Speaker 1In this class, we're going to discuss continent ileostomy, specifically the Koch pouch and the Barnett continent ileal reservoir. We will tell you up front, this is not where you want to spend a lot of time and focus because this procedure is rarely done today, but there are still patients out there who have had it done in the past and who might show up in your emergency room and it may be done in the future. So you need just a basic understanding of what these procedures involve, the basics of management and the ability to look it up if you need a refresher. So we're going to go over the basics. We're going to talk about the surgical technique. We are going to talk about the surgical technique for creation of a continent ileostomy. The indications, contraindications and criteria for this procedure and management of the patient with a continent ileostomy. So just a little bit of background. Remember that for many years, people with ileostomies really struggled to maintain an intact pouch seal. They had a lot of problems with peristomal skin complications. They had huge issues with reintegrating into their lives because of the issues maintaining a pouch seal. So back in the 60s, 70s, Dr. Nils Koch decided, you know, I wonder if instead of making these people dependent on a pouch that's worn externally, I wonder if there's any way to create an internal reservoir connected to the abdominal wall with a stomach. And so he decided to create an internal pouch that was connected to the abdominal wall and an abdominal stoma, but with a one-way valve between the stoma and the reservoir. And then they wouldn't have to wear a pouch. They could just pass the catheter and drain the reservoir periodically. So that's the basic concept. You see here, if you look at the illustration on top, they've created an internal pouch. You can see here that it's a two-way valve between the stoma and the reservoir that maintains continence. So the pouch is created from detubularized loops of ileum. The continence mechanism is created by intussuscepting the bowel between the stoma and the reservoir. We'll come back to that. And then the patient manages by passing the catheter in two to four times a day to drain the reservoir. And in between, they just wear a little tube. And finally, remember that the patient has to be able to intubate the reservoir at intervals. So if there are any physical issues, lack of dexterity, issues with eye-hand coordination, if there's cognitive impairment, the patient would not be a candidate for this procedure. Now, we're going to quickly go through the surgical construction, just so you have a basic understanding. Again, we don't want you to get lost in the details here, because you may never, ever see a patient with this procedure. But what we want you to understand, what you should be able to explain to a patient, is that the surgeon takes the end of the small intestine, lines loops of bowel up side by side, and then essentially reconfigures those loops, the loops of bowel, to form a flat sleeve. So the analogy I used to use with patients when we were doing this is, imagine that you have a long-sleeved shirt or blouse. You don't really want that shirt or blouse anymore, but you would love to make a scarf out of that material. So you can disconnect the sleeve, a tubular structure from the garment, open up the seams, and so now you have converted, a tubular structure to a flat piece of material. And essentially, that's what the surgeon does. He or she lines up two loops of bowel side by side. They measure them carefully. They suture the front wall of those two loops together so that they are attached. Then, as you can see from the illustration on top, they make an incision around that suture line, and then they suture the back wall together. So what I want you to pay attention to, if you look at the bottom left, I hope you'll be able to appreciate that they have taken two loops of bowel, opened them up, and created a flat plate. And once you create a flat plate, you can reconfigure it in any shape that you need. So then when you look at the bottom right, you see that now they've folded that flat piece of bowel up on itself to form a reservoir. You have a loop of bowel with its tubular structure intact, feeding into the reservoir. And then you have another loop of bowel that is going to be used to construct the catheterizable channel and the abdominal stoma. When they open those loops of bowel, and then they fold the bowel onto itself and form like a pouch, that is a catheterizable channel. And it's going to interrupt the muscle fibers that normally control peristalsis. And that's advantageous, because once you interrupt those muscle fibers, you stop peristaltic activity, and the reservoir becomes acontractile, which further supports continence. Now let's talk about the continence mechanism. So they have the segment of bowel between the reservoir and the abdominal wall. And what they do is, They have the segment of bowel between the reservoir and the abdominal wall. And what they do is, If you can look again to the left, they reach in and they double that section of bowel back on itself. They intersuscept it. So it's like if you held one end of a sweater sleeve and then reached in with your hand and doubled up the sweater. Now this works because of several things. First of all, the ilium is only an inch in diameter. So you think it's narrow to begin with. And it's a muscular sleeve. So if I reach in and I pull that bowel back on itself, Now I've doubled up a narrow sleeve, and it's muscular. So what you end up with is a potential path, but not an open channel. So that means that when you insert the catheter to intubate this reservoir, you can go through the stoma easily. Because the intersusceptive section begins just proximal to the stoma. So you go into the stoma, and then you hit a little wall. And you have to feel your way through that intersusceptive portion to be able to intubate the reservoir. I know exactly what it feels like because I've done it. It's hard to imagine, but if you ever care for a patient who has a stoma, or a patient who has a continent ileostomy, that patient's been catheterizing, intubating their reservoir. And they can walk you through exactly how they angle the catheter, and where they get the most resistance. And then you end up with a skin-level stoma. Now the Burnett Continent Ileal Reservoir is a modification of the original Coke pouch. And of course, the Coke pouch was named after me. The Coke pouch was named after Nils Coke, who was the surgeon who developed the procedure. Burnett Continent Ileal Reservoir was named after William Burnett, the surgeon who came up with the modification. So Dr. Burnett looked at outcomes with the Coke pouch and realized that the most common problem was slippage of the continence mechanism. And he thought, "I wonder if there's something we could do to reinforce that continence mechanism and to make slippage less likely." So here's what he did. He basically created the reservoir in exactly the same manner as Dr. Coke had done. So really nothing different about reservoir construction. He intussuscepted the bowel between the stoma and the reservoir. So that was the same. But then he created what he called a living collar. So he took a loop of bowel and wrapped it around the continence mechanism. So if you can look at the illustration on bottom, you can see that there is a loop of bowel that's closed on one end and that communicates with the reservoir on the other end. So that means that as the reservoir fills, that little section of bowel fills and compresses the continence mechanism, compresses the component of bowel that has been intussuscepted. And then when you pass a catheter into the reservoir and you drain the reservoir, that little collar drains as well. So the collar fills and drains, fills and drains. It provides additional support to the continence mechanism when the reservoir is full. And then when the reservoir is empty, the collar empties as well. So it's just added support for continence. In terms of day-to-day management, that living collar does not change management. But it does mean that that patient's lower risk for leakage. What would our responsibilities be if we had a patient who was undergoing a continence ileostomy? Well, preoperatively, we want them to understand what is going to be done, the basic principles behind a continence ileostomy. Critically important for them to understand that they're going to have to pass a catheter through the stoma into the reservoir to drain it several times a day. For most people, it's two to four times a day for the rest of their life. So we want them to know this is one option. Standard ileostomy is another option. And we want to answer their questions. What are the potential problems with a standard ileostomy? Why do people sometimes have this done instead? What are the potential problems with this? What's management like with a continence ileostomy versus management with a standard ileostomy? Again, we have to assess their cognitive ability to do intubation two to four times a day, as well as their manual dexterity and eye-hand coordination. And what we have learned is that we need to tell that patient, you will probably require periodic revisions of the continence mechanism of the stoma of the reservoir. So Dr. Barnett sometimes told his patients, the initial procedure is like a down payment, but there will be additional payments that are required. So don't think this is a one and done. This is the big operation, but you might have to have minor procedures throughout the rest of your life to maintain continence and to keep this continence ileostomy functional. We do typically mark them for the stoma site. It can be low, as you can see in the illustration mid-screen. Her stoma is definitely lower than a standard ileostomy because she's going to manage with intubation intubation, not with pouching, but we do want it within the visual field, if at all possible, and we want it on the flat surface just in case there are issues with the continence mechanism and pouching is required. Now, during the early post-op phase, it's all about promoting healing of this newly constructed reservoir and promoting healing of the newly constructed continence mechanism. So you can see, by looking at the illustration on top and at the middle of your screen, you've got long staple lines or suture lines, and those have to heal. And we don't want the reservoir to distend at all until that suture line, that staple line, is well-healed. So we are going to keep the reservoir, keep that internal pouch decompressed until healing is complete. We do not want to be doing intubations. We don't want to put a catheter in, take it out, put it in, take it out during that initial healing phase. First of all, we'd have to do it very frequently to keep the pouch decompressed, and every time we did that, we would be caught. Okay. So what we're going to do is we're going to put in a large bore catheter at the time of surgery, typically about a 32 French catheter, so a very large bore catheter at the time of surgery is left in place for two to three weeks. That allows for healing of the reservoir, and it's going to allow for healing of the uterus. And then we're going to put in a large bore catheter at the time of surgery. reservoir, keeps the reservoir decompressed, supports and stabilizes the intussusception, the continence mechanism, and prevents any trauma associated with in and out catheterization. Now it's important to irrigate the catheter routinely with about 30 milliliters of saline to keep it patent so that we keep the reservoir decompressed. And we also typically put patients on low fiber diets because if they take in significant roughage in soluble fiber, it can clog the catheter. It can be very difficult in that situation to reestablish and maintain patency. Okay, so we've gotten through the first two to three weeks. We've had the catheter in place the whole time. We've been irrigating at PRN. We've kept the reservoir decompressed. We've supported and protected the intussusception, the continence mechanism. So now we're at the late post-op phase. Typically three weeks post-op is when we move into phase two. And now we're going to remove the catheter. We're going to teach the patient in and out catheterization. Okay. We're going to gradually lengthen the catheterization intervals so that the reservoir begins to stretch and to increase in capacity. So we typically bring the patient back to clinic, take the catheter out, show the patient how to pass the catheter, have the patient practice, have them do it several times during that clinic visit. So these are the basic principles of intubation. You're going to lubricate the catheter. You're going to push it through the stoma. It goes through the stoma very readily. Once it reaches the intussusceptive section of the bowel, now you have resistance. So now you have to kind of feel your way through. We usually use kind of a twirling motion to kind of feel our way through. Steady pressure. We never force it. If you force it, you could go right through the intussusception. You could perforate the bowel. So you never force it. You emphasize to the patient, do not force. Feel your way through. Typically we start out having them catheterize every two hours during the day, every three to four hours at night. Pretty rapidly we increase the intervals so that long term. Most patients are catheterizing every four to six hours during the day. So they usually catheterize two, possibly three times a day. Also we have to teach them, pay attention. When your reservoir feels full, you need to go to the bathroom and drain it because there's no way for gas to get out until you pass that catheter. So you're going to catheterize on schedule. Also PRN for feelings of fullness. Now they definitely have to be careful with their diet. Much more careful than an individual with a standard ileostomy because you have to think about the fact that everything is going to drain through a 32 to 34 French catheter. So if they eat insoluble fiber, they have to chew it really, really well. They have to grind it down so that it can go through that catheter. So we usually teach them no peels. I remember one of our patients, we forgot to tell her, don't eat grapes. And I got a Monday morning call, "Darcy, was there something you didn't tell me about grapes?" So she had spent a memorable afternoon putting the catheter in, draining the reservoir till it got, the catheter got blocked by a grape peel, taking the catheter out, taking the peel out, putting the catheter back in. So yes, we have to teach them no peels. Be very, very careful with nuts. Be very, very careful with stringy vegetables. Best to generally avoid them. So really much more stringent than the guidelines we provide a patient with standard ileostomy. Hydration issues, exactly the same as for a patient with an ileostomy. And actually the patient with a continent ileostomy is in a slightly better position because the liquid stool sits in the reservoir, which is lined with mucosa. So they get more water reabsorption than the patient with the standard ileostomy. But basically we tell them you need at least two liters a day baseline and then every time you drain your reservoir. You need to drink a glass of replacement fluid. Also, you need to be very alert to early signs of dehydration. So dry mouth, dark urine, dull headache, feeling more tired than usual, and you need to increase your fluid intake accordingly. Just like a patient with a standard ileostomy, if a patient with a coke pouch is having issues with diarrhea, they're having to drain their reservoir. More frequently, they're having higher volume, more liquid stool, and they're unable to replace fluid losses because of nausea and vomiting, they need to go to the emergency department. Medications can also be an issue. Now again, anything that gets to the coke pouch is going to sit there for a while before the reservoir is intubated. Absorption is not as big an issue as it is for a patient with a standard ileostomy, but there are some unique issues associated with a patient with a coke pouch. So in general, we tell them don't take sustained release because it's going to be hard to tell whether or not you got the full dose. Critically important to tell them do not take wax-based medications. Now there's not too many out there, but there are a few. Stained release medications that are embedded in a wax matrix, and the medication's leached out of that wax matrix as it goes through the intestinal tract, but the wax shell is left behind. And normally it's no issue. If the patient has an ostomy, it just goes through the stoma. If they have a rectum, anal canal, it just passes out with the stool, but here you have no way to get that wax shell out of the reservoir. It's certainly not going to drain through the catheter. And I remember one patient who literally became blocked from his wax matrix medications. They had to take him to surgery, open the reservoir, take out all of those wax shells. It was like, I'm trying to remember, 480-something. Some nurse had to count all of those I know, but bottom line, no wax matrix medications. So we need to tell the patient, any time somebody is talking to you about medications, you need to tell them, I have something known as a continent ileostomy. Everything has to drain out through a catheter. I can't take sustained release because of incomplete absorption. I can't take anything with a wax base because I can't get it out of my reservoir. And, of course, we don't want them taking stimulant laxatives like Sinicod or Dalklax. Now, here's another pretty common problem, and that is thick drainage. So they're going to have the same kind of output as the patient with an ileostomy. It's actually going to be slightly less fluid because of water absorption by the mucosa of the reservoir. So critical for them to maintain adequate fluid intake. A lot of patients find that they benefit from drinking prune juice or grape juice a couple of times a day to keep the drainage thin enough to pass through that large bore catheter. You don't want it to take forever to drain your reservoir. So when you put the catheter in, you want it to drain readily. But if the drainage is very, very thick, it's not going to drain readily. So keeping the stool thinned out a little bit is really helpful for these people. If they put the catheter in and nothing wants to drain, they can instill lukewarm water to kind of fluidize the stool so that it drains more readily. And some clinicians have their patients use low-dose polymers. Polyethylene glycol like Miralax or Clearlax, one of those agents, on a daily basis just to keep the stool thin enough to drain readily through the catheter. What about the stoma? Well, they don't need a pouch, but they do need to cover the stoma because it's going to be wet and secrete mucus and it can get their clothing wet. And also you want to protect it from friction and trauma. So most. Most patients cover the stoma with like a stoma cap or a soft gauze dressing and a strip of tape. Some people just take like a mini pad and strip it to their underwear so that when their underwear is up, the stoma is protected. But when they're ready to intubate, all they have to do is take down their underwear and now they have access to the stoma. And then that protects their skin from repetitive tape applications. There is a company that makes caps specifically for continent diversion. It's Alston Medical. They have an Alston Medical patch. So if you're talking to a patient, you can give them that information. The skin right around the stoma is going to be exposed to mucus. So occasionally you might get a yeast infection or you might get some maceration. A lot of patients routinely use a liquid skin. And they use a liquid skin barrier like skin prep or Kevlon or SurePrep to protect their skin. Long-term considerations, a lot to teach these patients. So again, we have to reinforce the correct approach to intubation. Critical importance of never, ever forcing the catheter. The importance of having one to two catheters on hand at all times because that catheter is like. They're like their anal canal. They should always have access to a catheter. The company that provides these catheters, they're Medina Catheters. Notice that we typically range from 28 to 32 French. So they're very large bore catheters. All they need to do to take care of the catheter is wash it in warm sudsy water, rinse it, dry it, store it. They should replace it if they start to develop any rough edges. Critically important for them to wear a medic alert bracelet or a medallion because otherwise no one's going to know what that is. So it should say something like "continent ileostomy, must insert catheter to drain" and a phone number so that if they do end up in an emergency room, someone can follow up and identify critically. And then they can identify critical interventions to keep the reservoir drained. We want the patient to know the importance of maintaining a healthy weight and avoiding significant weight gain, avoiding obesity because healthy weight protects their continence mechanism. Obesity puts their continence mechanism at risk. And then they should be followed routinely by the surgical team for lab work. And for periodic endoscopy of the pouch to make sure that the pouch is healthy. What are the potential complications? Difficult intubation is probably the one that patients worry about the most. So you have to think, "Okay, what would make it really difficult to get the catheter through the stoma, through the continence mechanism into the reservoir?" Well, the first is that it's really hard to get the catheter through the stoma, through the continence mechanism into the reservoir. Well, the first and probably the most common is allowing the reservoir to overfill. Because when it overfills, look at the illustration on top. You can see that if the reservoir is super full, it's going to compress the sides of that intersusceptive bowel together. And it's going to tremendously increase resistance to catheter insertion. So don't let it overfill. Sometimes it's hard to pass it because the patient is anxious and worried. And they have inadvertently tightened their abdominal muscles, which also creates abnormal resistance because it's squeezing around the continence mechanism. So sometimes we are talking to patients about deep breathing, voluntary relaxation, to make it easier to pass the catheter. The other very common reason why it's hard to get the catheter through the reservoir, the very common reason is a very mild inflammation, like a very mild gastroenteritis. Maybe they don't even notice any significant symptoms. They just notice their reservoir is filling a little more often. So they have very mild diarrhea. But a very mild gastroenteritis can cause edema of the bowel wall. And that makes a tight sleeve a super tight sleeve. And it can make it more difficult to pass the catheter. And then the worst of the options for difficulty with intubation is if you've had slippage of the continence mechanism. So we start out, we want them to have basic strategies that they can use to facilitate intubation. And then they need to know, if you've done all these things and it hasn't worked, go to the emergency department. Because the whole time you're trying to pass the catheter and drain the reservoir, it's continuing to fill. So you have a limited timeframe for response. So we tell them, first of all, make sure you intubate on schedule. Make sure you intubate if the reservoir feels full. Because you might be having some diarrhea, you might have excess gas that's causing the tumor to distend. Secondly, if you're having trouble passing the catheter, focus on relaxing your abdominal wall. Some people will take a warm bath. And do deep breathing. Just relax. Then lubricate the catheter. Try intubating in a different position. So if you typically intubate while sitting on the toilet but that's not working, try standing. Try lying down. Try intubating in the bathtub. And then a lot of patients who can't get in a 32, which is their standard, will find that they can get in a 28 or a 26. So I encourage patients to always have a smaller catheter available, and if you can't get your standard catheter in, reach for your smaller catheter, because if the pathway is very tight, it's going to be easier to get a smaller catheter in. But don't mess around. If you can't get it in, go to the emergency room. Sometimes they'll have to do endoscopy to be able to effectively intubate. So here you can see, I want you to just look at the bottom, because this is kind of a continuation of our previous discussion. We're going to talk about valve slippage and failure of intubation. Before we talk about pouchitis, so look at the illustration on the bottom, and you see what happens when the pouch attachment to the abdominal wall becomes loose, when the pouch separates, when the continence mechanism separates. So now you can get all kinds of angles and kinks in that intussusceptive section of bowel that makes it almost impossible to pass the catheter. And also allows leakage. So how would they know there was a problem with their continence mechanism? First of all, they might find it almost impossible to pass the catheter. Secondly, they might start to experience some leakage from the stoma. And what they're going to have to do, go to the emergency room. A gastroenterologist is going to have to take a pediatric scope so that they can visualize the pathway and feed a catheter through the pathway into the reservoir to decompress the reservoir. They'll usually leave the catheter in place short-term while they determine next steps. Usually they have to take the patient back to surgery for surgical revision, which means getting the patient back to a center where they do these procedures and they repair slipped valves. Okay, so we've talked about that. Now let's talk briefly about pouchitis. Pouchitis is inflammation of the mucosal lobe. It is the lining of the reservoir and it can occur in patients with a continent ileostomy because instead of everything just going straight through the bowel and out into the colon or out into a pouch, now you've taken the end of the reservoir or you've taken the end of the small bowel and you've created a reservoir. So now you've got prolonged contact between the stool and the mucosa. And now you have the opportunity for the patient to come back to the hospital. for bacteria to proliferate. You can get bacterial overgrowth. You can get an imbalance between pathogenic bacteria and beneficial bacteria. And the result is an inflammatory reaction at the mucosal level. So what patients report is they have higher volume output. They have more mucus. Sometimes they have bleeding. They have increased odor. They might have cramping pain. They might have nausea and vomiting. They might have fever. A lot of times they'll tell you they feel like they have the flu. So typically we treat them by limiting solid intake, allowing oral intake, putting them on antibiotics, usually Flagyl or Cipro, adding probiotics to the mix to hopefully prevent a recurrence. Okay, so in summary, don't spend a ton of time on this content. You may never see one of these patients. But if you see a patient who has had a coke pouch or a Barnett continent ileal reservoir, or if their chart just says continent ileostomy, you should know that that means that the surgeon constructed an a-contractile reservoir in the abdominal cavity and that that a-contractile reservoir is connected to the abdominal wall where there's a stoma, that between the stoma and the reservoir, there's a section of bowel that has been intussuscepted to provide resistance to outflow. That's the continence mechanism. Early post-op care is all about, you know, about allowing the reservoir to heal, preventing distention during the initial healing phase, supporting the continence mechanism while it heals. So there will be a large bore catheter inserted into the reservoir, connected typically to a bedside bag, sometimes to wall suction. We'll be irrigating periodically to keep it patent. Long-term care, we take out that catheter, we teach the patient to put the catheter in at intervals and to drain the reservoir. We teach them to maintain hydration. We teach them to avoid large amounts of insoluble fiber, to chew their food extremely well, to avoid wax-based medications and sustained release medications. And then in terms of looking at complications, the two, most common long-term complications are pouchitis and valve slippage, both of which require medical intervention. Valve slippage requires surgical intervention. Okay. Thank you.
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