Continent Ileostomy: The K Pouch Option

Medical breakthroughs don't always make headlines. Sometimes they're the innovations that quietly transform lives.

In this episode of MedStar Health DocTalk, host Debra Schindler talks with colorectal surgeon Dr. Sherief Shawki to discuss the K-pouch (Kock pouch), a highly specialized surgical procedure that offers a life-changing alternative for some patients living with an ileostomy or experiencing complications from a J-pouch.

Dr. Shawki explains:

• What a K-pouch is and how it works
• The difference between a J-pouch and a K-pouch
• Who may be a candidate for this specialized surgery
• Why so few surgeons perform K-pouch procedures
• What patients can expect during recovery
• How the procedure can restore independence and quality of life

You'll also hear how advances in surgical expertise are helping patients from across the country, including those who have exhausted other treatment options; find hope through one of the nation's few dedicated K-pouch programs.

If you or someone you know is living with an ileostomy, has experienced J-pouch complications, or is exploring reconstructive colorectal surgery options, this conversation provides valuable insight from one of the country's experienced K-pouch surgeons.

To schedule a consultation with Dr. Sherief Shawki, call 443-777-2475.

Learn more about colorectal surgery at MedStar Health: MedStarHealth.org

Subscribe to MedStar Health DocTalk for conversations with physician experts covering the latest advances in medicine, surgery, and patient care. 

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Transcript

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Comprehensive, relevant, and insightful conversations about health and medicine happen here on MedStar Health Doc Talk. These are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. Medical breakthroughs don't always make headlines. Sometimes they're advances that quietly transform people's lives, helping them regain their independence, their confidence, and even a sense of normalcy. Today, we're talking about one of those advancements. It's called the K-Pouch, a highly specialized surgical option that relatively few people have heard of and even fewer surgeons perform. Yet for some patients who no longer have a functioning colon and require an ileostomy, it can return them to a quality life. I'm happy to have Dr. Sherief Shawki back with us. He's a colorectal surgeon at MedStar Health, and he's here to tell us about what the K-Pouch is, how it works, and who may benefit from it. I'm your host, Debra Schindler. Welcome to DocTalk. Dr. Shawki, thanks for being here. Thank you very much, Deborah. It's always a pleasure to be with you on DocTalk and talk with our audience about what do we have and what we offer at MedStar. Today's topic is very, very good topic and interesting to many of our patient population, the colorectal surgery. And I'm looking forward for a great discussion with you. It can be a difficult topic for many to discuss, maybe even to think about because it really is very personal. Bowel function, ostomies, incontinence are topics many people don't feel comfortable to discuss. So before we get into the surgery, can you explain why someone might need their colon and rectum removed in the first place? Excellent question. There are certain diseases that affect the colon and the rectum. And despite the advancement in medical treatment and medical management, still a decent amount of patient population were required to remove all their colon and rectum. And these patients are deemed to live with an end ileostomy with external bag for the rest of their lives. The big portion of this is inflammatory bowel disease, which specifically is the chronic ulcerative colitis. That's a disease that affects the colon and the rectum with significant inflammation. Patients have diarrhea, bloody diarrhea, abdominal cramps, temperature, and they basically, their life is centered around their colony rectum as well as finding a bathroom. A very compromised lifestyle, it sounds Like. Significantly impaired quality of life. With the advancement in medical treatment, these people need significant medication that suppress the inflammation that's caused by the inflammatory process. And with the medical advancements, it's called biologic medications. Still 15 to 20% of patients will not respond to medical treatment, will continue to experience these symptoms either for prolonged period of time or for repetitive episodes known as flare-ups, which requires admission to hospitals and disruption of lifestyle, disruption of family life and of course the sequela of all of this. These patients are deemed refractory to medical treatment. Therefore, they get referred to colorectal surgeons to remove the colon and the rectum. By the time patients come to see you, they've often been through years living with serious colorectal disease. And they've seen many specialists. They've probably been on many medications that are now failing. At what point does the conversation shift from managing the disease to considering surgery? When they become refractory to the medical treatment experiencing more flare-ups, more inflammatory signs and symptoms, more diarrhea than normal, then this mean that they are not really responding to the medical treatment. And when their quality of life is significantly impaired, this is when we say, listen, surgery is not, does not mean that you are failing. Surgery is one of the option. And simply speaking, removing the colon and the rectum results in cure because as I said before, this disease affect the colon and the rectum only. Once the colon and the rectum is removed, most of the patients, they are cured from the ulcerative colitis that they had. But that would require either an ileostomy or a colostomy bag, right? Is that the first step? Very good follow up. Yes, that will require an ileostomy, external bag, until we get them ready to use their natural pathway of elimination, their anus, by using something called ileal J-pouch. So you can reconnect that? Excellent point. So while we are getting the patient body physiology rebalanced after the significant disruption of the dis - of the physiology with the disease, we give them temporary endileostomy. Then we connect the Bowel - Which is, let's, for anybody who doesn't understand what that is, a temporary ileostomy is? We connect the ileum, the last portion of the small bowel to their skin that empties in a bag attached to their abdominal wall. Okay. And that results into spontaneous passage of stool content as well as gas content. That's known as ileostomy. Okay. Also known as a bag. And sometimes it's known as colostomy. Although the location of that stoma is different, but I'm providing the different names that I, I hear people talking about. Sure. Now, in order to preserve the natural pathway of the elimination, which using the anal canal, we create a reservoir from that last portion of the small bowel called the ileum. That reservoir is created by folding two loops next to each other. Cut the wall between them. Now we have front wall and back wall. Basically, we create an atrium that can accumulate stool instead of the nat - the, the normal rectum that we had. We connect that reservoir or atrium to the top of the inner canal. Therefore, the patient can use their natural pathway of elimination after we remove their colon and rectum out. And that's the J pouch. That is the ileal J pouch because it looks like the letter J, like the candy. And what's that Pouch made out of? Is it natural body part? Very good question. It is made from the natural body part, which is the last portion of the small bowel, known as ileum. Okay. And then the rectal muscles still work in the same way? It's ima - it's a prerequisite for patients to have ileal J pouch, to have a functioning sphincter muscle. Deborah? So that's the first reconstructive option. I think one of the biggest questions listeners may have is if there's no ostomy bag, how do they empty it from the J pouch? But it sounds like they're just going to the bathroom like normal. Correct. And if I may add, Deborah, they usually go, the stool consistency is soft, applesauce-like, and the frequency is more. So in an, in an ideal situation, they go to the bathroom, eliminate naturally as normal, about four to six times. It can go up to eight to 10 times. They are also expected to have some seepage. And because of the disruption of the mechanism of cont - of continence, they may have night leakage as well. With a J-pouch? With a J pouch, yes. But that's occur in a very small patient population, but we always explain and set the patient expectations for those outcomes. So I guess like any surgery, there can be setbacks or things might not go as well as planned. Or with time, something changes. And the consideration then becomes this K pouch named after a doctor named Koch with a K. Correct. Tell me what the K pouch is, how it differs from the J pouch, and why is it so specialized? Why is it so unheard of really? Very good. So if a patient is not candidate for a J pouch to use their natural elimination pathway, example, a patient with disrupted anal sphincter mechanism that will not allow them to control the elimination of the stool, they will be incontinent all the time. They cannot live like this. A patient that they had some sort of malignancy or, or inflammatory bowel disease associated pre-malignant lesions in their lower rectum that we cannot keep any of this part and we have to take it out. These patients are doomed to have a permanent ileostomy, as we said before, where they poop in a bag attached to their abdominal wall. One more level up. What if a patient had an ileal J pouch, but they experience significant complication that they cannot retain their ileal J pouch anymore? Then these patients are doomed to remove the J pouch and revert to the permanent external bag, as we call it ileostomy. Which is not ideal for many reasons. For - It's hanging off your body, skin infections. For many reason. So this, although we look at the end ileostomy at its life saving for the patient. Sure, Sure. But let's assume there is a young, motivated female who is in a relationship and she doesn't want to be wearing a bag all the time. Let's think of another young lawyer who, who is having meeting, and this bag is basically adding some emotional and social stress, especially with the spontaneous passage of stool or noises coming out from the bag in the middle of important meeting or in a social dinner. These patients are candidates for the K pouch. Before I say what is a K pouch, I want to highlight Deborah that we say ileal J pouch because the configuration looks like the letter J. When we say a K-pouch, we are using the initial of Dr. Nils Cook who devised the pouch. It, it does, the pouch does not look like a letter K. Okay. Yeah. Now what is a K-pouch? So we call it a continent ileostomy, which means it's a reservoir that accumulates and retains stool under the abdominal wall. And it has a continence mechanism that provides the person the control on when to eliminate. And instead of having a bag on the outside, they don't have to wear a bag and they don't have to have a sto - a, a small, a piece of, they don't have to wear a bag and they don't have to have a small piece of their bowel sticking above their skin level because this type of stoma is flush with the skin. So nobody would ever know that they have stoma there and they cover it with a bandaid. That's it. Now the last question you asked was how does the patient eliminate and how the patient has control and elimination? We have a con - a continence mechanism that we build into that reservoir by telescoping the bowel in itself. This results into a one way valve. So we use the natural patient bowel. We create the reservoir, which is the atrium. We create the continence mechanism, which is the, the telescoping of the bowel in itself, creating one way valve. The pouch, the K-pouch lives under the front abdominal wall. And it connects to the skin with a very short segment of bowel and it stops at the skin. The one way valve does not allow the spontaneous excretion of the bowel content in the K-pouch reservoir. So no leakage. No leakage. And gas? Gas Can Escape? No gas. No Gas can come out. Does that then become very uncomfortable? The patient will know when they want to empty. When they have to go and release. Yes. Okay. And at that point, how to bypass that one way valve is by inserting a tube the size of your pinky in that stoma. And it goes in like a straw in a juice box. It go through the stoma, through the valve, into the reservoir, and then the fluid stool comes out. And then they take the tube out and they're done. I assume there's something on the other end of that tube, the catheter that they - 100%. There are different ways. Some people sit on the toilet seat. Okay. And put the other end of the tube into the toilet bowl. Some people stand the front of the sink and they put a collecting jar that they collect the stool in and then they throw it into the toilet bowl. There are different ways. Now how much does that pouch hold? How frequently do they have to use a cath to drain it? Is that the right word? Drain it? Yes. Empty It? Empty it or drain it, that's the right word. Usually we tell them to, when the pouch is mature, we tell them to empty the pouch or drain the pouch four to six times a day. And then we tell them before you sleep, empty the pouch. And if you wake up in the middle of the night to go to the bathroom, also try to empty the pouch. We like to keep the pouch on the empty side, but it does not, the, the key Adebra is it does not disrupt their daily activity. If you are having a meeting and instead of the bag is getting filled while you are in the meeting and you can feel it and you get stressed out, you can actually empty your pouch. And you know for the next hour or two hours or three hours, you are good. You are not worried about your elimination. And you can focus on the activity on hand. A far more controlled scenario it seems Like. 100%. And that's why we call it continent ileostomy, because it provides control for the person to empty and eliminate their bowel content or their stool. Now when someone has this K-pouch and the pouch becomes full, do they feel a sensation as we do when we need to use the bathroom? Yes. It's not the same sensation. But they feel - But it's equivalent. So they know. They know. Yes. It sounds ideal. It actually sounds pretty ideal. Why not just jump to the K-pouch and skip the J pouch? This is a very, very good question. So I'm going to try to explain for the audience in a, in an, in an organized way. The initial proposal for people with permanent end ileostomy with external bag was the K-pouch, but the procedure is very intricate. And historically, there is bad repetition that the complication of the K pouch was very high, going up to 50, 60%. But that was old days. Subsequently, the J-pouch came to life and the J-pouch preserved the natural pathway. And honestly, if I ha, if I choose which one, I will choose to use a J-pouch to keep my anus and to keep using my natural pathway. This is what I'm used to as a human being. Sure. Okay. But if I am not candidate for a J-pouch, for whatever reason of what we talked about earlier, my sphincter is not working well. I am incontinent. I am leaking. I develop significant complications of the J-pouch. I have severe refractory, non-responsive pouchitis, which means severe inflammation in the pouch. And that also express itself. Same thing like ulcerative colitis. Inflammation, cramps, bloody diarrhea, lack of control because of the, the, the forceful, you know, passage of mucus. Then I am doomed to have permanent ileostomy. And me personally, I would definitely try the continental ileostomy, which is the K-pouch, before I wear a permanent ileostomy forever. Now in fairness, like any surgery, this isn't perfect. What are some of the risks or complications? Same complications like any other surgery. Infection, bleeding, leaks, and fistulas. What does this mean? The suture lines that I create this pouch from can come undone, can fall apart. And this will result into leaking of fecal matter into the abdominal cavity. This is an emergency. And sometimes we have to take the patient back to the OR to clean their abdomen and put drains. And the risk, as I said before, the risk of these complications are about 15%, which is way better than historically labeled as 50 to 60% because we know how to do it better. We have done so many of it, and we understand the intricacy of the valve creation and the pouch creation. Therefore, our complication rate significantly dropped compared to the 70s and the 80s. As a surgeon, is it a very challenging surgery to perform technically? I mean, because it's not done everywhere. That's true. And thank you for bringing this point. It's a very intricate procedure to create a K-pouch. As we know from other surgical specialties, and in our specialties particularly, high volume surgeons and high volume centers, they have better outcomes. The more complex the surgery is, the fewer centers you have. Therefore, in the country, in the USA, there are about maybe four or five centers. And maybe there are four or five surgeons who are capable of taking care of those patients and their complications and how to fix any issues that happen in the future. And we are very proud to share that we have our very own K-pouch program at MedStar Franklin Square Hospital, that we are now receiving patients from all over the country who either have had a K-pouch and they need to fix their complications, or patients who are interested to learn about it and to have it if they have issues with their J-pouches or they don't want J-pouch. Anybody getting a K-pouch has to have a J-pouch first. Does it ever happen that you would perform a surgery to build a K-pouch? Deborah, your questions today as every time, spot on. I, I, I really congratulate you. Thank you. The majority of the patients who are deemed to have their colon and rectum removed, the standard of care is the ileal J pouch to keep their anus and their natural pathway of elimination. A very, very short patient population, either they are done using their natural elimination pathway because they are done with the diarrhea. They are done with the multiple bowel movement. And I've had this actually, many patients come to me from the get go. An engineer and a businessman that travels all over the world. He came and he said, "I know I am, I am, I'm a candidate for ilio J pouch, but I don't want to use my anus anymore. I am done. I read about the K-pouch. I know you're one of the surgeons who do this in the country. I want to get K-pouch from the get go." The other person is an engineer father of three. And he said same thing, "I am done. I need a K-pouch and my, I did my homework and I am ready." And some patients are actually candidate for the K pouch, for the J-pouch, and they want a J-pouch, but they have disrupted anal sphincter mechanism. So if you connect their small bowel and the J-pouch with the anus, they will leak stool all, all day long, and then eventually they will have irritation and they will be sitting on fire basically. Okay. So these patients, when they come to me and I told them, "You are a candidate for the J-pouch, but this is the expected function." And I never push. But if they tell me, "Is there another option?" I present to them the option of the K-pouch, AKA continent ileostomy. And almost more than 90% of those patients, they end up having the continent ileostomy. And I guess if you don't have enough colon left, maybe too many resections, that would be a good option for patients. Same concept applies. If you don't have much colon left, but you can use your anus, then you go to the ileal J-pouch pathway. If the ileal J pouch pathway is not going to work for either patient preference or sphincter function or J-pouch related complications, then the K-pouch or the contact ostomy becomes, in my mind, the second best option. So where is the, the K-pouch actually located? If I'm looking at somebody's belly, where would the opening be? Center right? Center left? It's actually very far low in their belly. So they can wear shorts and nobody can see anything. Oh, Really? That is even - It's just above the groin. It's that low. Wow. Okay. How would you want a patient to ask you if you've had experience? How many surgeries do you think it takes for a surgeon to claim that he is very proficient with this surgery? I read about a case where a woman had the K-patch created and had to go in for a revision because she was passing fecal matter out of her vagina. And that sounded like a catastrophe to me. I mean, how does that happen? The higher complexity of the surgery, the higher this takes. And I'm known to be very honest with my patients and with my audience. I've had complications. This is not my patient, by the way, but I myself- Yeah, no. It definitely Wasn't. I myself had my, my share of complications, but I sit down with my patients and I tell them, "This is what we're going to be going through. This is the expectation. These are the potential complications." And in my recent experience before I joined MedStar, out of 105 cases of a K-pouch, this is a very high volume in the whole world, by the way. I guess we had like the 10, 15% complication, which is very much equivalent to the complication of the ileal J pouch. A patient who is interested in the K-pouch, goes to a, a surgeon at whatever hospital, what do they ask them? A GI surgeon or a colorectal surgeon and ask them, "Do you perform a K-pouch? I'm interested in having this surgery." What should their expectation be for someone who was proficient or skilled to perform that? Should it be five surgeries behind them? 10 surgeries? So this is a very good question. I cannot give an exact number. So I'm going to say in my opinion, in my humble opinion, having done 20 cases should be enough to overtake something like this. And the reason I'm saying this is this. This, that's why, this needs a program. That's why it is not a surgeon effort. To do the K-pouch, Deborah, it requires a surgeon. It requires OR team, surgical team who knows how to help me do the surgery. It requires the postoperative nursing team to know how to take care of this patient. It requires the regular floor nurses to know how to take care of the postoperative care of this patient. It requires the stoma nurses to go and do the education required for those patients and the care required for those patients. This program is not surgeon dependent. It's a big team. So if the surgeon have done hundred cases, but they don't have the program - The support behind them. I would, I would say don't do it in that center. Okay. And that's why we say it's a program. To specifically answer this question, surgeon experience starts after 20 to 30 cases. Wow. However, the program around the K-pouch is of utmost importance. Who's an ideal candidate for this? The patient who cannot use their anus, the patient who has a complication with ileal J-pouch and they can, they want the J-pouch to be excised. And the patients who have end ileostomy that they are not happy with their quality of life. These are the patient that could come and ask about their candidacy for a K-pouch. And who wouldn't be a good candidate? Number one, enemy. This type of procedure is excess fat either around the bowel or under the skin. So visceral obesity when the fat is around the organs and central obesity when the fat is high in the subcutaneous portion, the, under the skin, these affect the functional outcomes of a K-pouch and make it at higher risk of failure. So I don't create K-pouch for people who have either high visceral obesity or high subcutaneous fat. What about people who have Crohn's disease? This is another contraindication because we suspect that Crohn's disease will activate in the terms of fistulization, like creating abnormal connections between the pouch and the surrounding structures. So therefore that take, that take the Crohn's disease off the list. Let's talk about the surgery itself. How long is it? It didn't seem that long when I was in there with you. The surgery usually takes as short as three, four hours. As long as seven, eight, nine hours. It depends upon identifying the anatomy. When anatomy is straightforward, then three, four hours. It takes lots of suturing. And to build the valve, it takes some time. And then to seat the pouch inside the abdomen, to have it seated appropriately, and to create the, the stoma for it, to be able to intubate without kinking. So these all takes mental thought processing from me when I'm doing the surgery. And I don't rush. So straightforward case, about three, four hours. Now, if I have to do adhesions, take adhesions down, identify anatomy, it all depends on how long it will take me to define anatomy. And, and you mean by adhesions if the person had had previous surgeries And maybe had some Scar tissue? If the patient had scar tissue from previous surgeries, yes. Okay. And the valve that you're talking about that you just mentioned, the building, is that built also out of their own anatomy? Correct. So there's nothing - Or external. Implants or anything like that? Okay. Correct. What's the recovery like? How long are they in the, in the hospital typically? Between seven days and 10 days. Once they get home from the hospital, can they eat? Are they in pain? Before they leave the hospital, we make sure that they are eating and the, the tube, which stays inside the pouch for four weeks. The tube is producing stool and they come back and see us in four to five weeks where we take the tube out and they start intubating themselves on their own. So until then, is there still an ileostomy when they leave? There is no. So they, they always have ileostomy. The ileostomy, as I said before, it is flush with the skin. So nothing is protruding. They don't wear a bag. Oh, I see. But we leave the tube, the catheter that they drain their pouch. We leave it in place. I see. Until the pouch suture lines heal, which takes about weeks plus or, plus or minus. This is when they come back and we take that tube out. Okay. So They Have a drain tube. Yes. Maybe a bubble or something is connected to that. And then they start intubating themselves. And what has been the feedback from your patients? How do they respond to having that? What's their lives like in your experience in talking with them? Thank you for asking this question. So I want to categorize them by patients who had ileal J-pouch that did not work, and they had a K-pouch. I want to start with this group of patients. Everybody says this pouch, I mean the K-pouch, gave me my life back. And those who had a J-pouch, like our recent patient we were talking about, she had good day with the J-pouch and then she developed complications. And we tried to keep her J-pouch in place, but we couldn't. I converted her J-pouch to a K-pouch, and she is very happy with her life now. Wonderful. I have another patient who did not have a good pra, good function or good outcome with her J-pouch. I converted her J-Pouch to a K-pouch. She is doing hiking with her dog. She's doing fishing trips with her significant other. She is traveling. The person I told you about, the businessman who did opted out of the J-pouch and he wanted a K-pouch. This person travels to Kenya, travels to the Asia with his K-pouch. Right. And he intubates before he goes to the, on the flight. Right. And maybe he'll need to intubate while he's on the flight. So it's, he's functional. Can he swim with it? Yes. Hot tubs. Hot tubs, swimming, golfing, intimacy, you name it. That is amazing. And there is no bag in between you and whatever you're doing. For someone listening today who may feel they've run out of options, what would you like them to know? If you have an ileal J pouch that is failing and you are doomed to have permanent bag, or if you have a permanent bag, permanent ileostomy, and you are not happy with your current quality of life, I would say please reach out to us and let's discuss your candidacy for a K-pouch because this can change your life. Do you love what you do? 100%. People's lives are being changed. You have no idea when you see a patient before the surgery, when their facial expressions carry an anxiety, carry fear and discomfort and loss of quality. And then when you see the real smile after a successful surgery, this is invaluable. Sure. Well, having recently met one of your young patients, a young mom, I came away thinking this podcast isn't so much about a surgical procedure. It's about hope, it's ingenuity, and seriously, it's about medical craftsmanship. 100%. Any final thoughts for listeners? If you or somebody you know that you believe would benefit from a continent ileostomy or K-pouch, particularly those who are not happy with their J-pouch function, those who are carrying a bag and they are not happy with it, I would say either come, ask us or direct your loved ones to us, and we are more than happy to answer their questions. Thank you for all that you do, Dr. Shaki. We've been talking with colorectal surgeon, Dr. Sherief Shawki at MedStar Franklin Square Medical Center in Baltimore. And thank you for sharing your expertise with us here on Doctor. Thank you very much, Deborah. It's always a pleasure and looking forward for our next one. On the J-Pouch. On the J-Pouch. If you'd like to consult with Dr. Shawki about the K-pouch or a J-Pouch, call 443-777-2475.