Kock Pouch Research Articles

Luminal Nitric Oxide in Ileal Reservoirs for Continent Cutaneous Diversion or Orthotopic Bladder Reconstruction

Objectives: To measure mucosal inflammation as reflected in nitric oxide (NO) production in ileal reservoirs for the storage of urine and to correlate it with the growth of bacteria as well as CRP. Methods: Intraluminal gas NO concentrations were determined using the chemoluminescence technique in 25 patients with continent cutaneous ileal reservoirs (Kock pouch) and 12 patients with orthotopic bladders (hemi-Kock or T-pouch). NO concentrations were determined in both intestinal reservoir gas and silicon catheter balloon gas. Urinary culture and blood CRP determinations were performed. Results: NO concentrations in reservoir gas were higher than in silicon catheter balloons. Bacteriuria was associated with approximately 20 times higher NO concentrations than sterile urine. NO concentrations did not differ between continent cutaneous reservoirs or orthotopic bladders when due attention was paid to variance in the rate of bacteriuria. Elevated CRP was associated with higher NO concentrations. Bacteriuria with acinetobacter, enterococci and pseudomonas appeared to cause comparatively lower NO concentrations. The inflammatory response of reservoir walls to bacteriuria did not decrease with time. Conclusions: Urine in itself causes much less intestinal wall inflammation than bacteriuria, as reflected in NO production. High CRP values are associated with high NO concentrations. The inflammatory response varies with the bacterial specimens.

Clinical Aspects of Continent Ileostomies

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached the height of its popularity soon after its introduction in 1969, but subsequently was supplanted by ileal pouch-anal anastomosis (IPAA), an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for IPAA or for whom IPAA or end ileostomy have failed. Complication rates that initially were high have decreased during the past three decades following the steady introduction of technical improvements.

54: Prophylaxis Against Bone Loss in Kock Reservoir Patients with Reduced GFR

You have accessJournal of UrologyDiscussed Poster, Saturday, May 8, 2004, 1:00 - 5:00 pm1 Apr 200454: Prophylaxis Against Bone Loss in Kock Reservoir Patients with Reduced GFR Olaf K. Jonsson, Hans Herlitz, Elisabet Lindholm, Gӧran Lindstedt, David Pazooki, Harriet Tӧrnqvist, and Dan Mellstrӧm Olaf K. JonssonOlaf K. Jonsson More articles by this author , Hans HerlitzHans Herlitz More articles by this author , Elisabet LindholmElisabet Lindholm More articles by this author , Gӧran LindstedtGӧran Lindstedt More articles by this author , David PazookiDavid Pazooki More articles by this author , Harriet TӧrnqvistHarriet Tӧrnqvist More articles by this author , and Dan MellstrӧmDan Mellstrӧm More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(18)37316-6AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "54: Prophylaxis Against Bone Loss in Kock Reservoir Patients with Reduced GFR." The Journal of Urology, 171(4S), pp. 14–15 © 2016 by American Urological AssociationFiguresReferencesRelatedDetails Volume 171Issue 4SApril 2004Page: 14-15 Advertisement Copyright & Permissions© 2016 by American Urological AssociationMetricsAuthor Information Olaf K. Jonsson More articles by this author Hans Herlitz More articles by this author Elisabet Lindholm More articles by this author Gӧran Lindstedt More articles by this author David Pazooki More articles by this author Harriet Tӧrnqvist More articles by this author Dan Mellstrӧm More articles by this author Expand All Advertisement PDF downloadLoading ...

Evolving technique for continent ileostomy: valveless pouch design.

A continent ileostomy, or Kock pouch, is a useful option for patients with inflammatory bowel disease whose only alternative is an end ileostomy. This technique has a high morbidity rate. Nipple valve slippage is the most common complication, causing incontinence or intubation problems. A novel, valveless continent ileostomy technique is described here. A porcine model was used to create the continent ileostomy. Two pouches were created and tested for integrity and continence using lactated Ringer's solution. Pouch pressure and volume were recorded in one pouch. The valveless continent ileostomy was successfully created twice, and both pouches were continent. An intraluminal pressure of 30 mmHg and a volume of 225 ml were measured in one pouch. In this preliminary report of a valveless continent ileostomy, we had promising results. The future of this technique in clinical practice needs to be addressed with further studies.

Endoscopic Therapy for Inflammatory Bowel Disease.

Endoscopic therapy can be employed and may be useful in inflammatory bowel disease patients with dysplastic polyps, inflammatory strictures (enteric and biliary), bleeding, and for treatment of some complications of continent ileostomies. Dysplastic polyps can be removed endoscopically safely and effectively without resorting to colectomy, as long as there is no other detectable dysplasia in flat mucosa and complete removal can be assured (by biopsy of adjacent mucosa and close follow-up). Some colonic strictures in Crohn's disease can be dilated using endoscopes of graded caliber or with through-the-scope balloons, with or without stent placement. Endoscopy is most useful in dilating anastomotic strictures and less useful for long strictures in active inflammatory disease. Strictures in ulcerative colitis are suspicious for neoplasia and, if dilated at all, should be biopsied extensively and followed closely. We prefer colectomy to endoscopic dilatation for strictures in ulcerative colitis. Biliary endoscopy can be used to dilate strictures in primary sclerosing cholangitis and to sample these areas for malignancy. Although dilatation may improve morbidity and prolong survival, it may not prevent progression to cirrhosis. In cholangiocarcinomas, endoscopic dilatation with or without stents can offer palliation and perhaps be used to deliver photodynamic therapy. Injection and sclerotherapy can be employed in Crohn's disease bleeding from a discrete site. In obstructed continent ileostomies (both Kock pouches and pelvic ileoanal reservoirs), endoscopy can be employed effectively to both determine the cause of the obstruction and re-establish patency. We do not advocate endoscopic treatment of toxic megacolon because of the heightened risk of perforation. Endoscopic therapy of Crohn's fistulas is a possible emerging technology, but it has not been used in large cohorts of patients.

Diagnosis and management of pouchitis

Diagnosis and management of pouchitis

A modified intussuscepted nipple in the Kock pouch urinary diversion: assessment of perioperative complications and functional results.

To assess the complications and continence of a modified intussuscepted nipple in Kock pouch urinary diversions. From February 1992 to December 2000, 40 patients (mean age 55.8 years, range 21-74) with bladder cancer (24), gynaecological tumours (eight) or previous lower tract reconstructive surgery (eight) underwent cystectomy and cutaneous continent urinary diversion using the Kock pouch procedure. The first 23 procedures (group I) used Henriet's technique, whereas a modified fixation of the intussuscepted efferent limb was applied in the last 17 (group II). Complications and functional results (focused on continence and the upper urinary tract) were reviewed. The median (range) follow-up was 47.6 (10-124) months; one patient died 4 weeks after surgery. Early complications occurred in 11 (28%) and re-operation was required in two (5%). Of the late complications reported (38%), extussusception (8%) and efferent nipple prolapse (3%) only occurred in group I and required surgical revision. Late complications were minor (15%) including two asymptomatic refluxes and four with stoma sclerosis. The continence rate at 6 months in groups I and II were 78% and 94%, respectively (P = 0.13). Efferent limb prolapse and extussusception of the Kock pouch were the main complications requiring surgical revision. Applying the modified nipple fixation the complications can be reduced and reservoir continence improved.

Treatment of uretero-intestinal and ureterovesical strictures by Acucise balloon catheter.

Acucise balloon catheter has been proposed as an alternative to open surgery for the treatment of strictures of the ureteropelvic junction because of its low morbidity and the short hospital stay following the endoscopic procedure. The objective of this study was to evaluate the results of this technique applied to patients developing strictures after surgical reimplantation of the ureterovesical (UV) or uretero-intestinal (UI) junction. Between March 1997 and January 2000, 12 strictures (11 patients) were treated by Acucise balloon catheter via an antegrade and/or retrograde approach with double J stenting for an average of 6 weeks (range: 4-12 weeks): six uretero-ileal strictures (three Bricker, one uretero-ileoplasty, one enterocystoplasty and one Kock pouch) and six ureterovesical strictures (Lich-Grégoir or Paquin UV reimplantations after gynaecological, vascular or endoscopic surgery). The median postoperative follow-up was 16 months (range: 10-36 months). A good result was defined by the absence of recurrence of the stricture evaluated both clinically and radiologically (regression of stasis measured by IVU and/or ultrasonography). The mean operating time was 70 minutes and the mean hospital stay was 4.8 days (range: 3-14 days). Only one intraoperative complication was observed (migration of the double J stent to the kidney). The operation was successful in eight patients (75%). The success rate was 83% for ureterovesical strictures and 50% for uretero-ileal strictures. A history of previous irradiation appeared to be a factor of failure. The Acucise procedure is a minimally invasive and effective (75% success rate) treatment option for the treatment of postoperative stricture after ureteric reimplantations. In our department, this option is considered to be first-line treatment, as surgical reimplantation is reserved for failures of the endoscopic technique.

Mucosal Assessment for Dysplasia and Cancer in the Ileal Pouch Mucosa in Patients Operated on for Ulcerative Colitis—A 30-Year Follow-Up Study

Sporadic reports of epithelial dysplasia and the occasional development of adenocarcinoma in the ileal pouch mucosa have recently appeared in the literature, pointing toward yet another long-term complication of the continent ileostomy and the pelvic pouch. The incidence of dysplasia and the risk for developing cancer has not been critically evaluated, however, and the reports are contradictory, with most having short observation times. The purpose of this study was to report long-term mucosal adaptation patterns and the incidence of dysplasia in Kock pouches after a mean follow-up of 30 years for patients previously operated on for ulcerative proctocolitis. Two sets of two pathologists each (in Gothenburg, Sweden, and Manchester, United Kingdom) examined sequential, small-intestinal biopsy specimens from 40 patients with Kock pouch to observe long-term epithelial changes, with particular reference to the presence of dysplasia. There was full agreement between the two groups regarding the absence of high-grade dysplasia and invasive carcinoma (Categories 4 and 5 of the Vienna classification). There was, however, significant disagreement in reporting the frequency of low-grade and indefinite categories of dysplasia (Categories 2 and 3, of the Vienna classification). No attempt was made to report the differences within each set of pathologists. Because no case of high-grade dysplasia or invasive carcinoma was found in this study after a mean follow-up of 30 years, we conclude that it is very unlikely for invasive carcinoma to be a complication in ileal pouch mucosa.

T-pouch: a new valve design for a continent ileostomy.

After proctocolectomy for ulcerative colitis or familial adenomatous polyposis, creation of a continent ileostomy is one of the surgical options. Although most patients will be offered a pull-through procedure, the continent ileostomy is a valuable alternative in patients who are either not candidates for or have failed an ileal pouch-anal anastomosis or who--for other reasons--prefer a permanent ileostomy. The traditional continent reservoirs (Kock or Barnett pouch) with an intussuscepted bowel segment as valve mechanism have an unsatisfactorily high incidence of dysfunction and frequent reoperations. The objective of this study was to adapt the T-pouch valve concept, previously used for urinary reservoirs, for a continent stool reservoir and to construct a valve mechanism that omits intussusception of the bowel and maintains the blood supply to the valve segment. The technique for the critical valve construction is described in detail. It consists of isolating the terminal segment of the small bowel with its blood supply. The valve mechanism is created by embedding this segment in a serosa-lined tunnel of two apposed limbs of bowel that will form the pouch reservoir. Preliminary results in six patients indicate complete continence of the pouch. Although long-term results are not yet available, the new T-pouch concept is suitable as a continent stool reservoir and promises a significant improvement as compared with the traditional Kock pouch.

Vitamin B12 and folate after 5-12 years of continent ileal urostomy (Kock reservoir) in children and adolescents.

To assess B12 and folate deficiency after continent urinary diversion via a Kock continent urinary reservoir in children and adolescents. Ten boys and 10 girls (10.8-18 years old at surgery) were operated with a Kock reservoir and followed for 5-12 years (mean 8.5). The follow-up period was divided into early (3 months-5 years, EFU) and late (5-12 years, LFU) follow-up. Patients were investigated for haemoglobin, serum iron, total iron binding capacity (TIBC), serum Vitamin B12, serum and blood folate, methylmalonic acid (MMA), homocystine and glomerular filtration rate. Two patients developed subnormal B12 values (median 107.5 pmol/l), one at the EFU, and the other at LFW. The B12 value decreased during the LFU compared to the EFU in nine patients, but it was still within the normal range. Two patients with renal impairment had elevated MMA with normal B12 values. Five patients had high values of homocystine with folate deficiency and/or B12 deficiency and renal impairment. Plasma folate mean value was normal during the whole follow-up. Blood folate was below normal in five patients at the EFU. Two of these five patients, in addition to three patients, had low values at the LFU. Three of four patients with remaining short terminal ileum (20-45 cm) had normal B12 values at both the EFU & LFU and one had low values at the LFU. Six patients had subnormal GFR at the LFU. To a similar degree as in adults, Vitamin B12, folate and iron deficiency can occur in children and adolescents after continent urinary diversion using an ileal segment. Therefore, Vitamin B12 and folate should be monitored regularly in these patients. Serum MMA and homocystine may offer increased detection of Vitamin B12 deficiency, especially in the patients with normal renal function. Vitamin B12 deficiency is neither correlated with the time elapsed since surgery, nor with the ileum length. Patients are usually asymptomatic, so patients with true B12 deficiency should be identified and placed on life-long Vitamin B12 therapy. An adequate synthetic folic acid as supplements or fortified food is recommended for patients with folate deficiency.

In vitro determination of active bile acid absorption in small biopsy specimens obtained endoscopically or surgically from the human intestine.

In the construction of a Kock reservoir for continent urinary diversion, 70 cm of the distal ileum are used. Impaired absorption of bile acids in these patients might cause diarrhoea. Data on the absorption of bile acids in different parts of the human intestine are limited. Biopsies were taken during endoscopy from the duodenum, the terminal ileum or the right colon, and during surgery 10, 50, 100 and 150 cm proximally to the ileo-caecal valve using standard endoscopy biopsy forceps. The biopsy specimens were incubated in vitro with radio-labelled taurocholic acid at 37 degrees C for 22 or 45 min The radioactivity was determined using the liquid scintillation technique. A linear increase in the uptake was observed, with increased concentrations of taurocholic acid between 100 and 500 microm in all specimens tested, that represented passive uptake or unspecific binding. The active uptake could be calculated from the intercept of the line representing passive uptake with the ordinate. The active uptake in the terminal ileum was 3-4 times greater than 100 cm proximal to the valve. The active absorption of bile acids in humans can be determined in small biopsy specimens taken using standard biopsy forceps during endoscopy or surgery. This method is suitable for clinical studies of bile acid absorption. Active uptake of bile acids not only takes place in the very distal part of the ileum but also to a considerable degree 100 cm proximally to the ileo-colonic valve. This should be taken into account when selecting the ileal segment for continent urinary diversion.

Health-related quality of life after 5-12 years of continent ileal urostomy (Kock reservoir) in children and adolescents.

To assess quality of life after continent ileal reservoir diversion in children and adolescents. Nine boys and 9 girls (10.8-18 years old at surgery) were operated with a Kock reservoir and followed for 5-12 years. They participated in an interview using a questionnaire based on the Swedish self-esteem inventory, "I think I am". The questionnaire consisted of 76 questions that covered medical, physical, psychological, social, body image and sexual aspects. Six of 18 patients had some difficulties on catheterization. Five complained of pain or bleeding during evacuation. Two patients had slight urinary leakage between evacuations and 6 had mucus secretion. Ten patients had diarrhea with different frequencies. Physical activities were not hampered by the operation in any patient. Instead, activities such as full day outside home, friend at home overnight, using all types of clothes, and participation in camps were increased in 8, 6, 5 and 5 patients, respectively. All patients but 2 had an excellent relation with friends and family members. More than half of patients had excellent positive self-esteem and body image and the rest had very good self-esteem. However, some patients were concerned about how they looked and felt that life was unfair to them. The patients were satisfied with their operation. They were physically active and declared a positive perspective regarding self-esteem and body image. The medical problems related to the operation did not have any negative influence on the self-esteem or body image. The choice of the operation can only be determined on the basis of an attentive dialogue between surgeon, child and parents.

Continent Ileostomy: Evolution of Design

Continent ileostomy (Kock pouch) is an alternative to end ileostomy for patients who have undergone total proctocolectomy. The procedure reached the height of its popularity soon after its introduction in 1969, but subsequently was supplanted by ileal pouch anal anastomosis (IPAA), an operation that preserves the natural route of defecation. Continent ileostomy is still appropriate for selected patients with ulcerative colitis and familial polyposis who are not candidates for IPAA or for whom IPAA or end ileostomy have failed. Complication rates that initially were high have decreased during the past three decades following the steady introduction of technical improvements.

Long–Time Experience with the Kock Ileal Reservoir for Continent Urinary Diversion

Objectives: N.G. Kock performed the first continent cutaneous ileal reservoir for urinary diversion in 1975 at the Sahlgrenska University Hospital, Göteborg, Sweden. We have investigated the fate of the patients operated during the following 25 years at this hospital and analyzed their health–related quality of life (SF–36) as well as their psychological adjustment to a life with a continent urinary reservoir (OAS). Material and Methods: Between 1975 and 1999, 176 patients underwent continent urinary diversion using a Kock reservoir. At the end of 1999, 126 patients were known to be alive. Their reservoir function was estimated from their journals as well as from a questionnaire answered by the patients. Results: Almost 90% of the survivors had a well–functioning reservoir at the time of follow–up. The need for reoperation has been high, mainly due to nipple problems. Kidney function is not influenced by the continent diversion per se. The health status of the patients is more influenced by the underlying disease than by their reservoirs. Patients with benign functional or inflammatory diseases experience comparatively more problems with their reservoirs. Conclusions: The functional end results as well as patient acceptance of continent urinary diversion with a Kock reservoir are excellent.

Choices in Creating Continent Urostomies Following Pelvic Exenteration for Gynecologic Malignancies

Objective. The purpose of this report was to describe a rationale for choosing from a variety of techniques to construct continent urinary diversions for patients who undergo pelvic exenterations. Moreover, this report evaluated the technique and utility of a continent urostomy created from a supracecal segment of colon.Methods. The charts from patients who underwent pelvic exenterations and urinary diversions by DFS between September 1999 and December 2000 were reviewed after institutional review board approval. Data were recorded and evaluated.Results. Four patients underwent total pelvic exenterations and one received an anterior exenteration. Recurrent vulvar, vaginal, and cervical cancers were diagnosed in one, one, and two of the patients. One patient had an unknown primary squamous cell carcinoma in the pelvis. Four of the five received prior pelvic radiotherapy either in the neoadjuvant setting or as treatment for their primary disease. All five patients chose to have continent urostomies constructed. One Kock (ileal) pouch, one Miami (iliocolonic) pouch, and three supracecal colonic continent urostomies (SCCCU) were built. All five maintained continence over the follow-up period (mean follow-up time = 8.2 months). No complications related to the urostomies required reoperation. A new technique to for the construction of a SCCCU is described.Conclusion. With a variety of procedures established to build continent urostomies, the choice of which to use should be individualized to the patient's situation as well as to the surgeon's experience. The use of a SCCCU requires moderately complex manipulations of the colon (described in the text) and a slight increase in the operative time; however, it results in successful continence and avoids complications related to radiation-injured bowel. It may be considered the procedure of choice for patients who have received prior radiation therapy. Long-term follow-up is needed.

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

MULTI-INSTITUTIONAL EXPERIENCE WITH THE GASTROINTESTINAL COMPOSITE RESERVOIR

FUNCTIONAL RESULTS OF ORTHOTOPIC ILEAL NEOBLADDER WITH SEROUS-LINED EXTRAMURAL URETERAL REIMPLANTATION: EXPERIENCE WITH 450 PATIENTS

We report functional results of the orthotopic ileal neobladder using a serous-lined extramural tunnel as an antireflux procedure. One-stage radical cystectomy and orthotopic ileal W-shaped neobladder creation were performed in 353 male and 97 female patients for invasive bladder cancer. The ureters were reimplanted using a serous-lined extramural tunnel for reflux prevention. Of the patients 344 were evaluable at a mean followup plus or minus standard deviation of 38 +/- 25 months. Evaluation included clinical and radiographic studies to determine functional and oncological outcomes. Four patients (0.8%) died in the hospital. Early complications in 42 patients (9%) were treated conservatively but 3 women underwent vaginal repair of a pouch-vaginal fistula. During the observation period there were 90 oncological failures, of which 3 were isolated urethral recurrence. Late complications included pouch stones in 10 cases, outflow obstruction in 11, mucous retention in 2, adhesive bowel obstruction in 3 and hypercontinence in 9 females. The incidence of daytime and nighttime continence was 93.3% and 80%, respectively. The upper tracts remain unchanged or improved in 96.2% of the reimplanted renal units, while reflux was observed in 3%. The serous-lined extramural tunnel has proved its efficiency and durability as an antireflux technique.

Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy

Restorative proctocolectomy and ileal pouch-anal anastomosis is the surgical treatment of choice for patients with ulcerative colitis. As a long-term complication of this procedure, chronic pouchitis impairs the outcome in a number of patients. Aneuploidia and dysplasia have been observed after long-lasting inflammation of ileal mucosa. The question arises whether chronic inflammation of ileal mucosa predisposes to malignant transformation similar to the situation in the chronically inflamed colon. Cancer of the ileal mucosa has been reported in patients with Brooke's ileostomy and in patients with Kock pouch but not as yet in those with an ileoanal pouch. We report a patient with carcinoma in an ileoanal pouch originating from terminal ileal mucosa who had been suffering from pancolitis with long-term backwash ileitis before, and from chronic pouchitis after, restorative proctocolectomy. This case demonstrates the importance of regular follow-up with pouchoscopy and random biopsies in all patients with long-standing inflammation of the ileal mucosa.

Management and Aetiology of Stones in Intestinal Urinary Reservoirs in Adolescents

Objective: To review the aetiology and management of reservoir stones in patients with intestinal urinary reservoirs. Subjects and Methods: Since 1983 patients with enterocystoplasty have been followed prospectively by protocol. The data sets and notes of 148 patients reconstructed for congenital anomalies were reviewed to retrieve information on the incidence, management and aetiology of reservoir stones. Results: Data were complete on 146 patients, 2 others having been lost to follow–up. Mean follow–up was 3.4 (range 1–14) years. Twenty–three patients formed stones (15.8%). Mean time to stone formation was 45 months (range 1 month to 10 years). In 13 patients the stones were removed by a percutaneous approach. In 9 patients with large stones (>5 cm) an open removal was performed. One patient had a small stone removed through a Kock nipple. All stones were struvite on analysis. All patients with an augmented bladder drained by a supra–pubic Mitrofanoff formed stones at some time. The incidence of stones in other groups was: Kock pouch 50%; reservoirs drained by urethral catheterisation 9%; all other abdominal reservoirs 7.5%. No patient who voided spontaneously formed stones. Conclusion: Reservoir stones are infective in composition. The incidence is strongly related to the lack of downward, gravitational emptying. Stones up to 5 cm can be removed percutaneously.