The Continent Ileostomy (or

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The Continent Ileostomy (or Kock Pouch)-
update May 2014Fran WoodhouseAdvanced Nurse
PractitionerOxford University HospitalsNHS
Trust.
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Evolution of Surgeries for UC

• 1951 Brooke end ileostomy
• 1969 Kock pouch Continent ileostomy
• 1978 Parks and Nicholls ileo- anal pouch

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• Background
• 2007 a female patient aged 52 approached
  Professor Mortensen. (Oxford) To date 12 patients
  .
• Western General, Edingburgh 20 over 17 years
  (14 current)

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Indications (for CI)

• UC
• FAP
• Failed ileo-anal pouch
• Previous proctectomy

• Poor/absent anal sphincter
• Patient preference psychological/social/ sexual-
  those having difficulty coming to terms with
  conventional stoma

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Contraindications

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

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So what is the Continent Ileostomy?
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New Dressing around K pouch catheter. Hollister
9782
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Some of the problems.........
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• 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

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Reasons for re-operation

• -Slippage of nipple valve
• -Parastomal sepsis
• Parastomal hernia
• Prolapse valve
• Difficulty with intubation
• Ischemic valve
• Fistula formation
• Other

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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

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Then what?

• Catheter out 2 - 3 weeks post op.
• Teach patient to catheterise.
• Order plenty of caps!!

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Medic Alert Bracelet

• Internal pouch/Continent ileostomy/ Koch pouch.
• Medina catheter to be inserted 4-6 hourly into
  pouch.

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Updates
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• 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

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Booklet for patients

• In progress with Alison and Julia.

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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.

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• 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.

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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)

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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.

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Recommendations for practice

• 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)

• 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.

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• 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.

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The future of the Kock pouch?

• Interest is growing.
• Referrals from all over the UK and beyond
• Revival.

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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

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Thank you. Any Questions?