Evolution of the Kock Continent Reservoir Ileostomy

A continent reservoir ileostomy was constructed in 85 patients, 9 of whom were adolescents. Indications for the procedure included organic problems related to the ileostomy as well as psychologic and sexual difficulties related to an external appliance. Fifty-eight patients had conversion from a conventional ileostomy. Twenty-five patients underwent total proctocolectomy and Kock ileostomy. An intussuscepted "nipple valve" was used in all cases. Follow-up ranged from 4 to 10 months. There were no operative deaths. Eighty-two patients are completely continent with regard to both flatus and stool. Only two patients wear an external appliance. No one has requested a return to a conventional ileostomy. No reservoirs have been removed. Ten of the initial 17 patients (59%) required at least one additional surgical procedure for early or late complications, the most frequent of which were intestinal obstruction, sliding or prolapse of the nipple valve and fistula. Technical modifications have reduced this morbidity; they included using SGIA staples across the nipple valve and a fascial sling around the outlet. These modifications have been used in 28 additional patients and in 5 from the original series. Ten of these 33 patients (30%) have required intra-abdominal operation for revision, 5 because of sliding of the nipple valve. Further modifications using a Marlex mesh sling have been made in 40 additional patients and in 7 patients from the original series. Six of these 47 patients (11%) have undergone or will undergo intra-abdominal operation for revision. Only one case of nipple valve sliding has occurred in this group. Marlex mesh has now been replaced by Prolene mesh. The benefits of the continent ileostomy are substantial. The author's results have continued to improve with experience and with the technical modifications outlined.