Ask Dr. Schiller: What Is The Kock Pouch Procedure And How Does It Work?

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The Kock Pouch is a type of continent ileostomy. It is a viable option for those who must have their colons removed due to inflammatory bowel diseases, trauma or cancer.

A Kock Pouch is created using your own intestines. After your colon is removed, a reservoir made from small intestine tissue. The reservoir is connected to your small intestine on one end and a stoma (opening in the skin) on the other. The stoma is usually placed just above the pubic area.

There is no external bag with this ileostomy option.

When waste accumulates in the reservoir, it is emptied several times per day by inserting a thin catheter into the stoma. The process isn’t difficult, but it may take you several weeks to become comfortable emptying the pouch. How often you should empty the reservoir depends on your unique body and diet, but there are some general guidelines. Immediately following surgery, you will have an indwelling catheter that provides constant drainage. The indwelling catheter will be left in place for about a month while the pouch “matures.” After your surgeon removes the catheter, you will drain the pouch several times each day. As time goes by, you can empty the pouch less often.

Guidelines for draining the Kock Pouch:

After the indwelling catheter is removed, you’ll need to start emptying the pouch several times per day as instructed by your surgeon. In the weeks to follow when the indwelling catheter is removed, you’ll need to:

  • Empty the pouch every two hours during the day while you are awake.
  • Empty just before going to bed and right when you wake.
  • Refrain from eating or drinking within two hours of bedtime.

When inserting the catheter into the pouch, remember the following:

  • Try to relax your abdominal muscles.
  • Bend your knees as your muscles relax.
  • Only use water-soluble lubricants. Never use products that include petroleum jelly, such as Vaseline.
  • If you have difficulty inserting the catheter, change positions, relax and try again.

You’ll probably need to use a catheter to provide constant drainage overnight, but as time goes on you’ll be able to go longer between pouch empties. Within three months of surgery, you should be able to empty the pouch between 4-6 times per day. If you feel bloated or distended, you’ll need to empty you pouch and you should always empty the pouch prior to physical activity.

The major problem with the Kock procedure is maintaining the valve in the proper position.

If a patient develops a slipped valve (loss of continence), there will be difficulty inserting the drainage catheter as well as incontinence (waste and/or gas escapes from the stoma spontaneously). This caused many doctors, surgeons and gastroenterologists to abandon the K-pouch procedure and not recommend it to their patients. However, a small number of dedicated surgeons continued to work on improving the original techniques of Dr. Kock in order to reduce the incidence of the valve slipping.

Some modifications relieved the problem but created new issues. This includes wrapping the outer surface of the valve/pouch with mesh. While this was very effective in eliminating the slipped valve problem, the mesh would gradually erode into the pouch causing a fistula with drainage of waste from the pouch out to the skin near the stoma or through the original surgical incision. This was an even more serious problem because infection is part of the fistula process.

Dr. William O. Barnett created another modification to reduce the incidence of slipped valve. This involves an adjacent segment of intestine that encircles the base of the valve as a "collar" mechanism. As the pouch fills, the collar also fills creating a noose-like effect, resisting the tendency of a valve to slip out of position. This has been called the Barnett modification of the Kock Pouch, or the Barnett Continent Intestinal Reservoir (BCIR).

Kock_Pouch_lateral_pouch

Further improvement on the Kock Pouch: A Collar on the Nipple Valve, the Barnett Modification

Patients with a K-pouch who require revision can have the pouch transformed into the Barnett design to help reduce the likelihood of recurrent valve slippage. Usually when surgery is required to correct a malfunctioning Kock Pouch, the pouch itself is preserved, saving valuable intestinal tissue.

A new valve and stoma can be created and attached to the side of the pouch, and another connection for the collar wrap is made as well. In that way a Kock pouch becomes a Barnett type pouch. There is a very high success rate with these revisions, allowing patients to maintain their internal continent ileostomy pouch instead of having a conventional ileostomy with an external appliance.