We spoke with Gabriela Möslein, ESCP's General Secretary and Director of the Center for Hereditary Tumors at Helios University Hospital Wuppertal in Germany. She will be leading the ‘Standardised trainee video: Continent Kock pouch’ at ESCP’s September annual meet, Virtually Vilnius.
Continent ileostomies, (also called Kock pouches) are suitable for patients that have required a proctocolectomy for whichever underlying condition and require a terminal ileostomy. The procedure includes fashioning of a reservoir and additionally a valve, both constructed from the small bowel, which leads to a small ostomy (usually placed in the low abdomen, concealed by usual underwear) that is entirely continent for both faeces and air. This allows omission of wearing a bag and the small opening can be covered by a skin-friendly parch and removed 4-5 times a day in order to evacuate the content of the reservoir via a soft tube directly into the toilet, or a bag. Importantly, the timing of this short process is not urgent and can easily be fit into a normal timing of going to a restroom.
Why is it an important topic?
There are serious medical issues around ileostomies, which relate to the loss of the large bowel and the associated function. Most importantly, this involves serious episodes of dehydration especially in the elderly or physically active younger patients. Not infrequently, primary and secondary (chronic) renal failure is the result.
Beyond these issues that can be managed but require the awareness of the patient and the physician, quality of life with an ileostomy is deteriorated. The most important problem is the large amount of faecal discharge that can be quite fluid, depending on individual and nutritional factors. This leads to the requirement of frequent evacuating of bags, but also - more so than with colostomies - frequent leaks and importantly skin problems. Patients may find so much discomfort that their social life deteriorates. For active, sporty people, an ileostomy may lead to them stopping their activities that are so beneficial for a variety of reasons - and from a medical point of view, this immobility may cause secondary health issues.
It is important to raise awareness of the option of a continent ileostomy and rectify an old opinion, mainly among surgeons, that the procedure is not to be recommended. This notion arose in the early days, when Nils Kock in 1969 described the procedure. It was very successful for many patients and until today his patients will request a revision of the valve rather than have the incontinent ileostomy.
However, please remember that back then linear cutters and staplers were not yet on the market, so slippage of the valve was frequent. If a valve slips, continence is not maintained and patients experience the downsides of this and need to wear a bag and will also have discomfort and malfunctioning of the pouch. It is an elegant and very useful option for younger and more active patients and after extensive information and good communication to patients, a Kock pouch may be their preferred choice.
The revival of the procedure has evolved and is especially useful for patients that have an ileoanal pouch failure or a low cancer, or any other reason that requires excision of an ileoanal pouch.
What are the key points to know?
The procedure can be offered to patients that are in a good state of health, cognisant to understand the principle of functioning and able to handle a tube for evacuation of faeces. It is an option to consider if a permanent ileostomy is required and is applicable for any underlying cause (also Crohn’s disease). It leads to entire continence and removes the need to wear a bag, enabling more physical activity (including swimming, running, fitness exercising and even climbing) without risking a leak.
It is important for patients to understand that a Kock pouch may require repair surgery, but as a rule of thumb, if there is sufficient small bowel and no increased risk for a short bowel syndrome, these problems can be surgically repaired. Importantly, this is possible mostly without the loss of (relevant amount) of the small bowel.
Why is the session different/useful to attend – and who will benefit most from attending?
We will introduce the principles of the procedure, which are straightforward, but not easily understood without visual demonstration. This is not a procedure to learn by reading, but rather by doing!
This session will be the introductory module to a hands-on course that will be implemented into an educational ESC course on 'Continent Ileostomy'. The course will cover the continent S-pouch, as well as all other types of continent ileostomies. This training session at #ESCP2020 will introduce the course and qualifies for the next modules that are being developed.
In any case, after watching this session you will understand the fascination of the genius idea by Nils Kock, that has wrongly been forgotten. Admittedly, the procedure described by him in 1969 has evolved further and now includes the modern elements of surgery and an improved understanding of why intussusception may slip and how to prevent this complication in the primary surgery.
What are the future developments in the field?
At this stage there are 4 major designs for incontinent ileotomies, with substantial differences in concept and design. To date it is unclear if there are any advantages or disadvantages and interestingly, surgeons usually commit to one design based on experience and theoretical considerations.
It is essential to document ALL prospective Kock pouches in a global registry that will be implemented by the ESC (European School of Coloproctology) of the ESCP. This detailed documentation in addition to patient reporting will add a major contribution to the future implementation of the safest and technically most successful procedure(s).
The 'Standardised trainee video on the Continent Kock pouch' at ESCP Virtually Vilnius 2020 will take place between 15:30-15:45 on Monday 21 September 2020.