The continent ileostomy (Kock's pouch) versus the restorative proctocolectomy (pelvic pouch)

The Kock continent ileostomy and the ileoanal anastomosis with a pelvic ileal reservoir are each alternatives to conventional ileostomy in patients undergoing proctocolectomy for ulcerative colitis and polyposis coli. Problems associated with construction of the nipple valve have been the chief factor limiting the popularity of continent ileostomy, but these can be minimized by strict attention to technique. The cumulative revision rate for nipple valve dysfunction over a 7‐year period has been below 30%, and continence can usually be restored by reoperation. A successful pelvic reservoir procedure maintains both the normal defecation pathway and satisfactory continence, although rectal sensation is impaired; pelvic sepsis is the major postoperative risk (15–20%). Both types of operation are associated with nonspecific inflammation of the reservoir (“pouchitis”) in some 20% of patients. The pelvic pouch procedure is likely to become the chief method for preserving fecal continence after proctocolectomy, but the Kock pouch should be considered for inappropriate or unsuccessful cases.