• Joel Bauer MD
  • Stephen Gorfine MD
  • David Chessin MD
  • Daniel Popowich MD

The Kock Pouch

The Kock Pouch (continent ileostomy) was the first alternative to a permanent, incontinent ileostomy after total proctocolectomy, usually in the setting of chronic ulcerative colitis and familial adenomatous polyposis. A Kock Pouch is made from the last portion of the small bowel, the ileum. It includes the pouch or reservoir and a nipple valve, both fashioned from the small intestine. There is a flush abdominal wall stoma, usually placed well below the belt line. A permanently worn appliance or bag is not necessary. The pouch is emptied by passing a special catheter through the stoma into the pouch. The waste is directed into the toilet. Once the pouch is emptied (usually three or four times daily) a small pad is used to cover the stoma.

The surgeons at Manhattan Surgical Associates learned the technique directly from Dr. Nils Kock and have since continued to improve the procedure. Dr. Gelernt, one of the founding members of Manhattan Surgical Associates, first trained with Dr. Kock in the early 1970s in Gothenberg, Sweden. Then in the late 1970s, Dr. Bauer trained with Dr. Kock in Sweden and continued to develop several modifications and refinements to the procedure, especially with construction of the valve, which Dr. Bauer has continued to use to today. Drs. Gelernt and Bauer performed over 550 Kock pouch procedures between 1975 and 1983, representing one of the largest experiences in the world. Dr. Gorfine learned the technique from his mentors, Drs. Gelernt and Bauer, during his residency when the Kock procedure was more commonly performed.

The J pouch procedure with ileoanal anastomosis, a second continence preserving procedure, was described in 1979. By 1983, J pouch surgery had become established as the surgical procedure of choice for providing fecal continence in patients requiring total proctocolectomy, lessening the need for the Kock Pouch procedure. However, there are still indications for performing this surgery for patients desiring an alternative to a standard ileostomy.

 

Indications for Kock Pouch include:

  1. Patients who have had removal of the colon, rectum and anus including the anal sphincter muscles.

  2. Patients who have weak anal sphincter muscles in which case a J pouch would be likely to fail.

  3. Patients with chronic ulcerative colitis or familial polyposis and cancer or pre-cancer (dysplasia) in the rectum requiring removal of the colon, rectum and the anal sphincter muscles.

  4. Patients who have had J Pouch surgery that has failed or has resulted in unacceptable functional results due to infection, fistula, pouchitis, excessive fecal frequency or incontinence due to anal muscle weakness.

 

There are some patients who had a Kock Pouch performed in the past, did well for many years, but then developed problems with the pouch. Potential problems include difficulty catheterizing the pouch or issues of incontinence. These pouches can often be repaired by stabilizing the original valve or forming a new valve without making an entirely new pouch, allowing the patient to avoid a permanent incontinent stoma.

The surgeons at Manhattan Surgical Associates continue to revise and repair previously created and malfunctioning Kock pouches in significant numbers every year.

 

Dr. Bauer has developed several techniques to repair the valve while leaving the pouch intact with minimal to no loss of intestine including:

1. Restabilization of the existing valve (with or without pouch-o-pexy).

2. Reversal of the inflow or outflow (turn-around procedure).

3. Intestinal pedicle graft to create a new valve.