Oct. 26, 2024
Certain medical conditions require the removal of both the colon and the rectum for effective treatment. For instance, individuals with chronic ulcerative colitis or familial adenomatous polyposis may require such surgical intervention. Currently, the standard of care for these patients is to undergo ileal J-pouch-anal anastomosis, a procedure offered at Mayo Clinic.
However, some patients with dysfunctional anal sphincters or those who experience complications related to their ileal J-pouch are not suitable candidates for this procedure. Complications can include infection or recurrent inflammation, known as pouchitis, that has exhausted nonsurgical management. In this case, patients must live with a permanent stoma and carry an external bag.
Several decades ago, elective total proctocolectomy (TPC) with end ileostomy was the standard care for patients with conditions that required surgery. Since then, additional surgical approaches have been developed, including restorative proctocolectomy with ileal pouch-anal anastomosis (RPC-IPAA) and continent ileostomy.
RPC-IPAA
Restorative proctocolectomy with ileal pouch-anal anastomosis is the restorative procedure of choice for patients who require surgery. Also known as a J-pouch procedure, RPC-IPAA preserves the anal sphincter and fecal continence, and it eliminates the need for an external ostomy after surgery.
Continent ileostomy
Unlike traditional ileostomies, which divert waste through an external opening and into a bag, the continent ileal reservoir provides a more discreet and manageable solution offering greater independence and improved quality of life.
Sherief F. Shawki, M.B., B.Ch., M.D., a colon and rectal surgeon at Mayo Clinic in Rochester, Minnesota, says, "The continent ileostomy, also known as a Kock pouch or K-pouch and once considered part of the past, is making a comeback. This procedure provides patients with a life-changing option — one that eliminates the need for an external bag while allowing them to regain control over their bodily functions."
First introduced in the 1970s, the continent ileostomy procedure involves the removal of the entire colon, rectum and anus without reestablishing gastrointestinal continuity. Subsequently, a reservoir to collect the stool is made from the small bowel, known as the pouch. A valve is then created to prevent the spontaneous passage of stool to provide control. The valve leads to the stoma, which is created flush with the skin so that it does not protrude. After the procedure is complete, stool collects in the internal pouch until the patient passes a catheter through the valve to drain it.
- Creating the reservoir. Using the small bowel, the surgeon creates a reservoir inside the abdomen, underneath the skin where the stoma will be. That reservoir collects stool and gas, serving as a space for waste, tucked away from external view.
- The internal valve. The true key lies in the internal valve, fashioned from the bowel itself. This one-way valve does not allow the spontaneous passage of stool. The valve allows the patient to regulate the flow of stool via intubation, transforming the elimination process into a manageable and controlled experience.
- Exit channel. An exit channel connects the continent reservoir to the skin surface. Unlike traditional ostomies, which require external bags, this channel ends flush with the skin, minimizing visibility and maximizing comfort.
Patients who have had a continent ileostomy for many years may need help with pouch care and maintenance. Some might require a revision in the future. Dr. Shawki emphasizes the importance of working with a surgeon who understands the intricacy in these cases.
Treatment that goes beyond the pouch
Mayo Clinic surgeons and care team members have extensive experience in managing the different configurations of continent ileostomy. "We know how to care for them. We know how to scope them and what to anticipate. And more importantly, we know how to interact with any need," says Dr. Shawki.
"If the J-pouch is not an option," explains Dr. Shawki, "the continent ileal reservoir could be a great alternative when deemed appropriate for the right candidate. When the procedure is done by experienced physicians, outcomes can lead to a greater quality of life for these patients," explains Dr. Shawki. "I've had patients come back after the procedure and say, 'This pouch gave me my life back.' "
Mayo Clinic has a convenient process for patients who want to learn more about reconstructive surgery options. Patients can begin this journey with a virtual or in-person visit during which the surgeon explains the available surgical options and gives an overview of the multidisciplinary team.
For more information
Refer a patient to Mayo Clinic.