The management of a conventional Brooke ileostomy is quite easy, both for the surgeon and the patient. As soon as possible, the patient is allowed to drink to easily achieve a correct balance of fluid intake. Beginning in the early post-operative period, a stoma care nurse should instruct the patient and his partner to empty and change the bag and to apply the flange. Although the rehabilitation mainly depends on patient motivation, the availability of a stoma care unit greatly helps the patient. They have to be informed about the correct volume of fluid intake, the need of wound dressing until complete healing is achieved and the risk of intestinal obstruction due to stoma impairment or post-operative adhesions. Mortality is related to the proctocolectomy and ranges between 2 and 3%, but for emergency procedures, a mortality of 23% has been reported. A depression may occur in the first period probably due to the new perception of the self-image and to the suspension of steroids medication. The most frequent complications in the early post-operative period are perineal sepsis and bleeding from the perineal wound, which are conservatively treated; a persistent sepsis or bleeding from the abdomen or the pelvis may require a second laparotomy. The loss of a large volume of fluid and electrolytes through the ileosto-my may represent a serious problem, particularly in the first days after the post-operative ileus has resolved; therefore, it may be necessary to continue intravenous infusion to replace fluid loss. In some cases, chronic ileostomy diarrhoea occurs and the patients need to increase the volume of fluid and electrolyte intake. As the follow-up lengthens, an increased incidence of urolithiasis is reported, probably related to the extent of bowel excision. As in all, the patient who undergoes a bowel resection, an intestinal obstruction due to adhesions may complicate the early and late post-operative course; it must be remarked that this occurrence may be disastrous for these patients since a reoperation may lead to a further loss of bowel.
What is more difficult, is the management of a reservoir ileostomy in the early and late post-operative periods; however, the selected patients are usually very strongly motivated to actively cope with the new condition. At the end of the operation, and as long as the ileus has completely resolved, a permanent catheter is placed in the reservoir in order to drain the pouch and avoid disruption, leakage and nipple valve desusception. Subsequently, the catheter is periodically occluded and the time of drainage is progressively reduced. Some irrigation may be necessary to avoid faeces and food particles obstructing the catheter both in the early post-operative period, when the patient starts eating, and then at the time when the pouch is functioning. After a few weeks, the patient becomes aware of the necessity of emptying the reservoir and, usually, this manoeuvre is easily accomplished three or four times a day. Besides the complications already mentioned as being associated with any ileostomy and major laparotomy, there are a few others that are specific to a stoma reservoir construction. Some patients complain of continuous abdominal bloating and pain and others need to spend too much time in frequent catheterisations and irrigations to wash out the pouch from smelly particulate contents. These complaints are likely to be more frequent in patients with slow small-bowel transit. Accordingly, some authors consider that patients having a chronic constipation with a slow bowel transit, for which a conventional total procto-
colectomy has been indicated as the last option, should have a Brooke ileostomy rather than a reservoir ileostomy [8, 19]. In the past years, valve slippage was reported as the most common complication, up to 44% of incidence, but this problem has been almost completely solved by using stapling machines. More important complications are the ischaemia or the fistula of a part of the ileostomy such as the exit conduit, the nipple valve or, at worst, the pouch. The fistula may be a consequence of an ischaemic tract, a suture line dehiscence or a perforation subsequent to catheterisation. Obviously, the most serious complication is the leakage in the abdomen of bowel contents particularly from the pouch since, if the fistula is not immediately recognised, the life of the patient may be threatened. In such circumstances, salvage surgery is mandatory. In case of a simple slippage of the valve, a new nipple valve can be refashioned . When the valve or the exit conduit are ischaemic with a possible fistula, or the bowel tract is not sufficient, a reconstruction procedure is needed such as a rotational procedure or an interposed loop, in which a new bowel segment is adopted for the new valve and conduit. However, in the worst cases, the pouch cannot be saved. In these circumstances the reservoir must be entirely removed, and a completely new pouch ileostomy may be performed or, in some cases, a conversion to a Brooke ileostomy. Failes reported a 21% of reoperation rate and most of the revisions were undertaken within 1 year from the first operation . In order to improve the functional results and reduce the early and late complications, over the last years a series of novel techniques for performing a continent ileostomy have been described such as the Barnett reservoir, the T pouch, and the ileocecal valve-preserving ileostomy [14, 22, 23, 24]. These new procedures are reported as improving the continence and the quality of life of the patients. However, although the preliminary reports are encouraging, a long-term follow-up is not yet available for correctly comparing the results.
The incidence of pouchitis has been reported to range between 4 and 40% in patients with a Kock reservoir for ulcerative colitis [25, 26]. The diagnosis is based on the typical above-mentioned symptoms and on an endoscopic biopsy that reveals diffuse bleeding inflammation and/or a villous atrophy. However, the histological features are often non-specific and may hide Crohn's disease. It is likely that this pouchitis rate is higher in patients who underwent the same operation for Crohn's disease than in those with ulcerative colitis, and much lower in patients operated on for familial adenomatous polyposis; besides, the more the follow-up lengthens, the more the incidence of pouchitis increases. In 1993, the group from Göteborg University compared the pouchitis rate after a long-lasting follow-up of patients with a Kock reservoir to that of patients with a pelvic reservoir. Pouchitis was found to be more frequent in the pelvic pouches as it occurred in 34% of the Kock procedures and 51% of the pelvic pouches; and in 64 and 76% of the cases there was only a single episode or a slight and short form of disease . Nevertheless, patients with a Kock reservoir more frequently developed a chronic form of pouchitis than those with a pelvic pouch: 18 vs. 6%. Pouchitis is likely to be due to a bacterial overgrowth and a delayed small-bowel transit, and thus in most of the cases it quickly responds to conservative treatment with metronidazole and pouch catheterisation. Some metabolic disturbances such as fluid and electrolyte deficiencies, megaloblastic anaemia due to the depletion of vitamin B12, fat or bile-salt malabsorption, as well as villous atrophy, may occur both in patients with pouchitis and those with a normal functioning reservoir. Moreover, the same metabolic complications have been found in patients with a conventional Brooke ileostomy, so it is likely that these metabolic imbalances depend on the volume of the ileostomy output, regardless of the type of ileostomy.
Many authors have reported a better quality of life in patients who underwent a restorative proctocolec-tomy than those who underwent a conventional proctocolectomy with ileostomy [5, 6]. In 1991, in order to assess whether the improvement of the quality of life in patients with restorative proctocolecto-my was due to the absence of a stoma or to a better faecal continence, Kohler and Pemberton examined functional and performance activities in 406 patients with Brooke ileostomies (stoma present, incontinent), 313 with Kock pouches (stoma present, continent), and 298 with ileal pouch-anal anastomoses (stoma absent, continent). All the patients had been operated on for ulcerative colitis or familial adeno-matous polyposis. Patients with ileal pouch-anal anastomoses had fewer restrictions in sports and sexual activities than those with Kock pouch, whereas those with Kock pouches, in turn, had fewer restrictions in these activities but more restrictions in travel than those with Brooke ileostomies. Performance in the categories of family, work and social life were similar between the groups. They concluded that both the presence of a stoma and faecal incontinence impair the quality of life after proctectomy, so therefore the ileal pouch-anal anastomosis allows the best quality of life . On the contrary, more recently, some other authors reached more controversial conclusions. Mikkola evaluated the clinical differences between conventional and restorative proctocolecto-my among 240 patients, the reoperation rate was 38 and 36% respectively; but as major complications were more frequent in the pouch group, he therefore concluded that ulcerative colitis can safely be managed with either conventional or restorative procto-colectomy, and more remarkable, in most cases the patient's preference should dictate the choice of procedure . Likewise, in 2003, Camilleri-Brennan  analysed morbidity and quality of life in two matched groups of patients who underwent a restorative proctocolectomy or a conventional proc-tocolectomy with a Brooke ileostomy. The restorative proctocolectomy was found to be associated with a significantly better perception of body image than a permanent stoma, although the quality of life in general was similar in both groups and the patients with the pelvic pouch had more long-term complications than patients with ileostomy: 52.6 vs. 26.3% respectively. Therefore, because of the higher complication rate and the relatively small advantage in terms of quality of life associated with the restorative procto-colectomy, patients should be thoroughly advised before agreeing to this operation . Moreover, conventional ileostomy usually represents the ultimate procedure after unsuccessful salvage surgery for patients who have experienced the failure of an ileal anal-pouch. As an alternative, the group from Göteborg University converted 13 patients with a failed previous restorative proctocolectomy to a continent ileostomy with reservoir. Subsequent revision-al surgery was required in eight patients but, after a follow-up of 6 years, ten patients with intact ileosto-my were fully continent and none had to use a stoma appliance. Provided that this operation should certainly be done in specialised units, it may be considered as an alternative salvage surgery to the Brooke ileostomy in motivated patients .
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