Long-term Outcomes Following Continent Ileostomy Creation in Patients With Crohn’s Disease

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The continent ileostomy (CI or Kock pouch) was first described as a procedure for ileostomy continence in 1970.1,2 The pouch construction technique has evolved through the years, but the basic principles of a relatively aperistaltic reservoir with an outlet obstruction has remained the fundamental concept. The procedure was commonly performed at a number of institutions in the mid- and late-1970s. The development of other alternatives, however, has decreased the use of this alternative, and, now, just a few centers have the expertise to perform this procedure.
Usage of the pouch was originally conceived as an alternative to the Brooke ileostomy for patients requiring a proctocolectomy (eg, patients with IBD and familial polyposis). Its use today is relegated to rare patients with lifestyles that make the other alternatives impractical or those with allergic sensitivities to appliances. Nevertheless, I feel it is 1 of the 4 reconstruction alternatives after proctocolectomy—Brooke ileostomy (BI), ileorectal anastomosis, restorative proctocolectomy (RP), and continent ileostomy—that should be discussed with each patient considering proctocolectomy. Each of these alternatives has advantages and disadvantages that the informed patient needs to understand.
After 1970 and 1971,3–6 we described our experience with the CI as a primary procedure in patients with Crohn’s disease (CD) and noted that 7 of 9 patients had recurrent Crohn’s in their pouch within the first year. Based on this experience, we recommend that the procedure not be used for CD. In retrospect, all these patients had active small-bowel CD. We did not consider what the outcome might be in patients with only colonic CD or with patients who had a long disease-free interval after a proctocolectomy and a BI.
The cause of delayed failure of CI has proved to be varied and often difficult to diagnose. Intubation of the pouch can cause local trauma resulting in conduit or pouch ulceration and conduit stricturing. The presence of ulceration or stricturing is not de facto evidence of CD. In addition, both CI and RP fail because of delayed fistulas.7 Although most of these fistulas occur in patients with a history of IBD, as opposed to familial polyposis, these fistulas are usually not associated with histologic evidence of CD and may represent a delayed spontaneous fistula, an occult sinus tract that later manifests as a fistula, or, perhaps, a form of IBD not easily characterized as Crohn’s disease, chronic ulcerative colitis, or indeterminate colitis.
In this issue of Diseases of the Colon & Rectum, Aytac and coauthors revisit the issue of using CI in patients with CD.8 Only 15 of their patients had a known diagnosis of CD before formation of the CI. Sixty-six percent of these patients had long-term success, and this success was increased by the use of prophylactic medications. Among the 15 with known CD, 9 had histologic proof of recurrence. Although a 33% failure rate may be considered high, it may be an acceptable risk to patients whose lifestyle is otherwise compromised by a BI. However, a word of caution. In our experience,6 unless there were clear and measureable physical problems related to the BI, conversion to a CI was not usually associated with the patient’s perception that their quality of life was improved. Many patients look at the BI and feel that their social failures are caused by the BI, and BI is not usually the cause.
It is important to note that 33 patients were thought to not have CD before creation of a CI, but it is not clear whether they, preoperatively, had IBD or a noninflammatory bowel disease diagnosis. In either event, the issue of CD would not have influenced the choice of offering a CI.
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