are completed by being inserted through the posterior rectus sheath and sutured. The lateral para-ileostomy space is closed and a catheter is then installed for continuous postoperative drainage. The drainage catheter is left in the lumen of pouch body for approximately 4 weeks to allow for complete healing of all suture or staple lines. Patients are normally scheduled for the first outpatient visit at several weeks postoperatively, to have their pouches tested. The anatomy and landmarks of the Kock pouch are illustrated in Figs. 1 and 2. The main components of a Kock pouch include the nipple valve, pouch body, pouch inlet, and afferent limb.
Indications and Contraindications The indication for Kock pouch includes patients who are not candidates for pelvic ileal pouches; those who failed pelvic pouches; or those who are not satisfied with conventional ileostomy. IPAA, either J- or S-pouches, preserves the natural route of defecation and is the standard surgical treatment modality for patients with UC or FAP. However, pelvic J pouch procedure is not suitable for patient with either poor anal sphincter function or involvement of the anal canal by malignancy. In addition, the IPAA is associated with a significant rate of complications, which may eventually result in pouch failure in 10%–15% of patients [2]. A conversion of a failed J ileal pouch to a continent ileostomy in highly selected patients, using old, functioned J-pouch body, or constructing with a new segment of small bowel. In a historical cohort study from Cleveland Clinic, the investigators identified 64 patients with Kock pouches which were constructed as a rescue procedure for failed J-pouches. The most common underlying diagnoses were UC (N = 44, 68.8%) and CD with perianal disease only (N = 13, 20.3%). The previous pelvic pouch was used in 16 (25%) patients. During a median follow-up of 5 years, the rate of Kock pouch dysfunction was 50% and the rate of complication rate was 60.9%, and the revision rate was 45.3%. However, the retention rate of Kock pouches was 95.3% with a median pouch survival of 4.2 (range, 1–19) years [3] (Fig. 3). Finally, convertion of a conventional end ileostomy to a continent ileostomy may be “earned” by those who are concerned their body image or have difficulties in external appliance.
FIG. 1 Anatomy of a healthy Kock pouch. (A) Valve opening on skin; (B) lumen of the nipple valve; (C) intact nipple valve on endoscopic retroflex view; and (D) afferent limb proximal to the pouch inlet.
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FIG. 2 Anatomy of Kock pouch on cross-sectional imaging. (A and B) Pouch body and nipple valve (green arrow).
FIG. 3 Conversion of J-pouch to Kock pouch. (A) Perianal disease with J-pouch; (B) normal pouch body and afferent limb of the J-pouch; (C) intact nipple valve of a Kock pouch converted from the failed J-pouch with a diagnosis of Crohn’s disease; and (D) normal body and afferent limb of the Kock pouch.
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Contradictions for the construction of the continent ileostomy are CD, limited small bowel reserve, obesity, and significant comorbidities. Handelsman et al. [4] evaluated 95 patients who underwent Kock pouch surgery for inflammatory bowel disease (IBD) and found that all 8 patients (100%) with a precotocolectomy diagnosis of CD or indeterminate colitis suffered from serious complications. In contrast, the majority of remaining 87 patients with preoperative diagnosis of UC did well with the surgery and only 17 (20%) had complications, with 6 having readily corrected complications. The construction of a de novo Kock pouch requires a 50–70 cm segment of the small intestine. Patients with anticipated risk for Kock pouch failure should not have the surgery. In addition, Kock pouch surgery should not be offered to those with a limited small bowel length due to previous surgery of bowel resection or diseased small bowel. Obese patients are not candidates for continent ileostomy, as excessive cutaneous and mesenteric fat increases the risk of complications of the valve.
Disorders of Nipple Valve of the Kock Pouch The Kock pouch surgery is a complex procedure with a high rate of complications. The majority of complication of Kock pouch is associated with the nipple valve, including valve slippage, prolapse, stricture, and fistula formation. Other complications including pouchitis, strictures at the pouch inlet or afferent limb, CD of the pouch, and pouch bezoars have also been reported. A healthy Kock pouch is largely dependent on the structure and function of the nipple valve. On the other hand, the nipple valve disorders, such as slippage, prolapse, stricture, and fistula formation are the most frequently encountered complications (Fig. 4). Denoya et al. [5] reviewed 31 patients who developed complications after having a normal Kock pouch for >10 years and found 26 (83.9%) patients with nipple valve slippage. Nipple valve slippage can be partial or total. The partial slippage makes intubation difficult or impossible, while total valve slippage can lead to pouch incontinence. Obesity or excessive weight gain is a common risk factor for nipple valve slippage (Fig. 5). Obesity or weight gain can cause fat deposition in both mesentery of the intussuscepted ileum and abdominal wall, which may act to dessuscept and weaken the
FIG. 4 Dysfunctional nipple valve of a Kock pouch. (A) Prolapsed valve; (B) ulcerated, angulated, and strictured valve due to repeat intubation; and (C) enterocutaneous fistula with internal opening at the base of the nipple valve.
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FIG. 5 Weight gain and partial valve slippage in a patient with the Kock pouch. (A) Persistent weight gain; (B) retracted opening of the valve due to obesity (green arrow); (C) long, intact valve 2 years prior; and (D) partially slippage of the valve.
valve. Nessjar et al. [6] found a 1.8-folds higher rate of valve slippage for every 5-point increase in body mass index (BMI). Therefore, the avoidance of weight gain has been a key to maintain an intact pouch valve. The stricture of Kock pouch may occur at the skin level, the nipple valve, pouch inlet, or afferent limb. The causes of skin-level stricture include too small skin opening, tissue contraction, ischemia, infection, valve retraction, and repeated trauma. The causes of non-skin-level Kock pouch strictures include CD of the pouch, surgery-related ischemia, inappropriate techniques of catheter intubation, or the use of nonsteroidal anti-inflammatory drug (NSAID). A slipped or strictured valve may cause difficulty in catheter intubation and symptom of bowel obstruction. Patient may try to place a Foley catheter to relieve obstruction. If available, urgent endoscopic intubation should be attempted to suction air and fecal contents in the pouch reservoir, followed by placement of a guide wire. Subsequently, a drainage catheter can be inserted into the pouch over the guide wire to provide longer-term drainage and to bridge more definitive therapy. Surgical stomaplasty or revision of the stoma is the main stay for the treatment of slipped nipple valve. In contrast, endoscopic treatment may be attempted first for the treatment of nipple valve stricture before surgical intervention. Endoscopic treatment modalities for nipple valve stricture include balloon dilation (Fig. 6), electroincision with stricturotomy with needle knife or isolated-tip knife (Fig. 7), and even polypectomy (Fig. 8). In the past decades, endoscopic therapy, especially needle knife stricturotomy has emerged as a valid alternative to surgery for the management of strictures in patients with Kock pouches. Our previous study of 16 consecutive patients in the Kock pouch, including 10 patients having 10 nipple valve strictures (33.3%), 12 having 12 pouch inlet strictures (40.0%), and 4 having 8 afferent limb strictures (26.7%). A total of 60 sessions of endoscopic therapy (balloon dilation and/or endoscopic stricturotomy) were performed in the 16 patients for the treatment of 90 Kock pouch strictures. During a median follow-up of 32 months (interquartile range: 12–64-months), none of the 16 patients required surgical intervention. The study showed that endoscopic therapy in treating Kock pouch strictures was feasible, effective, and safe [7]. Surgical modalities in the treatment of Kock pouch strictures include revision of the valve (Fig. 9), strictureplasty, small bowel resection/reanastomosis, and pouch excision. Although surgical therapy is effective, it is associated with significant risk for the development of postoperative complications and recurrent strictures [8]. In addition, surgical revision of Kock
FIG. 6 Nipple valve stricture at skin level. (A) Tight stricture at the skin level; (B) balloon dilation of the stricture; (C) the stricture after dilation; and (D) slipped valve.
FIG. 7 Nipple valve stricture at skin level. (A) Tight stricture at the skin level; (B) needle knife electroincision of the stricture; and (C and D) the stricture after the therapy.
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FIG. 8 Nipple valve stricture. (A) The stricture with polypoid lesions;and (B) snare “polypectomy.”
FIG. 9 Nipple valve stricture at skin level with surgical revision. (A) Before treatment; and (B) after surgical revision of the valve.
pouch stricture is technically challenging due to the complex anatomy, as well as concern about iatrogenic injury to the pouch body and adjacent visceral organs [9]. The valve prolapse occurs when the fascia defect around the efferent loop is too large (Fig. 4A). It is less common than valve slippage or stricture. Denoya et al. [5] reviewed 31 patients undergoing pouch revision who had a normal pouch for >10 years, 26 (83.9%) of them had valve slippage, while 3 (9.7%) had a prolapsed valve. In another study, Nessar et al. [6] followed 330 patients undergoing Kock pouch surgery at Cleveland Clinic, 20 (6.1%) had a prolapsed valve, while 98 (29.7%) had a valve slippage. Valve prolapse may be managed by surgical revision or repair of fascia. Fistula of the Kock pouch can develop at the nipple valve, pouch body, or the distal small bowel. The main phenotype is enterocutaneous fistula, originated from the base of nipple valve (Fig. 4C), which is believed to result from mechanical or ischemic factors. The nipple valve area, including skin, subcutaneous fat, muscle, and fascia is prone to ischemic injury. Surgical technique problems, such as sutures being placed through the walls of the valve and tied too tightly, erosion of prosthetic materials, tension of mesentery, or improper placement of nonabsorbable mesh. In the past, a Marlex or Mersilene mesh was used in patients with Kock pouches as a sling to stabilize the valve or as a fundal wrap to prevent valve prolapse. However, this technique has been shown to increase the risk or formation of fistula and was then abandoned in the 1980s. Kock pouch-related fistula can be also caused by CD of the pouch. The fistula (mainly enterocutaneous fistula) often originates from a diseased afferent limb with downstream stricture. The treatment of CD-related fistula requires multidisciplinary approach, with medical, endoscopic, and surgical therapy.
Pouchitis of the Kock Pouch The reported cumulative frequency of pouchitis in patients with Kock pouches or Kock pouchitis varies from 10% to 30% [10–12]. From our Pouch Center at Cleveland Clinic, we evaluated 36 patients with continent ileostomies (33 Kock pouches
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and 3 BCIRs), 45 patients with-S pouches and 215-J pouches. We found that the rates of chronic antibiotic-refractory pouchitis (CARP) in the Kock pouch, S-pouch, and J-pouch were 8.3%, 0%, and 13.0%, respectively. The patients with Kock pouches have a lower risk for CARP than those with J-pouches [13]. In our clinical practice, we have noticed that Kock is characterized by asymmetric inflammation in the pouch body, with the most common locations being in the pouch inlet area, the area close to nipple valve, or surface of the valve (Fig. 10). We speculate that ischemia may be a main contributor to Kock pouchitis. Patients with pouchitis usually present with watery and foul smelling intestinal discharge, requiring more frequent catheter intubation. The patients may present with fever, nausea, abdominal pain. The pouchitis of patient with Kock pouch are mostly mild and transient, and usually response to antibiotics. We have also used topical mesalamines and corticosteroids to treat antibiotic-refractory Kock pouchitis. However, patients with severe or persistent Kock pouchitis are at risk for dehydration or even acute renal failure.
CD of the Kock Pouch CD can occur in patients with Kock pouches. Of 36 patients with continent ileostomies (33 Kock pouches and 3 BCIRs), 45 patients with S-pouches, and 215 J-pouches, the cumulative frequency of CD of the pouch was 25.0%, 24.4%, and 18.6%, respectively (P = .51) [13]. There is no consensus on the diagnostic criteria. The diagnosis of CD of the Kock pouch is often based on endoscopic histopathological, and radiographic features of the pouch or perioperative findings. CD of the Kock pouch may have patchy distribution of inflammation or ulceration of the pouch body, afferent limb, stricture or fistula, or transmural inflammation (on cross-sectional imaging or postoperative histopathology) (Fig. 11). Some patients may have noncaseating granulomas on biopsy of the pouch body or afferent limb. The postoperative histopathology CD of the pouch also includes fat wrapping of the small bowel, enlarged mesenteric lymph nodes, dense adherence, stricture, fistula, and abscess. In most cases of CD of the Kock pouch, the afferent limb is involved, with
FIG. 10 Patterns of Kock pouchitis. (A) Patchy inflammation and ulcers; (B) ulcers and nodularity along the suture line and on the valve; (C) diffuse inflammation; and (D) normal afferent limb.
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FIG. 11 Crohn’s disease of the Kock pouch. (A) Inlet stricture and ulcers; and (B) tight stricture with ulcerations at the afferent limb.
inflammation, stricture, or entero-enteric fistula, or enterocutaneous fistula. CD of the pouch, including that in the Kock pouch, has been a main cause of pouch failure. In one study including 330 patients with Kock pouches, the pouch excision rate in patients with CD of the pouch was much higher than those without CD of the pouch: 26% (11/42) versus 13.9% (40/288), respectively [6]. There are no published data on the medical management of CD of the Kock pouch. We believe that aggressive medical treatment with mono or combo (with immunomodulators)—biological agents are necessary in the majority of patients, as surgical excision of the pouch is not ideal or preferred option with a risk of loss of a long segment of valuable small bowel. Antibiotic therapy may provide additional benefits. CD-associated strictures may be treated with endoscopic balloon dilation or stricturotomy (Fig. 12).
FIG. 12 Pouch inlet strictures. (A and B) Endoscopic balloon dilation; and (C and D) endoscopic needle knife stricturotomy.
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Pouch Bezoars The formation and retention of foreign body and bezoars are unique complications of a Kock pouch (Fig. 13). The bezoars can be detected by cross-sectional imaging or pouchoscopy (Fig. 14). Capsule endoscopy has been used for the evaluation of small bowel disease in patients with ileal pouches, including those with Kock pouches [14]. Therefore, patients with Kock pouches undergoing capsule endoscopy should be prepared for pouchoscopy for the retrieval of retained capsule (Fig. 13A). Jarvinen et al. [15] evaluated the complications in 76 patients with Kock pouches after a following-up of 9 years, they found that the incidence of bezoars was 9.2% (7/76). The majority of patients with bezoars can be treated with endoscopy. Our group has reported a case with nipple valve stricture and large pill bezoars in the Kock pouch body. The dietary supplement pills taken by patients were undissolved and retained in the pouch reservoir, forming bezoars. The nipple valve stricture was dilated with balloon and the retained pills were then retrieved endoscopically in a piecemeal fashion [16]. Subsequently, we reported patients with ileal pouch bezoars, including 5 (0.4%) of the 1390 patients with J-pouch and 7 (13.0%) of 54 with continent ileostomy (P < .001). Of the 12 patients, 6 (50.0%) had phytobezoars; 4 (33.3%) had lithobezoars; 1 (8.3%) had pharmabezoar; and remaining 1 (8.3%) had a retained-Jackson-Pratt drain. Ten patients (83.3%) were symptomatic, including 7 (58.3%) who presented with symptoms of partial bowel obstructive. Eleven patients (91.7%) were initially managed with endoscopic treatment. The endoscopic tools included basket (N = 9, 81.8%), RothNet® (N = 6, 54.5%), mechanical lithotripsy (N = 3, 27.3%), tripod (N = 2, 18.2%) and snares (N = 2, 18.2%). After a median number of 1 (1–3) endoscopic therapies, bezoars were successfully removed in seven patients (63.6%). Surgical intervention was needed in the remaining five patients (41.7%) [17]. We found that endoscopic mechanical lithotripsy for lithobezoar has not been effective (Fig. 14C). For large lithobezoars, we have successfully performed ultrasound and laser lithotripsy of Kock pouch bezoars in operative room with a team of gastroenterologists and urologists (Figs. 15 and 16).
FIG. 13 Foreign bodies and bezoars in Kock pouches. (A) Retained endoscopy capsule; (B) lithobezoar; (C) pharmacobezoar; and (D) phytobezoars.
FIG. 14 Kock pouch bezoar. (A and B) A calcified bezoar at the afferent limb of the pouch and (C) attempted and failed endoscopic mechanical lithotripsy.
FIG. 15 Kock pouch bezoar. (A) Setting at operating room with gastroenterology and urology teams; (B) laser lithotripter unit; and (C) probe-based lithotripter in action.
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FIG. 16 Kock pouch bezoar. (A) Ultrasound lithotripsy in action; (B) a large calcified bezoar (lithobezoar) in the pouch body; and (C) fragmented bezoar.
Risk of Pouch Neoplasia The development of carcinoma can be a concern in patients with restorative proctocolectomy. The risk of dysplasia or carcinoma in patients with Kock pouches appears to be rare, with only one case reported in the literature to date [18]. This is a 39-year-old male patient with a long history of UC. He was found to have a large adenocarcinoma involving the intussusception valve after having a Kock pouch for 17 years [18]. Therefore, routine surveillance for pouch neoplasia is not recommended in patients with Kock pouches, unless the patient has a diagnosis of colitis-associated colorectal neoplasia before colectomy.
Long-Term Prognosis of Patients With Kock Pouches Patients with Kock pouches may have comparable quality of life (QOL) with those having IPAA [19]. However, a number of the patients with Kock pouches would need repeated revision surgery to treat the complications and maintain a functional pouch. Some may eventually have pouch excision due to refractory pouch disorders. For example, a small study of 11 patients with Kock pouches showed 5(45.5%) patients developed complications after a median follow-up of 7 years: two had pouch fistulas resulting in pouch excision; two had valve slippage and enterocutaneous fistula leading to pouch revision, and the remaining one had pouchitis [20]. In a study of 50 patients with Kock pouches, Wasmuth et al. [21] found that, 28 (56%) patients needed pouch revision and four (8%) patients required pouch excision, after a mean follow-up of 12 years. In a study of 330 patients from Cleveland Clinic by Nessar et al. [6], the 10- and 20-year pouch survivals were 87% and 77%, respectively, with a median follow-up of 11 years. They also found that the QOL measurements for patients with Kock pouches were higher on all scales than those with initial Kock pouch failure and then reverted to a Brooke ileostomy [6]. Despite the high rate of pouch revision, most patients with Kock pouches can maintain a functional pouch and have high QOL scores.
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BARNETT CONTINENT INTESTINAL RESEARVOIR The Kock pouch is associated with a high complication rate of valve slippage. Many surgical techniques have been modified over the years to solve this problem. In 1979, Spencer and Barnett [22,23] began to modify the Kock pouch with an attempt to decrease the complication of valve slippage. Barnett noted that intussusceptions often develop in a forward, isoperistaltic direction, and the weakest point of the valve is on the mesenteric side where intussusception produces a large bulk of fatty mesentery that prevented the two walls of the valve from firmly attaching to each other. They used an afferent limb of small bowel to construct a nipple valve by isoperistaltic intussusceptions, and then added this intestinal segment around the exit conduit to control valve slippage. The “living intestinal collar” supports the mesenteric side of the valve where slippage is initiated. It is believed that the intestinal collar of BCIR may help to reduce the incidence of valve slippage and fistula formation. The following is a brief technical description of the BCIR procedure. Approximately 60–65 cm of distal ileum is used during the procedures. This includes 8–10 cm for the collar, 15 cm doubled on itself to construct the pouch itself, 12 cm for the isoperistaltic valve, and 5–10 cm for the access segment to the outside. Limbs of the pouch are then doubled back on themselves and sutured with a double layer carried onto the anterior aspect of the pouch. The valve and access segment are measured and the bowel is divided proximal to this measurement. The valve segment is then intussuscepted on itself, making an isoperistaltic valve of 5 cm in length. An intestinal collar is brought through a defect in the mesentery and sutured tightly around the base of the valve. There are two main differences between the Kock pouch and BCIR: the valve and the pouch body. The Kock pouch uses an antiperistaltic valve that is held by surgical staples, while the BCIR uses an isoperistaltic valve that is held by surgical staple and a “living intestinal collar.” The other difference between the Kock pouch and BCIR is the pouch orientation. The Kock pouch is globular in orientation, which gives the pouch a naturally weak trifurcated suture line, while the BCIR uses a side-to-side orientation to eliminate the trifurcated suture line. The main structural components of BCIR include the valve, intestinal collar, pouch body, pouch inlet, and afferent limb (Figs. 17 and 18A).
FIG. 17 Anatomy of Barnett Continent Intestinal Reservoir (BCIR) pouch. (A and B) Intestinal collar-enhanced valve (green arrows); (C) endoscopic view of the valve—a pinched area from the intestinal collar (yellow arrow); and (D) lumen of BCIR body.
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FIG. 18 Healthy and diseased BCIR pouches. (A) Intact valve with an intestinal collar (green arrow); (B) stricture in the valve treated with endoscopic needle knife electroincision; (C) diffuse pouchitis; and (D) food bezoar in the lumen of the pouch.
Whether the construction of a BCIR helps to reduce the complication rate of valve slippage is controversial. Barnett et al. [24] published results on 16 consecutive isoperistaltic valve continent ileostomy reservoirs or BCIR, none of which necessitated reoperation for valve slippage within 3 years of follow-up. However, Nessar et al. [6] found that the rate of slipped valve for the subgroup of patients with isoperistaltic valve (23.7%) was similar to those in the anisoperistaltic group (25%). The authors believed that it is the physiological forces that work against the valve stabilization. Therefore, whether the valve is isoperistaltic or anisoperistaltic, the slippage may occur. In summary, BCIR is a complicated pouch to construct. Consequently, BCIR has not been popular since its introduction. Pouchitis, strictures in the valve, inlet or afferent limb, fistula, and bezoars can also occur in patients with BCIR (Fig. 18). Endoscopy is the main tool for the diagnosis. It is important to be familiar with the anatomy and landmarks of BCIR, particularly structure of intestinal collar.
DIVERTED POUCH When the pouch is separated from the fecal stream, it is called diverted pouch. Staged IPAA requires pouches to be temporally diverted, to promote the maturation of staple or suture lines. Temporary fecal diversion may be a part of pouch redo surgery or treatment for refractory pouch disorders, such as CD of the pouch and pouch-vaginal fistula. Permanent fecal diversion is performed in patients with pouch failure or a given-up pouch, for various causes, ranging from refractory pouchitis to CD of the pouch. Both temporarily diverted pouch and permanent diverted pouch can develop fecal diversionassociated adverse sequalae.
Diversion Pouchitis The patients may develop diversion pouchitis in the presence of proximal fecal diversion. The etiology of diversion pouchitis remains unclear. It is believed that the lack of short-chain fatty acids (SCFA) and other luminal nutrients in enterocyte or interference with their metabolism by alterations in gut flora may have a role [25,26].
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The diagnosis of diversion pouchitis is not straightforward. The diagnosis of diversion pouchitis should be considered if the patient with diverted pouch presents with cramping abdominal pain with a mucoid or bloody discharge. No specific pathogens have been identified in the development of diversion pouchitis. However, stool testing for specific enteric pathogens, such as cytomegalovirus (CMV), Clostridium difficile, Campylobacter species, and Escherichia coli 0157:H7, is recommended to exclude infectious etiology. Evaluation of albumin, erythrocyte sedimentation rate, and C-reactive protein (CRP) are also needed to assess disease activity. The endoscopic features of diversion pouchitis include erythema, extreme friability, edema, and granularity. In more severe cases, patients may have ulcers, filiform polyps, and stricture (Fig. 19A and B). Histopathological features are not diagnostic, but biopsies of the pouch are necessary to exclude other etiologies. The most common histopathological features of diversion pouchitis include expanded lymphoid aggregates and inflammation in the lamina propria with lymphocytes and plasma cells [27,28]. Although crypt architecture is usually preserved in mucosa of patients with diversion pouchitis, features which mimic IBD, including crypt distortion and basal lymphoplasmacytosis, may be seen [29–31]. The diversion pouchitis can be managed by surgical reanastomosis and medical therapy. Surgical reanastomosis is the first-line treatment in symptomatic patients with diversion pouchitis. In patients who have no contradiction for surgical reanastomosis, we recommend to restore the intestinal continuity as early as possible, which is an effective method to relieve the symptoms [32]. Medical therapy should only be reserved for symptomatic patients who are not candidates for surgery or in whom diversion pouchitis cannot be distinguished from active distal IBD. The diversion pouchitis can be managed by SCFA enemas, topical mesalamines, and topical glucocorticosteroids. Patients whose pouches were diverted for reasons other than UC seem to respond more consistently to SCFA enemas. In patients with underlying UC, we have used SCFA enemas in combination with topical mesalamines. The use of topical glucocorticosteroids should be limited to patients with diversion pouchitis who do not respond to or only partially respond to 2–4 weeks of therapy with SCFA enemas and topical mesalamines. A new approach with a combined probiotic and fiber supplement to generate “natural SCFA” has been investigated (Chapter 43).
FIG. 19 Diverted pouch. (A) Diversion pouchitis with friable mucosa; (B) distal pouch pinhole web-like stricture; (C) endoscopy stricturotomy over a guide wire; and (D) copious fluid collection in the lumen of the diverted pouch, which was suctioned.
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Distal Pouch Stricture Inflammation or long-term nonuse can lead to mild-to-severe stricture of the diverted pouch. Fecal diversion is performed in patients during staged IPAA or as a treatment of refractory pouch disorders. Endoscopic evaluation of a diverted ileal pouch should be performed to ensure that there is no stricture or leak before closing the stoma. Periodic endoscopic evaluation of a permanently diverted pouch is needed for diagnosis, treatment, and surveillance purpose. Common locations of pouch strictures are at the pouch outlet or anastomosis and the pouch inlet (Fig. 19B). The location, length, number, degree, and traversability of stricture should be documented. The majority of pouch strictures in diverted pouch can be safely managed endoscopically along with topical medical therapy. The main endoscopic modalities to treat diverted pouch stricture is balloon dilation and needle knife stricturotomy (Fig. 19C and D) [33]. Alternatively, the strictures can be dilated with a bougie. Unfortunately, most of the patients with periodic treatment. Definitive therapy for stricture and diversion inflammation in a diverted pouch is reestablishment of bowel continuity, if possible; or pouch excision. Pouch excision can be complicated with stump leak, perineal hernia, and small bowel obstruction. In patients who are not eligible to have stoma closure, we need balance risks and benefits of periodic endoscopic or bougie treatment of stricture as well as diversion pouchitis versus pouch excision.
Neoplasia in Diverted Pouch The risk of dysplasia or cancer in the diverted pouch appears to be low in patients with diverted pouch in the absence of a history of IBD. To date, only two cases of carcinoma in the diverted pouch were reported in the literature and both were patients with a long history of UC. One patients developed carcinoma from residual rectal mucosa [34], and the other one developed carcinoma from diverted ileal pouch body [35]. Nonetheless, surveillance for carcinoma in diverted pouch is still recommended especially for the patients who have underlying disease associated with an increased risk for carcinoma, such as a long history of IBD, family history of colon cancer, and presence precolectomy diagnosis of colitis-associated neoplasia.
Surgical Excision of Diseased Diverted Pouch Clinicians and patients with diseased diverted pouches may face a difficult decision on whether to keep the pouch permanently in situ or to excise the pouch. There has been concern on postoperative complications of pouch excision. In a study from Cleveland Clinic, the investigators identified 110 patients in their Pouch Registry undergoing pouch excision, of whom 48% of patients had CD. Persistent perineal sinus occurred in 40% patients and delayed perineal healing occurred in 51% of patients. The risk for persistent perineal sinus or delayed perineal healing was comparable between CD and non-CD patients. In addition, 4 of 15 (26.7%) patients with sphincter-preserving closure developed persistent perineal sinus [36]. In a separate study of 147 patients undergoing pouch excision from Mayo Clinic, 46 patients had the surgery for sepsis (31%) and 37 for CD (25%). Eighty-four (57%) patients experienced short-term (<30 days) postoperative complications; the most common one being surgical site infection (N = 32; 21%); and 55 (37%) patients had long-term complications (>30 days postoperatively), the most common one being return to the operating room (N = 19; 13%) largely due to perineal wounds [37]. The Cleveland Clinic team further performed a study of 136 patients with pouch failure who underwent either pouch left in situ (N = 31) or pouch excision (N = 105). In a median follow-up of 9.9 years, QOL scores were better in patients in the pouch excision group than those with pouch left in situ. Anal pain and seepage with pad use were the predominant concerns of patients in the pouch left in situ group. Despite technical difficulty, the investigators recommended pouch excision over leaving pouch in situ [38].
SUMMARY AND RECOMMENDATIONS While it spares function of the anal sphincter, the construction of a Kock pouch or BCIR is a complex procedure and requires a great technical expertise. Poor constructed continent ileostomy or change in body habitus, especially significant weight gain, can be associated with various mechanical complications. Inflammatory disorders of the continent ileostomy can also occur. Complications of the Kock pouch include nipple valve slippage, prolapse, fistula, pouchitis, pouch stricture, CD of the pouch, and pouch bezoars. Some of the complications, such as pouchitis, CD of the pouch, pouch stricture, and pouch bezoars can be managed by medical or endoscopic therapy. However, the majority of patients who developed mechanical complications of the Kock pouch or BCIR would need surgical intervention, including nipple valve revision. A majority of patients with Kock pouches or BCIR are able to maintain functional pouches and report of having a high QOL.
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Temporary fecal diversion is often needed as a part of the staged restorative proctocolectomy or as an adjunct treatment for refractory pouch disorders. Permanent fecal diversion with an ileostomy may be required for patients with pouch failure. All diverted pouches, especially permanent ones can develop diversion pouchitis. In symptomatic patients with diversion pouchitis, restoring intestinal continuity with surgical reanastomosis is the first-line treatment. The topical antiinflammatory therapy can be used for patients who are not candidates for surgery. Distal stricture is common in a long-term diverted pouch. It can be managed by endoscopic balloon dilation or endoscopic stricturotomy. In addition, diverted pouch may carry a risk for neoplasia, which requires endoscopic surveillance.
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[34] Puthu D, Rajan N, Rao R, Rao L, Venugopal P. Carcinoma of the rectal pouch following restorative proctocolectomy. Report of a case. Dis Colon Rectum 1992;35:257–60. [35] Iwama T, Kamikawa J, Higuchi T, et al. Development of invasive adenocarcinoma in a long-standing diverted ileal J-pouch for ulcerative colitis: report of a case. Dis Colon Rectum 2000;43:101–4. [36] Nisar PJ, Turina M, Lavery IC, Kiran RP. Perineal wound healing following ileoanal pouch excision. J Gastrointest Surg 2014;18:200–7. [37] Lightner AL, Dattani S, Dozois EJ, Moncrief SB, Pemberton JH, Mathis KL. Pouch excision: indications and outcomes. Colorectal Dis 2017;19:912–6. [38] Kiran RP, Kirat HT, Rottoli M, Xhaja X, Remzi FH, Fazio VW. Permanent ostomy after ileoanal pouch failure: pouch in situ or pouch excision. Dis Colon Rectum 2012;55:4–9.