The Continent Ileostomy The Continent Ileostomy (or “Kock Pouch”)- (or “Kock Pouch”)- update update May 2014May 2014

Fran WoodhouseFran WoodhouseAdvanced Nurse PractitionerAdvanced Nurse PractitionerOxford University HospitalsOxford University HospitalsNHS Trust.NHS Trust.

Evolution of Surgeries for UCEvolution of Surgeries for UC

• 1951 Brooke end ileostomy1951 Brooke end ileostomy

• 1969 Kock pouch – “Continent ileostomy”1969 Kock pouch – “Continent ileostomy”

• 1978 Parks and Nicholls – ileo- anal 1978 Parks and Nicholls – ileo- anal pouchpouch

BackgroundBackground

• 2007 a female patient 2007 a female patient aged 52 approached aged 52 approached Professor Mortensen. Professor Mortensen. (Oxford) To date 12 (Oxford) To date 12 patients .patients .

Western General, Western General, Edingburgh 20 over 17 Edingburgh 20 over 17 years (years (14 current14 current))

Indications (for CI)Indications (for CI)

• UCUC• FAPFAP• Failed ileo-anal pouchFailed ileo-anal pouch• Previous proctectomyPrevious proctectomy

• Poor/absent anal Poor/absent anal sphinctersphincter

• Patient Patient preference preference psychological/social/ psychological/social/ sexual- those having sexual- those having difficulty coming to difficulty coming to terms with terms with conventional stomaconventional stoma

Contraindications

• Physically incapable• Mentally incapable• Previous SBR• Desmoid Tumour• Crohns• Severe obesity

So what is the Continent So what is the Continent Ileostomy?Ileostomy?

New Dressing around K pouch catheter. Hollister 9782

Some of the problems.........

0

2

4

6

8

10

12

14

16

18

2007-2014

Number of K poucheson Database

Males

Females

K Pouches Oxford

K Pouches Elsewhere

Valve Slippage

Fistula

Intubation problems

Pouch Excision

• Pre-op preparation:

-Referral from consultant

-Booklet on Continent Ileostomy

-Pre-op counsel (ideally face-to-face)

-Contact with other K pouch owners

-Discuss the potential problems and re-operation rates+++

Reasons for re-operation

-Slippage of nipple valve

-Parastomal sepsis

– Parastomal hernia– Prolapse valve– Difficulty with intubation– Ischemic valve– Fistula formation– Other

Post op care

• Usual c/ o patient following laparotomy.• Catheter and stoma• Observe stoma TDS for blood supply-

use pen torch.• Flush medina catheter BD + more if

stops draining and patient feels bloated. 20-30mls warmed n/saline or sterile water. Do not withdraw

• Check dressing around stoma regularly. ? 2 piece appliance.

• Ensure that medina is well secured. Care on mobilising.

• Check tubing regularly for blockage.• If Medina falls out before 14 days, have

consultant/ SpReg re- insert

Then what?

• Catheter out 2 - 3 weeks post op.

• Teach patient to catheterise.

• Order plenty of caps!!

Medic Alert Bracelet

• “Internal pouch/Continent ileostomy/ Koch pouch.”

• Medina catheter to be inserted 4-6 hourly into pouch.

Updates

• Numbers of K pouches since 2007= 12

• Post op device for afixing catheter.

• Use of Marlen soft catheters

• Work with Julia Williams and Alison Crawshaw- regular telephone conferences.

• Article for BJN to be published (2014) supplement

Booklet for patients

• In progress with Alison and Julia.

New trial of Marlen catheters

• To study 20 patients using new Marlen catheter to determine if easier intubation with Marlen

• Asking patients for “testimonials “ to try and get these on FP10

• Currently only available in USA.

• My work with Clinimed to devise a new stoma cap for K pouchers.

• Pre-op counsel• Collaborative working

with surgeons, e.g Endoscopy

• Booklet for medical professionals (hopefully being written by Richard Lovegrove in conjunction with Graeme Wilson and David Bartolo)

• Follow up in Nurse-led pouch clinic- hopefully the pink form to be adapted.

MSc dissertation

• Wanting something “useful” which might benefit this group of patients.

• Literature Review.

Why? Why not collect primary data ?

Negative viewpoint

-complications +++

• Minimal published studies.

(Total of 11 from 1995-2012)

Summary- How is QOL after a CI?

• Avoidance of an external drainable appliance.

• Improved sex life.• Improved general

enjoyment and happiness

• Less work and social restrictions.

• Anxiety about emptying the CI away from home.

• Repeated operations.• The freedom of

continence.

Recommendations for practice• Dedicated centres.• A pre-assesment tool• Allow choice much

earlier for patients- not just as a last resort

• Clearer post-operative guidelines.

• Support groups specific to CI.

• Collaborative working with our surgical colleagues. Stoma nurses need more involvement. Would serve as a triage system and expediate care and treatment.

• Updated CI booklet with Alison Crawshaw and Julia Williams)

• Perform our own study to replicate the research.

• Guidelines on diet and obesity.

• Address the anxiety issue re catheterising outside of home.

• Structured programme for surgeons.

• Design of a new stoma cap to manage excessive mucous.

• To work with an appliance company to create a model for patient demonstration of catheterising.

The future of the Kock pouch?

• Interest is growing.

• Referrals from all over the UK and beyond

• Revival.

In her own words....

“I empty it three times a day and never at night which is great. The pouch is totally continent of faeces but produces a small amount of mucous”

“I am so happy with my Kock pouch and eternally grateful to those who made it possible. It has totally changed my life for the better”

Thank you. Any Questions?Thank you. Any Questions?