Ileal Pouches in Inflammatory Bowel Disease

Until the 1970’s, when a patient required removal of colon (whether because of uncontrollable ulcerative colitis or colon cancer) the result was the creation of an ileostomy, that is, a bag taped to the abdominal wall, into which the fecal stream was diverted. But pioneering gastrointestinal surgeons, including our colleagues at The Mount Sinai Hospital in New York City, worked to devise ways to refashion the intestine to allow for continence of stool without the use of a bag.

These surgeons extended earlier work of a Swedish urologist, Niki Kock, who had used the small intestine to create a substitute urinary bladder for patients whose bladders had been removed because of cancer. Building on this research the gastrointestinal surgeons devised techniques to reconfigure the lower small intestine (ileum) into an internal pouch with a valve. The valve served to keep stool in the pouch without the need for an external bag and could be periodically emptied by the patient by inserting a small tube into the valve. The pouch thus took over the functions of the colon – storage of waste and maintenance of continence. Thousands of patients benefitted from these “Kock pouches”, especially in the 1980’s and 1990’s.

Over the past twenty years further surgical advances have made it possible to attach the internal pouch directly to the anal sphincter. These “ileo-anal pelvic pouches” enable patients who have had their colon removed to defecate in the normal fashion on a toilet seat. Because of this convenience the IPP, rather than the Kock pouch, has become the preferred operation.

As marvelous as the Kock pouch and ileo-anal pelvic pouch operations are they are not completely problem-free. With these pouches the small intestine is being called upon to act like a colon, that is, solidify the intestinal contents. It takes time for this adaptation to occur and many patients will continue to have semi-formed and somewhat more frequent bowel movements. Occasionally pouches can become inflamed (“pouchitis”) leading to diarrhea and abdominal cramps. Pouchitis can be readily diagnosed and effectively treated by experienced gastroenterologists. In patients with Kock pouches, the valve mechanism may kink or weaken over time leading to trouble emptying the pouch or maintaining continence. These problems can be addressed by dietary, medical, and sometimes surgical corrective measures.

Nevertheless, despite potential problems, most patients feel that their quality of life has been improved significantly by undergoing pouch operations. Patient considering these procedures are strongly advised to consult with a team of gastroenterologists and surgeons who have experience in dealing with these complex issues. Communication between patients, families, gastroenterologists and surgeons is vital in determining whether pouch surgery is the best option. If a pouch procedure is undertaken, it should be performed at a center of excellence quipped to manage the surgery itself as well as the post-operative care of the patient in a multi-disciplinary fashion.

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