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The kock ileostomy reservoir: An experimental study of the value of reservoir fixation in improving valve stability and facilitating catheterization
JOURNAL
OF SURGICAL
31, 490-495 (1981)
RESEARCH
The Kock lleostomy Reservoir: An Experimental Study of the Value of Reservoir Fixation in Improving Valve Stability and Facilitating Catheterization FRCS, AND S. T. D. MCKELVEY,
BRIAN CRANLEY,
MCH.,
FRCS
Department of Surgery, The Queen’s University, Belfast, Northern Ireland Submitted for publication January 28, 1981 In an experimental study on dogs the importance of fixing the Kock continent ileostomy reservoir to the anterior abdominal wall was evaluated. It was found that this encouraged fibrous union to develop between reservoir and abdominal wall. This played an important role in holding the reservoir in its original position, and helped to prevent extrusion of the intussusception valve. Catheterization of the reservoir was significantly easier when this procedure was employed.
INTRODUCTION
The continent ileostomy reservoir was devised by Nils Kock of Sweden as an alternative to the conventional ileostomy with all its inherent problems. The reservoir is constructed by plicating two 15cm loops of terminal ileum together (Fig. 1A). The ileum is then opened to form a U-shaped plate (Fig. 1B) and an antiperistaltic intussusception valve measuring 3-4 cm in length is made from the distal ileal loop (Fig. IC). The apex of the U is folded upon itself and the edges are sutured, thus forming a reservoir which, according to Kock, is amotile (Fig. 1D). The distal loop is then brought through the abdominal wall as a stoma and the reservoir is emptied by self-catheterization. This system has been used with increasing frequency throughout the United States and many parts of Europe over the past 10 years. It eliminates the need for an appliance, reduces the incidence of peristomal skin excoriation, and allows the patient much greater freedom in work and leisure activities. There have, however, been many serious problems associated with this operation. The most intractible has been the tendency for the intussusception valve to extrude along the mesenteric border leading to difficulty with catheterization and incontinence [3 J. 0022-4804181/ 120490-06301.00/O Copyright 0 1981 by Academic Press. Inc. All rights of reproduction in any form rcscrvcd.
Since the inception of this operation workers have been attempting to find ways of preventing extrusion by modifying valve design. The problem, however, remains. It is generally felt that fixation of the reservoir to the abdominal wall is probably important in facilitating catheterization and helping to prevent valve extrusion. Its importance, however, has never been scientifically assessed. We have studied the value of this procedure in improving valve stability and facilitating catheterization experimentally under controlled laboratory conditions. MATERIALS
AND METHODS
A Kock ileostomy reservoir was fashioned as described above in each of 10 dogs. The animals used were 1- to 2-year-old healthy greyhound bitches (weight range 20-30 kg, mean 24.2 kg). A 3-cm intussusception valve was constructed in each reservoir and its final length at the time of construction was measured by taking the mean of both mesenteric and antimesenteric borders. All valves were of identical design and were made according to the method described by Madigan [6] of applying deep seromuscular diathermy to the opposing layers to encourage fibrous adhesion and holding the intussusception in position with 12 interrupted seromuscular silk sutures. The reservoirs were
490
CRANLEY
AND
MC KELVEY:
KOCK
ILEOSTOMY
RESERVOIR
491
15
3 CM INTUSSUSCEPTION VALVE FIG. 1. Stages in the construction of the Kock ileostomy reservoir.
all made in isolation from the gastrointestinal tract so that the valves could be subjected to identical stresses. The afferent loops were brought out through the abdominal wall as stomata. In five of the dogs (Group A) (Fig. 2) the reservoirs were secured to the parietal peritoneum of the anterior abdominal wall by placing six interrupted 2/O silk sutures around the bases of the valves. The other five dogs (Group B) did not have reservoir fixation. Care was taken in every case to ensure that the outlet conduit was kept as short and as straight as possible to help hold the reservoir in position and facilitate catheterization. Throughout the postoperative recovery
phase all the dogs remained in excellent condition. They were recommenced on their normal diet within 5 days of surgery and had regained their preoperative weight between the 10th and 14th postoperative day. After a period of 1 month chronic stress tests were applied to the valves by filling the reservoirs with normal saline at increasing pressures. A double lumen pressure probe was inserted through the afferent loop into the reservoir and intraluminal pressures were recorded graphically using a Bell and Howell pressure transducer and a Devices multichannel recorder (Fig. 3). Initially the pressure was maintained at 20 mm Hg for 30 min. This was carried out on each dog on 3 alternate days under neuroleptanalge-
492
JOURNAL OF SURGICAL RESEARCH: VOL. 31, NO. 6, DECEMBER 1981
GROUP A
5 DOGS
GROUP
1 6
5 DOGS
ABDOMINAL WALL FIXATION
FIG. 2. Group A-Reservoir fixation employed.
fixation to parietal peritoneum with interrupted 2/O silk. Group B-No
sia. The following week the pressure was raised to 40 mm Hg and the test was carried out again on three occasions. This was repeated at pressures of 60 and 80 mm Hg over a total period of 4 weeks. At the end of this time a laparotomy was performed and all valve lengths were remeasured. During each 30-min stress test two attempts were made at passing the tip of a size 18 latex Foley catheter, lubricated with KY jelly through the intussusception valve into the reservoir. The first attempt was at 15 min and the second at 30 min. Twentyfour attempts were made on each animal. There were classified into three groups: A. Easy-when the tip of the catheter slipped through the lumen of the valve into the reservoir at the first attempt. B. Difficult-when more than one attempt was required to slip the catheter through the valve into the reservoir.
C. Impossible-when, despite numerous attempts at catheterization, it was impossible to place the tip in the reservoir. RESULTS
Valve lengths measured before and after the chronic stress test are shown in Table 1. In the group where reservoir fixation was employed (Group A) a small reduction in length occurred in all of the valves after the four-week test period. This was most marked along the mesenteric borders. In Group B a large reduction in length occurred in all of the valves. Again this was maximal at the mesenteric borders. Figure 4 is a histogram comparing mean valve lengths before and after the chronic stress test in the two groups. When the valve lengths of the two groups, after the stress tests, were compared statistically it was found that a significantly
CRANLEY PREssuREmBg
AND
MC KELVEY:
KOCK
b
ILEOSTOMY
493
RESERVOIR a.
1
I
80 -Je
r
i I -A’
60 -2 40 -,
20 -J L
30 MINUTES -
k
RESERVOIR +#-----
..
,
DOUBLE-LLMEN TUBE
-~INTUSSUSCEPTION VALVE
FIG. 3. Schematic drawing of apparatus used for chronic stress tests.
greater reduction in length due to extrusion had occurred in Group B. (Student’s t test, t = 9.21, P < 0.001). In Group A it was observed that a strong fibrous union had developed between the reservoirs and the parietal peritoneum around the valve bases. In Group B, however, no such union was found. These reservoirs had migrated from their original position and were attached to the abdominal wall by the inlet and outlet conduits only. This produced a very long and tortuous outlet loop which interfered with catheterization. On each dog a total of 24 attempts at catheterization were made and the numbers of Easy, Difficult or Impossible attempts were recorded (Table 2). A comparison, based on the Mann-Whitney U test, was made between Group A and Group B for Easy catheterizations. These occurred significantly more frequently in Group A where abdominal wall fixation was employed (U = 1, P
I n
:
MEAN
VALVE
CHRONIC MEAN
VALVE
CHRONIC
LENGTH
STRESS
LENGTH
STRESS
BEFORE
TEST AFTER
TEST
FIG. 4. Comparison of mean valve lengths before and after chronic stress test in the “Fixed” and “Nonfixed” groups.
494
JOURNAL OF SURGICAL RESEARCH: VOL. 31, NO. 6, DECEMBER 1981 TABLE 1
VALVE LENGTHS MEASURED AT BOTH MESENTERIC AND ANTIMESENTERIC BORDERS BEFORE AND AFTER THE CHRONIC STRESS TEST IN THE Two GROUPS Valve lengths (cm) Before stress test
Group A, fixation
Group B, no fixation
After stress test
Dog no.
Mesenteric border
Antimesenteric border
Mean length”
Mesenteric border
Antimesenteric border
Mean length”
I 2 3 4 5
3 3 3 2.5 3.5
3 3 3 3.5 3.5
3 3 3 3 3.5
2.5 2.5 2.6 2.4 3.2
3 2.5 3.2 2.5 3.4
2.15 2.5 2.9 2.45 3.3
1 2 3 4 5
3 3 2.5 3 3
3 3 3 3 3
3 3 2.75 3 3
1 0.5 0.75 0.8 1.1
I.5 1 1.5 1 1.5
1.25 0.75 1.125 0.9 1.3
’ Mean valve lengths also shown.
< 0.01). A similar analysis of Difficult cath- was employed here because the results were eterizations showed that these occurred sig- not normally distributed. It was felt, therenificantly less frequently in Group A (U fore, that it would be more appropriate to = 1, P < 0.01). The Mann-Whitney U test use this nonparametric test. At no time was it impossible to catheter any of the reservoirs in Group A. This probTABLE 2 lem, however, was encountered in two of the COMPARISON OF CATHETERIZATION ATTEMPTS IN dogs in Group B (dogs 2 and 4) and was THE “FIXED” AND “NONFIXED” GROUPS more common when the pressure within these reservoirs was high. Easy Difficult Impossible Dog no.
catheterizations
catheterizations
Group A-reservoir I 2 3 4 5
24 21 24 24 23
catheterizations
Total
fixation
0 3 0 0 1
0 0 0 0 0
24 24 24 24 24
0 6 0 3 0
24 24 24 24 24
Group B-no fixation I 2 3 4 5
21 6 21 17 12
3 12 3 4 I2
DISCUSSION
While construction of a stable and efficient intussusception valve is most important in achieving continence in the Kock continent ileostomy reservoir, the value of reservoir fixation requires careful consideration. Failes [ 11, King [4], Loyque ef al. [5], and Madigan [6] have practiced this procedure and are of the opinion that it is important in helping to prevent valve extrusion. Weinstein et al. [ 71 have advocated removal of a peritoneal strip from the abdominal wall around the efferent loop of the reservoir to
CRANLEY
AND MC KELVEY: KOCK ILEOSTOMY
enhance adhesion formation. Goligher and Lintott [3] felt that in 2 of their patients incontinence may have been the result of failure to fix the reservoir to the abdominal wall. Our experimental study has confirmed the opinions of these workers that careful fixation of the reservoir to the abdominal wall helps to maintain the integrity of the intussusception valve even under fairly rigorous stress tests. We have found that the fixation process encourages a fibrous union to develop between the reservoir and the parietal peritoneum around the whole of the base of the valve. This has the effect of discouraging extrusion between the reservoir and the abdominal wall. Gelernt et al. [2] found that abdominal wall fixation enabled the patient to direct the catheter through the stoma and into the reservoir without encountering any cul-de-sacs in the out-flow tract. We have found that even when leakage is not a problem, catheterization is greatly facilitated where fixation has been carried out. Reservoir fixation is technically easy to
RESERVOIR
495
perform. It minimally increases total operating time and is probably just as important as the design of the valve in maintaining continence and facilitating catheterization in the ileostomy reservoir. REFERENCES
t. Failes, D. The Kock Continent Ileostomy: A preliminary report. AWL N. Z. J. Surg. 46: 125, 1976.
2. Gelernt, I. M., Batter, J. J., and Kreel, I. The reservoir ileostomy: Early experience with 54 patients. Ann. Surg. 185: 179, 1976. J. C., and Lintott, D. Experience with 26 3’ Goligher, reservoir ileostomies. hit. J. Surg. 62: 893, 1975. 4. King, S. A. Quality of life: The Continent Ileostomy. Ann. Surg. 182: 29, 1975. 5. Loyque, J., Salmon, R., St. Amand, Ph., and Levy, E. L’ileostomie continente. Experience de 17 cas. ChiFuFgie 104: 512, 1978. 6. Madigan, M. The continent ileostomy and the isolated _-__ileal bladder. Ann. R. Coil. Surg. Eng. 58: 62, IY Ib.
7. Weinstein, M., Rubin, R. J., and Salvati, E. P. Detachment of the continent ileostomy pouch from the anterior abdominal wall: Renort of 2 unusual cases. Dis. Cal. Reel. 19: 705, 1476.
OF SURGICAL
31, 490-495 (1981)
RESEARCH
The Kock lleostomy Reservoir: An Experimental Study of the Value of Reservoir Fixation in Improving Valve Stability and Facilitating Catheterization FRCS, AND S. T. D. MCKELVEY,
BRIAN CRANLEY,
MCH.,
FRCS
Department of Surgery, The Queen’s University, Belfast, Northern Ireland Submitted for publication January 28, 1981 In an experimental study on dogs the importance of fixing the Kock continent ileostomy reservoir to the anterior abdominal wall was evaluated. It was found that this encouraged fibrous union to develop between reservoir and abdominal wall. This played an important role in holding the reservoir in its original position, and helped to prevent extrusion of the intussusception valve. Catheterization of the reservoir was significantly easier when this procedure was employed.
INTRODUCTION
The continent ileostomy reservoir was devised by Nils Kock of Sweden as an alternative to the conventional ileostomy with all its inherent problems. The reservoir is constructed by plicating two 15cm loops of terminal ileum together (Fig. 1A). The ileum is then opened to form a U-shaped plate (Fig. 1B) and an antiperistaltic intussusception valve measuring 3-4 cm in length is made from the distal ileal loop (Fig. IC). The apex of the U is folded upon itself and the edges are sutured, thus forming a reservoir which, according to Kock, is amotile (Fig. 1D). The distal loop is then brought through the abdominal wall as a stoma and the reservoir is emptied by self-catheterization. This system has been used with increasing frequency throughout the United States and many parts of Europe over the past 10 years. It eliminates the need for an appliance, reduces the incidence of peristomal skin excoriation, and allows the patient much greater freedom in work and leisure activities. There have, however, been many serious problems associated with this operation. The most intractible has been the tendency for the intussusception valve to extrude along the mesenteric border leading to difficulty with catheterization and incontinence [3 J. 0022-4804181/ 120490-06301.00/O Copyright 0 1981 by Academic Press. Inc. All rights of reproduction in any form rcscrvcd.
Since the inception of this operation workers have been attempting to find ways of preventing extrusion by modifying valve design. The problem, however, remains. It is generally felt that fixation of the reservoir to the abdominal wall is probably important in facilitating catheterization and helping to prevent valve extrusion. Its importance, however, has never been scientifically assessed. We have studied the value of this procedure in improving valve stability and facilitating catheterization experimentally under controlled laboratory conditions. MATERIALS
AND METHODS
A Kock ileostomy reservoir was fashioned as described above in each of 10 dogs. The animals used were 1- to 2-year-old healthy greyhound bitches (weight range 20-30 kg, mean 24.2 kg). A 3-cm intussusception valve was constructed in each reservoir and its final length at the time of construction was measured by taking the mean of both mesenteric and antimesenteric borders. All valves were of identical design and were made according to the method described by Madigan [6] of applying deep seromuscular diathermy to the opposing layers to encourage fibrous adhesion and holding the intussusception in position with 12 interrupted seromuscular silk sutures. The reservoirs were
490
CRANLEY
AND
MC KELVEY:
KOCK
ILEOSTOMY
RESERVOIR
491
15
3 CM INTUSSUSCEPTION VALVE FIG. 1. Stages in the construction of the Kock ileostomy reservoir.
all made in isolation from the gastrointestinal tract so that the valves could be subjected to identical stresses. The afferent loops were brought out through the abdominal wall as stomata. In five of the dogs (Group A) (Fig. 2) the reservoirs were secured to the parietal peritoneum of the anterior abdominal wall by placing six interrupted 2/O silk sutures around the bases of the valves. The other five dogs (Group B) did not have reservoir fixation. Care was taken in every case to ensure that the outlet conduit was kept as short and as straight as possible to help hold the reservoir in position and facilitate catheterization. Throughout the postoperative recovery
phase all the dogs remained in excellent condition. They were recommenced on their normal diet within 5 days of surgery and had regained their preoperative weight between the 10th and 14th postoperative day. After a period of 1 month chronic stress tests were applied to the valves by filling the reservoirs with normal saline at increasing pressures. A double lumen pressure probe was inserted through the afferent loop into the reservoir and intraluminal pressures were recorded graphically using a Bell and Howell pressure transducer and a Devices multichannel recorder (Fig. 3). Initially the pressure was maintained at 20 mm Hg for 30 min. This was carried out on each dog on 3 alternate days under neuroleptanalge-
492
JOURNAL OF SURGICAL RESEARCH: VOL. 31, NO. 6, DECEMBER 1981
GROUP A
5 DOGS
GROUP
1 6
5 DOGS
ABDOMINAL WALL FIXATION
FIG. 2. Group A-Reservoir fixation employed.
fixation to parietal peritoneum with interrupted 2/O silk. Group B-No
sia. The following week the pressure was raised to 40 mm Hg and the test was carried out again on three occasions. This was repeated at pressures of 60 and 80 mm Hg over a total period of 4 weeks. At the end of this time a laparotomy was performed and all valve lengths were remeasured. During each 30-min stress test two attempts were made at passing the tip of a size 18 latex Foley catheter, lubricated with KY jelly through the intussusception valve into the reservoir. The first attempt was at 15 min and the second at 30 min. Twentyfour attempts were made on each animal. There were classified into three groups: A. Easy-when the tip of the catheter slipped through the lumen of the valve into the reservoir at the first attempt. B. Difficult-when more than one attempt was required to slip the catheter through the valve into the reservoir.
C. Impossible-when, despite numerous attempts at catheterization, it was impossible to place the tip in the reservoir. RESULTS
Valve lengths measured before and after the chronic stress test are shown in Table 1. In the group where reservoir fixation was employed (Group A) a small reduction in length occurred in all of the valves after the four-week test period. This was most marked along the mesenteric borders. In Group B a large reduction in length occurred in all of the valves. Again this was maximal at the mesenteric borders. Figure 4 is a histogram comparing mean valve lengths before and after the chronic stress test in the two groups. When the valve lengths of the two groups, after the stress tests, were compared statistically it was found that a significantly
CRANLEY PREssuREmBg
AND
MC KELVEY:
KOCK
b
ILEOSTOMY
493
RESERVOIR a.
1
I
80 -Je
r
i I -A’
60 -2 40 -,
20 -J L
30 MINUTES -
k
RESERVOIR +#-----
..
,
DOUBLE-LLMEN TUBE
-~INTUSSUSCEPTION VALVE
FIG. 3. Schematic drawing of apparatus used for chronic stress tests.
greater reduction in length due to extrusion had occurred in Group B. (Student’s t test, t = 9.21, P < 0.001). In Group A it was observed that a strong fibrous union had developed between the reservoirs and the parietal peritoneum around the valve bases. In Group B, however, no such union was found. These reservoirs had migrated from their original position and were attached to the abdominal wall by the inlet and outlet conduits only. This produced a very long and tortuous outlet loop which interfered with catheterization. On each dog a total of 24 attempts at catheterization were made and the numbers of Easy, Difficult or Impossible attempts were recorded (Table 2). A comparison, based on the Mann-Whitney U test, was made between Group A and Group B for Easy catheterizations. These occurred significantly more frequently in Group A where abdominal wall fixation was employed (U = 1, P
I n
:
MEAN
VALVE
CHRONIC MEAN
VALVE
CHRONIC
LENGTH
STRESS
LENGTH
STRESS
BEFORE
TEST AFTER
TEST
FIG. 4. Comparison of mean valve lengths before and after chronic stress test in the “Fixed” and “Nonfixed” groups.
494
JOURNAL OF SURGICAL RESEARCH: VOL. 31, NO. 6, DECEMBER 1981 TABLE 1
VALVE LENGTHS MEASURED AT BOTH MESENTERIC AND ANTIMESENTERIC BORDERS BEFORE AND AFTER THE CHRONIC STRESS TEST IN THE Two GROUPS Valve lengths (cm) Before stress test
Group A, fixation
Group B, no fixation
After stress test
Dog no.
Mesenteric border
Antimesenteric border
Mean length”
Mesenteric border
Antimesenteric border
Mean length”
I 2 3 4 5
3 3 3 2.5 3.5
3 3 3 3.5 3.5
3 3 3 3 3.5
2.5 2.5 2.6 2.4 3.2
3 2.5 3.2 2.5 3.4
2.15 2.5 2.9 2.45 3.3
1 2 3 4 5
3 3 2.5 3 3
3 3 3 3 3
3 3 2.75 3 3
1 0.5 0.75 0.8 1.1
I.5 1 1.5 1 1.5
1.25 0.75 1.125 0.9 1.3
’ Mean valve lengths also shown.
< 0.01). A similar analysis of Difficult cath- was employed here because the results were eterizations showed that these occurred sig- not normally distributed. It was felt, therenificantly less frequently in Group A (U fore, that it would be more appropriate to = 1, P < 0.01). The Mann-Whitney U test use this nonparametric test. At no time was it impossible to catheter any of the reservoirs in Group A. This probTABLE 2 lem, however, was encountered in two of the COMPARISON OF CATHETERIZATION ATTEMPTS IN dogs in Group B (dogs 2 and 4) and was THE “FIXED” AND “NONFIXED” GROUPS more common when the pressure within these reservoirs was high. Easy Difficult Impossible Dog no.
catheterizations
catheterizations
Group A-reservoir I 2 3 4 5
24 21 24 24 23
catheterizations
Total
fixation
0 3 0 0 1
0 0 0 0 0
24 24 24 24 24
0 6 0 3 0
24 24 24 24 24
Group B-no fixation I 2 3 4 5
21 6 21 17 12
3 12 3 4 I2
DISCUSSION
While construction of a stable and efficient intussusception valve is most important in achieving continence in the Kock continent ileostomy reservoir, the value of reservoir fixation requires careful consideration. Failes [ 11, King [4], Loyque ef al. [5], and Madigan [6] have practiced this procedure and are of the opinion that it is important in helping to prevent valve extrusion. Weinstein et al. [ 71 have advocated removal of a peritoneal strip from the abdominal wall around the efferent loop of the reservoir to
CRANLEY
AND MC KELVEY: KOCK ILEOSTOMY
enhance adhesion formation. Goligher and Lintott [3] felt that in 2 of their patients incontinence may have been the result of failure to fix the reservoir to the abdominal wall. Our experimental study has confirmed the opinions of these workers that careful fixation of the reservoir to the abdominal wall helps to maintain the integrity of the intussusception valve even under fairly rigorous stress tests. We have found that the fixation process encourages a fibrous union to develop between the reservoir and the parietal peritoneum around the whole of the base of the valve. This has the effect of discouraging extrusion between the reservoir and the abdominal wall. Gelernt et al. [2] found that abdominal wall fixation enabled the patient to direct the catheter through the stoma and into the reservoir without encountering any cul-de-sacs in the out-flow tract. We have found that even when leakage is not a problem, catheterization is greatly facilitated where fixation has been carried out. Reservoir fixation is technically easy to
RESERVOIR
495
perform. It minimally increases total operating time and is probably just as important as the design of the valve in maintaining continence and facilitating catheterization in the ileostomy reservoir. REFERENCES
t. Failes, D. The Kock Continent Ileostomy: A preliminary report. AWL N. Z. J. Surg. 46: 125, 1976.
2. Gelernt, I. M., Batter, J. J., and Kreel, I. The reservoir ileostomy: Early experience with 54 patients. Ann. Surg. 185: 179, 1976. J. C., and Lintott, D. Experience with 26 3’ Goligher, reservoir ileostomies. hit. J. Surg. 62: 893, 1975. 4. King, S. A. Quality of life: The Continent Ileostomy. Ann. Surg. 182: 29, 1975. 5. Loyque, J., Salmon, R., St. Amand, Ph., and Levy, E. L’ileostomie continente. Experience de 17 cas. ChiFuFgie 104: 512, 1978. 6. Madigan, M. The continent ileostomy and the isolated _-__ileal bladder. Ann. R. Coil. Surg. Eng. 58: 62, IY Ib.
7. Weinstein, M., Rubin, R. J., and Salvati, E. P. Detachment of the continent ileostomy pouch from the anterior abdominal wall: Renort of 2 unusual cases. Dis. Cal. Reel. 19: 705, 1476.