Chapter 38 - Kock Pouch, Barnett Continent Intestinal Reservoir, and Diverted Pouch

Abstract

There are two forms of continent ileostomy, Kock pouch and Barnett Continent Intestinal Reservoir. Although ileal pouch-anal anastomosis (IPAA) is the standard procedure for patients with ulcerative colitis or familial adenomatous polyposis who required colectomy, continent ileostomies remain to be valuable options for selected patients. Those patients are not candidates for IPAA mainly due to compromised anal sphincter function or for those who fail pelvic pouches. The nipple valve is a key structure for continent ileostomy, on which the fecal continence is relied. Despite their benefits, surgery for continent ileostomy is a complex procedure with a risk of complications. The most common complications are associated with dysfunctional nipple valve, including valve slippage, stricture, prolapse, and fistula formation. Other complications include pouchitis, Crohn’s disease of the pouch, and pouch bezoars. Fortunately, the risk for neoplasia in continent ileostomy is low. Temporary fecal diversion has been a part of the initial staged pelvic pouch surgery, treatment of refractory pouch disorders, or staged surgical revision or redo of the pouch. Permanent fecal diversion with an ileostomy may be required for patients with pouch failure. All diverted pouches, especially permanent ones, have some degree of endoscopic or histologic inflammation, namely diversion pouchitis. Patients with diversion pouchitis can present with cramping abdominal or pelvic pain and a mucoid or bloody discharge. While diversion pouchitis can be treated with topical anti-inflammatory therapy, surgical reestablishment of bowel continuity is the treatment of choice. Distal pouch stricture is common in a long-term diverted pouch. In addition, diverted pouch may still carry a risk for neoplasia, which requires endoscopic surveillance.