Continent Ileostomy Reservoir Research Articles

The Kock reservoir ileostomy: a review of its development, problems and role in modern surgical practice.

The Kock continent ileostomy reservoir was designed in an attempt to overcome many of the problems associated with the conventional ileostomy. An account is given of the technical developments of this procedure since its inception. An intussusception valve within the reservoir is necessary for continence. However, valve failure is a common problem and the developments in construction which have helped to overcome this are described. The major complications associated with the continent ileostomy are discussed in detail, and an attempt is made to define its present role in the treatment of inflammatory disease of the colon.

Radiology of the continent ileostomy reservoir: II. Findings in patient with late complications : Lycke KG, Göthlin JH, Jensen JK, et al. (Department of Radiology, University of Göteborg, Sahlgren's Hospital, S-413 45 Göteborg, Sweden). Abdom Imaging 1994;19:124–131

Radiology of the continent ileostomy reservoir: II. Findings in patient with late complications : Lycke KG, Göthlin JH, Jensen JK, et al. (Department of Radiology, University of Göteborg, Sahlgren's Hospital, S-413 45 Göteborg, Sweden). Abdom Imaging 1994;19:124–131

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings : Lycke KG, Göhlin JH, Jensen JK, et al. (Department of Radiology, University of Göteborg, Sahlgren's Hospital, S-413 45 Göteborg, Sweden). Abdom Imaging 1994;19:116–123

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings : Lycke KG, Göhlin JH, Jensen JK, et al. (Department of Radiology, University of Göteborg, Sahlgren's Hospital, S-413 45 Göteborg, Sweden). Abdom Imaging 1994;19:116–123

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings.

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications.

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Decreased absorption of 22Na and 36Cl in ileal reservoirs after exposure to urine

After urinary diversion to intestinal segments, reabsorption of chloride, ammonium, and hydrogen ions occurs, sometimes leading to hyperchloremic acidosis. The mucosa of ileal reservoirs exposed to urine show substantial atrophy, indicating a loss of absorptive capacity. In ten patients with urinary diversion via a continent ileal reservoir, the absorption of [22Na] and [36Cl] was studied after instillation for 15 min into the reservoir of a test solution containing 50 kBq [22Na] and 50 kBq [36Cl]. The activity of the radionuclides was determined in serum samples after 60 and 180 min and the fractions absorbed were calculated. Absorption of the two radionuclides was also calculated by comparison of the activities in samples of the test solution taken before and 15 min after instillation into the reservoir. The same investigations were performed in seven patients with continent ileostomy reservoirs. The study demonstrated a decreased capacity to absorb [22Na] and [36Cl] across the mucosa of the reservoirs exposed to urine compared to the mucosa of those exposed to feces. Due to the transformation of the ileal mucosa after exposure to urine, the risk for development of metabolic disturbances should be minimal after urinary diversion to a continent ileal reservoir.

Structure of mucosa in continent ileal reservoirs 15 to 19 years after construction

Mucosa biopsy specimens were obtained from 12 patients with continent ileostomy reservoirs constructed 15 to 19 years previously. Biopsies from normal ileal mucosa, taken from six other patients with no apparent bowel disease, served as controls. The specimens were processed for light and electron microscopy. The reservoir mucosae showed an increased amount of inflammatory cells, but there were no signs of dysplasia. In the goblet cells, sialomucins dominated over sulfomucins; in this respect no difference was found between reservoirs and controls. Morphometric studies showed an increase of mucus-storing goblet cells in the reservoir mucosae, both with regard to relative number and to volume density. The mitotic index was higher than normal in the reservoirs, but the relative number of the Paneth cells and the height of the villus epithelial cells were similar in the reservoirs and the controls. In the reservoirs, the surface amplification factors due to villi and to microvilli (near the villus tips) were reduced by some 29% and 20%, respectively, indicating villus hypotrophy. It is concluded that only minor morphologic changes appear in the ileal reservoir mucosa 15 to 19 years after construction. Morphometry provides a sensitive tool to demonstrate such changes in intestinal morphology.

The Kock continent ileostomy: influence of a defunctioning ileostomy and nipple valve stapling on early and late morbidity.

Early and late morbidity was studied in 45 consecutive patients submitted to the Kock continent ileostomy reservoir procedure protected by a temporary loop ileostomy. In 24 patients the nipple valve was made by simple intussusception of the ileal segment after stripping of its mesenteric peritoneum and fat, whereas in 21 patients the nipple valve was stapled in addition. The early complication rate was low with necrosis of the nipple valve occurring in 3 patients and a nipple valve fistula in 1. These complications were easily dealt with and revision was done subsequently on an elective basis. The overall revision rate for late nipple valve dysfunction, mainly caused by sliding of the nipple valve was 29%. The majority of these complications occurred within the first postoperative year. Stapling of the nipple valve did not significantly reduce the rate of sliding. The overall complication rate was significantly less compared with a historical series of 21 patients not provided with a loop ileostomy. A temporary defunctioning ileostomy may reduce early complications and their consequences. Whether it may also lessen the risk of later nipple valve sliding is, however, not clear from this study. The observation that sliding was as common in both unstapled and stapled patients could imply either that the loop ileostomy is beneficial in preventing this complication or that the stapling procedure is in this respect unimportant. Which step or steps among all the measures employed are important in increasing the success rate of this operation remains unclear. Randomised controlled studies are needed for a true evaluation of this issue.

SINGLE-PATIENT RANDOMISED CLINICAL TRIAL: Use in Determining Optimum Treatment for Patient with Inflammation of Kock Continent Ileostomy Reservoir

A single-patient randomised clinical trial was used to determine optimum treatment for a patient with inflammation of her continent ileostomy. The trial proved to be feasible and acceptable to both patient and clinician. As a result, both the diagnosis of inflammation and the efficacy of metronidazole in treating it were confirmed. The trial design, in which multiple courses of active and control treatments are given to one patient, may be useful in other clinical situations to determine the most effective therapy in an individual case.

Reflux from the continent ileostomy reservoir. A radiologic evaluation combined with pressure recording.

The reflux from the continent ileostomy reservoir was studied with radiologic and pressure recording techniques in ten patients. The contrast used was poly-iodine-styrene with a density of 0.8 to 1.1 gm/cm3. Reflux into the afferent loop was demonstrated in all patients at a filling volume of approximately 30 percent of the maximal volume capacity of the reservoir. The magnitude of reflux increased with the increasing volume of the reservoir contents and a rise in reservoir pressure. The reflux could temporarily be influenced by antiperistaltic or isoperistaltic motor activity in the afferent loop. Although no adverse effects were seen from the amount of reflux demonstrated in the present investigation, the finding of increasing reflux with increased fullness and intraluminal pressure of the reservoir would indicate that the reservoir should be emptied at regular intervals and before high pressures are built up.

Absorption of an oral contraceptive gestagen in ulcerative colitis before and after proctocolectomy and construction of a continent ileostomy

Plasma l-norgestrel (l-Ng) levels after administration of a common oral contraceptive in fertile women (mean age 29 ± 5 yrs) with mild ulcerative colitis before or after proctocolectomy with a conventional ileostomy or a continent ileostomy reservoir were determined and compared to those of a group of healthy volunteers serving as controls. Before operation, peak and 10-hour levels of 1-Ng were not statistically different from control. Levels in patients with either type of ileostomy were slightly lower than controls, but were only statistically significantly lower in patients with continent ileostomy ( p < 0.05). In a subgroup of patients studied both before and after proctocolectomy with construction of a continent ileostomy, there was a slight reduction in peak and 10-hour levels compared to control. After administration of the pill directly into the reservoir, significant levels of 1-Ng in plasma were found with peak and 10-hour levels approximately one-half of those achieved after oral administration. Although the material is small, it suggests that patients with mild ulcerative colitis and with small ileal resections (8.8 ± 8 cm) can use combined contraceptive pills containing 1-norgestrel with confidence. Caution should be exercised, however, in prescribing “minipills” to patients after proctocolectomy and ileal resection.

Hypertrophy of ileal smooth muscle after construction of ileal reservoir in the rat.

An experimental model of the continent ileostomy reservoir used in clinical practise has been adapted for rats in order to evaluate changes in the smooth muscle layers of the ileal wall. The reservoir was constructed in the distal part of ileum, with intestinal continuity in order to avoid emptying problems. The rats were sacrificed 3-7 months after construction of the reservoir. There was a significant dilatation of the reservoir with a 26-fold increase in the mean reservoir volume. Morphometric studies of the smooth muscle in the intestinal wall revealed an increased thickness of the circular and longitudinal layers after construction of the reservoir (p less than 0.001). The number of muscle cell nuclei per section in samples of the ileal reservoir was reduced (p less than 0.01), whereas the mean size of the individual nuclei was greater (p less than 0.001). These results indicate that the enormous dilatation of this ileal reservoir is related to a clear hypertrophy of the smooth muscle layer. Whether there is a concomitant hyperplasia remains to be studied.

Volume Capacity and Pressure Characteristics of the Continent Ileostomy Reservoir

The volume capacity and the pressure characteristics of the ileal reservoir were studied at intervals postoperatively in 28 patients with continent ileostomy. The reservoir volume increased during the first 6 months from 100 ml to approximately 700 ml, after which it remained stable. The basal pressure increased during filling to a maximum of roughly 10 cm H2O. Under 'physiological conditions' the basal pressure was around 4 cm H2O before emptying. Two types of pressure waves occurred, small pressure fluctuations with a frequency of 7-8/min and larger phasic waves appearing when approximately 40% of the reservoir volume capacity had been reached. The occurrence of both types of pressure waves decreased with time. The total motor activity, expressed as the area underneath the pressure waves, decreased considerably during the 1st year after operation, indicating an adaptation of the intestinal smooth muscle to distension. The results confirm the original concept proposed by Kock that the ileal reservoir constructed in this manner is a low-pressure reservoir.

The kock ileostomy reservoir: An experimental study of the value of reservoir fixation in improving valve stability and facilitating catheterization

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.

Morphological and histochemical changes in the mucosa of the continent ileostomy reservoir 6--10 years after its construction.

Morphological and histochemical changes in the mucosa of the continent ileostomy reservoir were studied in 13 patients who had been provided with a continent ileostomy reservoir 6--10 years before the investigation. Biopsy specimens were taken for evaluation of basal morphology, morphometry, and enzyme histochemical analyses. The villi were predominantly finger-like, but the villus height was reduced compared with normal. The crypt layer and the number of cells in each crypt were increased. The number of mitoses was normal or slightly subnormal. In comparison with biopsies taken 1 year after construction of the reservoir, there was an increase in villus height and mucosal volume and a decrease in the number of mitoses, whereas the number of cells per crypt was unchanged. The surface to volume ratio decreased progressively during the 6- to 10-year period. This decrease was partly caused by an increase of the mucosal volume. The epithelial cell layer was intact, and no changes were seen in the microvillus layer. No alarming changes in terms of dysplasia, fibrosis, or progressive atrophy were found. Histochemical investigation showed a high enzymatic activity in the epithelial cells as concerns both the oxidative metabolism and the secretory function.

Faecal excretion of intravenously injected 14C-cholic acid in patients with conventional ileostomy and in patients with continent ileostomy reservoir.

Bile salt absorption, as determined by the faecal excretion in i.v. injected 14C-cholic acid (FBS) was studied in 13 ileostomy patients before and after conversion to Kock's continent ileostomy reservoir. The result was compared with that obtained in 8 ileostomy patients in whom about 50 cm of the terminal ileum has also been removed. As compared with 16 healthy controls, FBS was moderately increased in the conventional ileostomy patients, but still within normal limits. After conversion to ileostomy reservoir all patients had pathological FBS, although less severe than in the ileostomy patients with ileal resection. Bacterial contamination probably contributes more than the structural mucosal changes to the bile malabsorption in the pouch, whereas reduced mucosal surface and short small-intestinal transit time are the main causes of malabsorption in ileostomy patients in whom an appreciable amount of the terminal ileum has been resected.

Morphology in the Cat Ileal Mucosa Following Construction of an Ileal Reservoir or Tranposition of Patches to Different Locations

In an attempt to examine the response of the ileal mucosa to different noxious environments and to correlate the results with findings in human continent ileostomy reservoirs, cat intestine was subjected to various operative procedures: first, ileal reservoirs were constructed in continuity with the small intestine, a technique that was slightly different from that employed in human subjects, and secondly, segments or patches of ileum were transposed to the colon, the urinary bladder, or the jejunum. Morphometric evaluation was subsequently performed on these samples. The mucosa of the reservoir revealed a decrease in villus height accompanied by an increased mitotic index. Identical changes were observed when ileal segments or patches were inserted in the colon, whilst transposition to the urinary bladder resulted in similar but more pronounced alterations. When ileal patches from the colon or urinary bladder were replaced in the jejunum, the villi were once again enlarged. The epithelial cells remained normal in all cases except following transposition to the urinary bladder, where flattening of the cells or partial denudation of the villus tips was encountered. The changes observed represent a classical hyper-regenerative transformation of the mucosa, and correspond closely with the changes recorded in human continent ileostomy reservoirs. Furthermore, the reversibility of such alterations has been demonstrated. The experimental design permitted the exclusion of intraluminal pressure, dilatation, and nervous and vascular derangements as the cause of the transformation; it is concluded that the intraluminal environment is the factor most probably responsible for such structural alterations.

Vitamin B12 Absorption in Patients with Continent Ileostomy

Vitamin B12 absorption was studied in 34 patients, 10 months to 6 years after construction of a continent ileostomy. Normal Schilling test values (greater than 10 percent) were obtained in 21 of the cases after a single determination. Repeated tests showed a normal B12 absorption in 8 of the 13 patients who had revealed a Schilling test value below 10 percent at the first determination. In the remaining 5 patients, repeated Schilling tests showed borderline values (5-10 percent) in 4 cases and a low value (mean 4.5 percent) in one case. One of the patients with borderline values had previously undergone resection of 80 cm of the terminal ileum. When vitamin B12-intrinsic factor complex was instilled directly into the reservoir in 3 patients, it was found that the vitamin was absorbed by the mucous membrane of the reservoir. The construction of a continent ileostomy reservoir thus does not appear to expose the patient to an increased risk of developing vitamin B12 malabsorption.

Function and structure of the mucosa of continent ileostomy reservoirs in dogs.

Continent ileostomy reservoirs were constructed in dogs. Nine to 29 days after formation of the pouches, they were excised together with a loop of adjacent ileum for biochemical and morphological assessment. The villous and epithelial cell heights were reduced, whereas villous width and mitotic index were increased. The mucosa of the pouch was able to absorb phenylalanine and Beta-methyl-glucoside against a concentration gradient, although this absorptive capaciti was lower than that of normal ileum. Similar considerations applied to oxygen consumption. The results indicate that the mucosa of the pouch undergoes transformation, but the intergrity of the epithelial layer is maintained.

Life with a conventional heostomy.

Fifty-two ileostomy patients were examined in a follow-up study and an attempt was made to evaluate the quality of life with regard to function of the ileostomy, ability to work, social adaptation, and sexual life. Forty-nine had existences considered within the normal range, whereas quality of life was considered unacceptable in three cases because of severe cutaneous or psychiatric problems. In the patients who had not adapted to ileostomy there would appear to be an indication for construction of a continent ileostomy reservoir using the technique of Kock.