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The continent ileostomy: diagnosis and treatment of problems by means of operative fiberoptic endoscopy
The continent ileostomy: diagnosis and treatment of problems by means of operative fiberoptic endoscopy Jerome D. Waye, Isadore Kreel, Joel Bauer, Irwin M. Gelernt,
MD MD MD MD
New York, New York
About 1 in 10 patients with internal pouch ileostomies may develop incontinence. Of 4 incontinent patients in this study, operative endoscopy has restored continence in 2 and has markedly improved symptoms in a third. Foreign bodies retained within the ileostomy pouch may be successfully removed endoscopically. All patients with an incontinent Kock ileostomy pouch should be endoscoped for adequate assessment and treatment.
I
ncontinence of air and i leal contents is the major problem in the patient who has a "continent ileostomy:' Continence in the reservoir ileostomy as devised by Kock' depends to a large extent on the presence of an intussuscepted portion of the ileal outflow tract, produci ng a valve-effect (Figure 1a). It has been the opinion of surgeons that incontinence is associated with a loss of this valve-like mechanism. We have inspected several normally functioning continent ileostomies in an attempt to ascertain the normal anatomy of the pouch, and we have examined patients with incontinence problems: Through the use of endoscopy we have establ ished that not all problems of continence are related to a loss of the valve mechanism. When a loss of length of the intussuscepted valve occurs, we have been able to recreate a functioning valve in a patient whose sutures had given way. One patient is included in this study from whom a pouch foreign body was removed. CASE MATERIAL Between 1972 and 1975, 54 patients have had continent ileostomies performed utilizing the Kock technique',2 with the Gelernt modification.3 All of these patients have been followed for 8 months to 3 Y2 years. A number of additional patients have had internal ileostomies constructed but were not included in this study as their follow-up was too short for adequate assessment of continence. Five patients developed incontinence for gas, stool, or both. Only 1 of 3 patients with fecal incontinence found it necessary to
wear a stomal appliance. Four of these 5 patients were endoscoped in an attempt to ascertain and treat the cause of incontinence. Two patients have had difficulty intubating the internal pouch with the plastic catheter used for periodic emptying. One of these patients used a specially fashioned rubber tipped catheter to negotiate the tortuous outflow tract; the retrieval of this dislodged tip will be described in this report, TECHNIQUES All endoscopies were performed using upper intestinal endoscopes manufactured by Olympus. Among those instruments used were the pediatric gastroscope (GIF-P), the direct forward-viewing gastroscope (GIF-D3), and the oblique-viewing endoscope (GIF-K). Before endoscopy, patients were given a clear liquid diet for 24 hours, then nothing by mouth 8 hours previous to the procedure. The pouch was emptied by the patient immediately before the endoscopic procedure. Sedation was not necessary. All of the instruments were passed under direct vision through the ileal outflow tract into the pouch. Endoscopy should be preceded by digital examination. If the index finger cannot be passed into the ileal stoma, the standard-sized endoscope cannot be utilized, and the pediatric instrument should be used. In almost every instance, however, the stoma is large enough to accept the standard gastroscope. Because of the tortuosity of some tracts, patients
From the departments of Medicine and Surgery, The Mount Sinai School of Medicine of the City University of New York, New York. Reprint requests: Jerome D. Waye, MD, 1065 Park Avenue, New York, NY 10028.
196
GASTROINTESTINAL ENDOSCOPY
are frequently helpful in guiding the endoscope into the pouch. Endoscopies were performed with the patient recumbent. After inspection of the pouch, a U-turn maneuver was always performed so that the tip of the instrument was directed toward the inverted nipple and the shaft of the instrument could be seen entering the pouch through the nipple. Having used a variety of instruments for ileoscopy, we feel thatthe GI F-K (30 0 oblique-view) gastroscope is the instrument of choice inasmuch as excellent visualization of the entire nipple can be obtained when the scope is retroflexed. NORMAL ENDOSCOPIC ANATOMY OF THE CONTINENT ILEOSTOMY POUCH The tip of the instrument should be placed in the ileostomy stoma and guided under direct vision into the ileal pouch. Frequently several adjustments of the tip-deflection control mechanism must be made during intubation because of outflow tract tortuosity. By continuous air
insufflation, the outflow tract lumen can usually be visualized as the instrument is advanced. Whitish, superficial ulcerations may be seen at angulated segments of the outflow tract caused by self-inflicted catheter-trauma, but these are usually of no importance. Upon traversing the 5 cm to 6 cm outflow tract, the air-distended pouch will be entered. The pouch configuration is similar to that of the antrum of the stomach; valvulae conniventes cannot be identified, having been lost within 1 month of pouch construction:' The normal pouch following emptying contains less than 30 ml of semiliquid stool. The mucosa is usually flat, but some rugal convolutions may be present. Neither erosion, ulceration, nor friability is normally seen in the pouch. Several long suture lines can be identified running circumferentially. The ileal inflow tract is located adjacent to the outflow tract and often cannot be identified unless the instrument is retroflexed in a U-turn maneuver. The ileal inflow tract has no valve-mechanism, and a few cen'-
Figure 1. (A) I/eal pouch partially fashioned and ready to be closed, The edge at the lower left will be sutured to the ''V''-shaped notch at the upper right portion of the picture. The free edges will be folded-over, and sutured to each other, creating the pouch. The inflow tract is at the upper portion of the picture, and the outflow tract, with its intussuscepted nipple is shown with its catheter in place. Multiple sutures are placed through the inverted nipple to create adhesions between the invaginated serosal surfaces. The cut end of ileum at the lower right portion of the slide is sutured flush to the skin wall. (B) View of the re-created "nipple" by endoscopic retroflexion, Maximal elongation of the nipple has been achieved by maximal introduction of the endoscope. The needle-injector is shown piercing the nipple-mucosa. (C) Retroflexion view of whitish bleb formed following injection of 0.5 mL hypertonic g/uCl;Jse into "nipple" mucosa. Bleeding occurred following introduction of needle into mucosa. (D) Adhesive band from edge of nipple to suture line. This band fixed the nipple in a bent position causing incontinence. VOLUME 23, NO.4, 1977
197
timeters of ileum may be seen through the inflow orifice. The U-turn maneuver is easily accomplished by flexing the tip (of any endoscope utilized) in a maximally "up" position and advancing the instrument into the pouch. The inner aspect of the intussuscepted valve (nipple) can be identified as a freely movable tube which surrounds the endoscope and is 3 cm to 4 cm in length. By moving the external portion of the endoscope to the right or left, the nipple can be observed to rock back and forth freely following the movement of the endoscope. As the endoscope is moved back and forth through the stoma, the nipple is seen to retain a fixed length and does not shorten or elongate as the instrument is advanced and withdrawn.
ASSESSMENT AND TREATMENT OF POUCH PROBLEMS (1) Incontinence Due to Loss of Nipple Length. In some patients with incontinence, the inflow tract nipple as observed during endoscopic retroflexion may be seen to elongate and shorten as the endoscope is moved in and out of the stoma. This phenomenon is caused by slidingofthe two full thickness layers of ileum which constitute the internal nipple. Sliding is caused by a loss of the adhesions created during pouch construction between the 2 apposing layers of inverted ileal serosa. Treatment of this problem was accomplished in 1 patient using an innovative experimental technique. A patient with fecal incontinence revealed the characteristic finding of elongation and shortening of the nipple as the endoscope was manipulated in the pouch. Following a complete explanation of the procedure and with the fully informed consent of the patient, a needle-injector was passed through the GIF-K endoscope, and multiple injections of 50% glucose (0.5 ml/injectionJ were delivered deep into the nipple while the scope was introduced maximally, elongating the internal portion of the nipple (Figure 7 b, c). After the instrument was withdrawn, a plastic catheter was inserted into the inflow tract and taped in place to maintain internal elongation of the nipple. The catheter remained in situ for 2 weeks until the inflammatory response to hypertonic glucose injections subsided. Upon removal of the "stent" catheter, continence was re-established, and the patient has remained continent during a year of follow-up. One patient was observed to have a fairly flat internal nipple, which did not elongate as the instrument was introduced. This patient may require operative the.:apy to restore the length of the original valve-like nipple as endoscopic reconstitution was not possible. (2) Incontinence Due to Adhesive Band. In 2 patients an adhesive band was seen to have formed between a suture line and one edge of the nipple (Figure 7d). This band held the nipple in a fixed position so that gas and fluid accumulating within the pouch could not exert circumferential pressure on the nipple. In both of these patients it was assumed that the band was responsible for incontinence, and the band was severed with a wire snare device passed through the endoscopic instrument. Electrocoagulation current was employed similar to that used for endoscopic polypectomy. In 1 patient, the nipple was seen to immediately spring erect, and this patient, previously incontinent during the stress of intercourse, has been completely continent for the past 9 months. The second patient, who had a thick fibrous band, has shown moderate improvement in her incontinence but still wears extra dressings because of occasional loss of gas during stress. 198
(3) Removal of Foreign Body from Pouch. During an emptying maneuver, a patient lost the flexible rubber tip of a specially fashioned catheter inside the ileostomy pouch. The special catheter was made because this patient had an especially tortuous tract and continually traumatized herself with the standard plastic catheter during intubation. On endoscopy, a superficial erosion was seen at the site of angulation of the inflow tract. Within the pouch, a 3 cm x 1 cm rubber catheter tip was found. The biopsy forceps were too small to grasp the edge of the tip, and a wire snare of the type used for polypectomy slipped off the small object. The wire snare was then taped to the outer aspect of the endoscope, and a biopsy forceps was passed through the endoscope. The forceps was manipulated into the holes at the tip ofthe catheter, traversing it through-and-through. The wire loop was then passed over the outstretched jaws of the biopsy forceps and tightened. With the biopsy forceps held in an open position and the wire snare snugged up tight on the shaft of the biopsy forceps just proximal to the open jaws, the entire apparatus was removed along with the rubber tip. The patient suffered no ill effects from this endoscopic removal. DISCUSSION Most patients with an internal ileostomy are completely continent of both air and feces. Patients with a properly functioning continent ileostomy need only empty the pouch every 6 to 8 hours and without wearing an external appliance, may seal the skin-level stoma with a small adjesive plaster. When incontinence occurs, the patient may have difficulty wearing an external ileostomy appliance since the stoma is flush with the skin surface. Most patients either suffer the embarrassment of leakage of gas or stool or have an operative revision of the internal, continence-producing nipple. The technique detailed herein represents an endosopic approach to problems of ileostomy incontinence, and in 3 out of 4 patients with incontinence the symptoms were either cured or ameliorated by operative endoscopy. Before the use of endoscopy for the evaluation of incontinence, it was thought that the problem was invariably caused by a shortening of the nipple length. Although this indeed may be the case, 2 of the 4 patients with incontinence in this study had their symptoms wholly or partially caused by the formation of an adhesive band from one of the suture lines to the edge of the nipple. Both these patients were treated by endoscopic lysis of the band. Continence was restored in a third patient by the endoscopic injection of hypertonic glucose into the walls of the nipple with reconstitution of the valve mechanism. All p,atients who have incontinence with an internally fashioned ileostomy should be endoscoped for elucidation of the primary problem causing loss of continence. Successful operative endoscopy may prevent a secondary operative procedure in some patients. Foreign bodies retained within the ileostomy pouch may be successfully removed. Operative endoscopy constitutes a safe, effective, and simple method of assessing and treating incontinence in the patient with an internal ileostomy.
REFERENCES 1. KOCK NG: Ileostomy without external appliance. Ann Surg 173:545, 1971 2. KOCK NG: Continent ileostomy. Prog in Surg (Karger, Basel) 12:180, 1973 3. GElERNT 1M, BAUER JJ, KREEl I: The continent ileostomy in the pediatric patient. J Pediat Surg (in press) 4. WAVE JD, GELERNT 1M, KREEl I: Endoscopy of the continent ileostomy (abstract). Gastroenterology 66:829, 1974 GASTROINTESTINAL ENDOSCOPY
MD MD MD MD
New York, New York
About 1 in 10 patients with internal pouch ileostomies may develop incontinence. Of 4 incontinent patients in this study, operative endoscopy has restored continence in 2 and has markedly improved symptoms in a third. Foreign bodies retained within the ileostomy pouch may be successfully removed endoscopically. All patients with an incontinent Kock ileostomy pouch should be endoscoped for adequate assessment and treatment.
I
ncontinence of air and i leal contents is the major problem in the patient who has a "continent ileostomy:' Continence in the reservoir ileostomy as devised by Kock' depends to a large extent on the presence of an intussuscepted portion of the ileal outflow tract, produci ng a valve-effect (Figure 1a). It has been the opinion of surgeons that incontinence is associated with a loss of this valve-like mechanism. We have inspected several normally functioning continent ileostomies in an attempt to ascertain the normal anatomy of the pouch, and we have examined patients with incontinence problems: Through the use of endoscopy we have establ ished that not all problems of continence are related to a loss of the valve mechanism. When a loss of length of the intussuscepted valve occurs, we have been able to recreate a functioning valve in a patient whose sutures had given way. One patient is included in this study from whom a pouch foreign body was removed. CASE MATERIAL Between 1972 and 1975, 54 patients have had continent ileostomies performed utilizing the Kock technique',2 with the Gelernt modification.3 All of these patients have been followed for 8 months to 3 Y2 years. A number of additional patients have had internal ileostomies constructed but were not included in this study as their follow-up was too short for adequate assessment of continence. Five patients developed incontinence for gas, stool, or both. Only 1 of 3 patients with fecal incontinence found it necessary to
wear a stomal appliance. Four of these 5 patients were endoscoped in an attempt to ascertain and treat the cause of incontinence. Two patients have had difficulty intubating the internal pouch with the plastic catheter used for periodic emptying. One of these patients used a specially fashioned rubber tipped catheter to negotiate the tortuous outflow tract; the retrieval of this dislodged tip will be described in this report, TECHNIQUES All endoscopies were performed using upper intestinal endoscopes manufactured by Olympus. Among those instruments used were the pediatric gastroscope (GIF-P), the direct forward-viewing gastroscope (GIF-D3), and the oblique-viewing endoscope (GIF-K). Before endoscopy, patients were given a clear liquid diet for 24 hours, then nothing by mouth 8 hours previous to the procedure. The pouch was emptied by the patient immediately before the endoscopic procedure. Sedation was not necessary. All of the instruments were passed under direct vision through the ileal outflow tract into the pouch. Endoscopy should be preceded by digital examination. If the index finger cannot be passed into the ileal stoma, the standard-sized endoscope cannot be utilized, and the pediatric instrument should be used. In almost every instance, however, the stoma is large enough to accept the standard gastroscope. Because of the tortuosity of some tracts, patients
From the departments of Medicine and Surgery, The Mount Sinai School of Medicine of the City University of New York, New York. Reprint requests: Jerome D. Waye, MD, 1065 Park Avenue, New York, NY 10028.
196
GASTROINTESTINAL ENDOSCOPY
are frequently helpful in guiding the endoscope into the pouch. Endoscopies were performed with the patient recumbent. After inspection of the pouch, a U-turn maneuver was always performed so that the tip of the instrument was directed toward the inverted nipple and the shaft of the instrument could be seen entering the pouch through the nipple. Having used a variety of instruments for ileoscopy, we feel thatthe GI F-K (30 0 oblique-view) gastroscope is the instrument of choice inasmuch as excellent visualization of the entire nipple can be obtained when the scope is retroflexed. NORMAL ENDOSCOPIC ANATOMY OF THE CONTINENT ILEOSTOMY POUCH The tip of the instrument should be placed in the ileostomy stoma and guided under direct vision into the ileal pouch. Frequently several adjustments of the tip-deflection control mechanism must be made during intubation because of outflow tract tortuosity. By continuous air
insufflation, the outflow tract lumen can usually be visualized as the instrument is advanced. Whitish, superficial ulcerations may be seen at angulated segments of the outflow tract caused by self-inflicted catheter-trauma, but these are usually of no importance. Upon traversing the 5 cm to 6 cm outflow tract, the air-distended pouch will be entered. The pouch configuration is similar to that of the antrum of the stomach; valvulae conniventes cannot be identified, having been lost within 1 month of pouch construction:' The normal pouch following emptying contains less than 30 ml of semiliquid stool. The mucosa is usually flat, but some rugal convolutions may be present. Neither erosion, ulceration, nor friability is normally seen in the pouch. Several long suture lines can be identified running circumferentially. The ileal inflow tract is located adjacent to the outflow tract and often cannot be identified unless the instrument is retroflexed in a U-turn maneuver. The ileal inflow tract has no valve-mechanism, and a few cen'-
Figure 1. (A) I/eal pouch partially fashioned and ready to be closed, The edge at the lower left will be sutured to the ''V''-shaped notch at the upper right portion of the picture. The free edges will be folded-over, and sutured to each other, creating the pouch. The inflow tract is at the upper portion of the picture, and the outflow tract, with its intussuscepted nipple is shown with its catheter in place. Multiple sutures are placed through the inverted nipple to create adhesions between the invaginated serosal surfaces. The cut end of ileum at the lower right portion of the slide is sutured flush to the skin wall. (B) View of the re-created "nipple" by endoscopic retroflexion, Maximal elongation of the nipple has been achieved by maximal introduction of the endoscope. The needle-injector is shown piercing the nipple-mucosa. (C) Retroflexion view of whitish bleb formed following injection of 0.5 mL hypertonic g/uCl;Jse into "nipple" mucosa. Bleeding occurred following introduction of needle into mucosa. (D) Adhesive band from edge of nipple to suture line. This band fixed the nipple in a bent position causing incontinence. VOLUME 23, NO.4, 1977
197
timeters of ileum may be seen through the inflow orifice. The U-turn maneuver is easily accomplished by flexing the tip (of any endoscope utilized) in a maximally "up" position and advancing the instrument into the pouch. The inner aspect of the intussuscepted valve (nipple) can be identified as a freely movable tube which surrounds the endoscope and is 3 cm to 4 cm in length. By moving the external portion of the endoscope to the right or left, the nipple can be observed to rock back and forth freely following the movement of the endoscope. As the endoscope is moved back and forth through the stoma, the nipple is seen to retain a fixed length and does not shorten or elongate as the instrument is advanced and withdrawn.
ASSESSMENT AND TREATMENT OF POUCH PROBLEMS (1) Incontinence Due to Loss of Nipple Length. In some patients with incontinence, the inflow tract nipple as observed during endoscopic retroflexion may be seen to elongate and shorten as the endoscope is moved in and out of the stoma. This phenomenon is caused by slidingofthe two full thickness layers of ileum which constitute the internal nipple. Sliding is caused by a loss of the adhesions created during pouch construction between the 2 apposing layers of inverted ileal serosa. Treatment of this problem was accomplished in 1 patient using an innovative experimental technique. A patient with fecal incontinence revealed the characteristic finding of elongation and shortening of the nipple as the endoscope was manipulated in the pouch. Following a complete explanation of the procedure and with the fully informed consent of the patient, a needle-injector was passed through the GIF-K endoscope, and multiple injections of 50% glucose (0.5 ml/injectionJ were delivered deep into the nipple while the scope was introduced maximally, elongating the internal portion of the nipple (Figure 7 b, c). After the instrument was withdrawn, a plastic catheter was inserted into the inflow tract and taped in place to maintain internal elongation of the nipple. The catheter remained in situ for 2 weeks until the inflammatory response to hypertonic glucose injections subsided. Upon removal of the "stent" catheter, continence was re-established, and the patient has remained continent during a year of follow-up. One patient was observed to have a fairly flat internal nipple, which did not elongate as the instrument was introduced. This patient may require operative the.:apy to restore the length of the original valve-like nipple as endoscopic reconstitution was not possible. (2) Incontinence Due to Adhesive Band. In 2 patients an adhesive band was seen to have formed between a suture line and one edge of the nipple (Figure 7d). This band held the nipple in a fixed position so that gas and fluid accumulating within the pouch could not exert circumferential pressure on the nipple. In both of these patients it was assumed that the band was responsible for incontinence, and the band was severed with a wire snare device passed through the endoscopic instrument. Electrocoagulation current was employed similar to that used for endoscopic polypectomy. In 1 patient, the nipple was seen to immediately spring erect, and this patient, previously incontinent during the stress of intercourse, has been completely continent for the past 9 months. The second patient, who had a thick fibrous band, has shown moderate improvement in her incontinence but still wears extra dressings because of occasional loss of gas during stress. 198
(3) Removal of Foreign Body from Pouch. During an emptying maneuver, a patient lost the flexible rubber tip of a specially fashioned catheter inside the ileostomy pouch. The special catheter was made because this patient had an especially tortuous tract and continually traumatized herself with the standard plastic catheter during intubation. On endoscopy, a superficial erosion was seen at the site of angulation of the inflow tract. Within the pouch, a 3 cm x 1 cm rubber catheter tip was found. The biopsy forceps were too small to grasp the edge of the tip, and a wire snare of the type used for polypectomy slipped off the small object. The wire snare was then taped to the outer aspect of the endoscope, and a biopsy forceps was passed through the endoscope. The forceps was manipulated into the holes at the tip ofthe catheter, traversing it through-and-through. The wire loop was then passed over the outstretched jaws of the biopsy forceps and tightened. With the biopsy forceps held in an open position and the wire snare snugged up tight on the shaft of the biopsy forceps just proximal to the open jaws, the entire apparatus was removed along with the rubber tip. The patient suffered no ill effects from this endoscopic removal. DISCUSSION Most patients with an internal ileostomy are completely continent of both air and feces. Patients with a properly functioning continent ileostomy need only empty the pouch every 6 to 8 hours and without wearing an external appliance, may seal the skin-level stoma with a small adjesive plaster. When incontinence occurs, the patient may have difficulty wearing an external ileostomy appliance since the stoma is flush with the skin surface. Most patients either suffer the embarrassment of leakage of gas or stool or have an operative revision of the internal, continence-producing nipple. The technique detailed herein represents an endosopic approach to problems of ileostomy incontinence, and in 3 out of 4 patients with incontinence the symptoms were either cured or ameliorated by operative endoscopy. Before the use of endoscopy for the evaluation of incontinence, it was thought that the problem was invariably caused by a shortening of the nipple length. Although this indeed may be the case, 2 of the 4 patients with incontinence in this study had their symptoms wholly or partially caused by the formation of an adhesive band from one of the suture lines to the edge of the nipple. Both these patients were treated by endoscopic lysis of the band. Continence was restored in a third patient by the endoscopic injection of hypertonic glucose into the walls of the nipple with reconstitution of the valve mechanism. All p,atients who have incontinence with an internally fashioned ileostomy should be endoscoped for elucidation of the primary problem causing loss of continence. Successful operative endoscopy may prevent a secondary operative procedure in some patients. Foreign bodies retained within the ileostomy pouch may be successfully removed. Operative endoscopy constitutes a safe, effective, and simple method of assessing and treating incontinence in the patient with an internal ileostomy.
REFERENCES 1. KOCK NG: Ileostomy without external appliance. Ann Surg 173:545, 1971 2. KOCK NG: Continent ileostomy. Prog in Surg (Karger, Basel) 12:180, 1973 3. GElERNT 1M, BAUER JJ, KREEl I: The continent ileostomy in the pediatric patient. J Pediat Surg (in press) 4. WAVE JD, GELERNT 1M, KREEl I: Endoscopy of the continent ileostomy (abstract). Gastroenterology 66:829, 1974 GASTROINTESTINAL ENDOSCOPY