When a patient needs to undergo removal of their entire large intestine (the colon and rectum) a new pathway for the evacuation of digestive waste will be necessary. There are four surgical options for patients who need to undergo total colectomy. All options are available for patients with both UC and FAP.
1. Conventional Brooke Ileostomy
The stoma and appliance for a traditional ileostomy
The procedure that has been performed for the longest period of time, since the mid-1950s, involves removing the colon and rectum, including the anal opening and anal canal, and creating a conventional Brooke ileostomy. The end of the small intestine is brought through an opening in the abdominal wall and sewn to the skin to create a projecting stoma about 3/4-inch long. This enables the intestinal waste to flow directly into the appliance, which is glued onto the skin around the intestinal stoma itself. Since the small intestine is a continuous flow system the patient must permanently and always wear the appliance.
Schematic of the J-pouch
2. Ileoanal "J" Pouch
The operation that has been performed since the early 1980s involves removing the colon and upper rectum but leaving the anal canal. An internal pouch is created from the small intestine and this is connected to the anal canal. This operation goes by many names including J-pouch, ileoanal pouch, the pull-through procedure, and the IPAA (ileal pouch-anal anastomosis).
3. Kock Pouch-Continent Ileostomy
Schematic of the Kock pouch
A Swedish surgeon named Dr. Nils Kock devised this operation in 1969. This was the first continent intestinal reservoir. It involves removing the colon, rectum, and anal canal in the traditional way. The contents of the small intestine stay within the body until the patient decides to empty it. While the procedure initially had about a 40% failure rate, mostly due to valve slippage, modifications have made over the last 20 years that reduce the complication and failure rate.
The first change was creating a “nipple valve” which involved taking a small segment of intestine and telescoping it back into itself making two layers of mucosa. This decreased the potential for the valve to prolapse. Another major modification involved wrapping a segment of bowel around the base of the valve referred to as a “living collar”. This collar is in concert with the reservoir and creates a “draw string effect” as the pressure in the pouch fills. This modification reduced the tendency of the valve to move out of position and improve continence. Another significant modification was to eliminate a triangulated surgical line in the round shaped Koch pouch. With Barnett’s modification, a lateral pouch design was created involving one midline incision thus reducing a potential fistula prone site.
Individuals who already have a Kock pouch and are experiencing difficulty can have their K pouch transformed into the Barnett version. We find that usually the pouch itself is large and healthy so to conserve small intestine, the reservoir is preserved. The weakness usually lies with the valve mechanism, so the efforts in the operating room involve creating a new valve, collar and stoma.
The Barnett Continent Intestinal Reservoir (BCIR)
The Barnett Continent Intestinal Reservoir (BCIR) is a modified version of the continent Kock Pouch. Several design modifications were made in an attempt to reduce the incidence of the most serious complication of continent reservoirs-slipped valves and fistulas. The major modifications are a collar made from a piece of the patient's own intestine, an isoperistaltic valve and a lateral pouch design.