Psychiatric Casualties Following Revision to the "Continent" Kock Ileostomy H E L E N KROSS GOLDEN, PhD

The advantages of the appliance-free "continent" Kock ileostomy over the conventional ileostomy may result in its earlier and more frequent use in treating ulcerative colitis. Caution must be observed in selecting patients for surgery because of the high incidence of psychological problems in this population. Increased restraint is especially indicated as such surgery may no longer be reserved for life-threatening or incapacitating conditions. As the Kock operation becomes more widely known, patients with conventional ileostomies are requesting revision to the reservoir. This paper addresses itself to unexpected problems that may arise in this group. Two cases are presented of men who made tenuous adjustments to the primary surgery but for whom revision to the continent ileostomy proved psychologically catastrophic. Psychiatric evaluation is urged in the absence of clear-cut medical indications for revision. Suggestions concerning selection of patients who seek such change are offered.

In 25 years, surgical techniques and external fecal collection appliances necessary to life with a conventional ileostomy have improved, and physicians are not as reluctant now to refer ulcerative colitis patients for definitive cure via proctocolectomy. Previously, this extreme remedy was used as a last resort to stave off threatened perforation of the bowel, obstruction, massive hemorrhage, or increasing invalidism. Under such circumstances, the pressure to p r e s e r v e life p u s h e d psychological considerations aside. Psychogenic factors are prominent in ulcerative colitis, and considerable variation in the degree of psychopathology has been observed. A highly significant correlation between severity of psychiatric diagnosis and poor psychological outcome was demonstrated in a carefully executed study extending over three decades (1, 2). About one third of a group of 57 patients was diagnosed schizophrenic. Four had required psychiatric hospitalization. Of those operated on, and of those who died, over half From the Department of Psychology, Hillside Division, and the Psychiatric Liaison and Consultation Service at the Long Island Jewish-Hillside Medical Center, Glen Oaks, New York. Address for reprint requests: Dr. Helen Kross Golden, Hillside Division, Box 38, Glen Oaks, New York, 11004. Digestive Diseases, Vol. 21, No. 11 (November 1976)

were schizophrenic. Since this group had sought or been referred for psychiatric evaluation, it would be incorrect to generalize to all ulcerative colitis patients. Nonetheless, in view of the widely observed incidence of emotional disorder in the colitis population as a whole, serious consideration should be given to the potential psychiatric hazards that surgery presents to people of tenuous emotional balance. The nonpsychiatric literature emphasizes that most ileostomy patients make an adequate functional adaptation and report a sense of improved wellbeing (3-7). This occurs despite feelings of bodily mutilation and drastic alteration of a fundamental function especially charged emotionally by its early childhood ties with issues of control and the expression of aggression. In contrast, psychiatric and psychoanalytic studies, while agreeing that most patients prefer t h e i r ileostomies to a painful, unpleasant, and often lifethreatening illness, describe a less benign picture. That is, functional adaptation may not be matched by equivalent psychic comfort (8). The risk of odor, leakage, embarrassing sounds, and limitations in choice of clothing often lead to feelings of social

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GOLDEN unease and inhibition, avoidance of athletic activities, and grave concern a b o u t the sexual p a r t n e r ' s reaction to the s t o m a and appliance (9-11). Currently, the K o c k operation, in which an internal reservoir is created f r o m the terminal portion of the ileum, obviates the need for appliances altogether (12-14). The patient is left with a skin-flush s t o m a in the pubic area, the s t o m a covered with a bandaid for protection. Several times daily a catheter is introduced through the s t o m a directly into the reservoir which drains spontaneously into the toilet in minutes. The projecting stoma and its uncontrollable discharge is r e m o v e d as a source of psychic burden. With this m o r e appealing procedure, elective surgery m a y be r e c o m m e n d e d earlier and with less trepidation. In addition, an increasing n u m b e r of patients previously operated on are learning of the K o c k procedure and requesting revision of their conventional ileostomies. This group is of particular interest since it m a y include s o m e who have made equivocal adjustments. T h e literature on revision is confusing. It fails to describe the specific difficulties in adaptation. N o r does it distinguish revisions that are selfsought f r o m those p e r f o r m e d on medical indication. This is a serious omission since difficulties in adaptation m a y relate as much to emotional as to medical and surgical considerations. Medical indications for revision include skin excoriation, ill-fitting appliances, prolapse, retraction, and stenosis. K o c k (12, 13) and C a m e r o n (15) cite a total of 7 medically indicated revisions, all successful. K o c k (I4) later describes 35 cases, an unspecified n u m b e r of w h o m s h o w e d an "inability to a d a p t to the conventional i l e o s t o m y . " H o w e v e r , he does not distinguish b e t w e e n the medically referred and self-selected patients in discussing outcome. K o c k et al (16) report on 10 " s e l e c t e d " revisions which m a y include some of those mentioned above. T w o patients had skin problems, and eight were self-referred. One of these found the need to e m p t y the reservoir m o r e d i s c o m m o d i n g than the appliance had been. Beahrs et al (17) report one w o m a n who refused to catheterize her reservoir and was compelled to w e a r an a p p l i a n c e again. Clearly t w o patients in this vaguely defined population had psychologically disappointing results with their revisions. T w o case histories follow in which two or three semistructured interviews focused on the adaptation to the contrasting surgeries each patient had undergone.

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CASE R E P O R T S Case 1 The patient, a 45-year-old Canadian attorney, was the last son in a family of male children. His own children were boys. Five months after the Kock revision he made a near-fatal suicide attempt, stabbing himself repeatedly in the abdomen and seriously damaging the new stoma. The patient's colitis began in his early twenties, requiring proctocolectomy two years later. After an uneventful postoperative course he married and established a successful law practice. He described life-long feelings of inadequacy which became heightened by the demands of his profession, and he felt himself a fraud, succeeding only as the proteg6 of an established older man. Nine years after surgery, he accepted a position that represented a major professional advance. He felt increasingly inadequate and hypocritical, and dates his downhill course from the following episode. Prior to making his acceptance speech, he went into the men's room to empty his ileostomy bag. He noted with apprehension that the stoma had prolapsed slightly, an innocuous situation that had occurred previously after strenuous exertion and which he managed easily by lying down to facilitate spon~taneous reduction. He felt torn between returning home to attend to the prolapse or going ahead with his talk, aware of the potential danger to the stoma. He opted for the latter and soon discovered his fears justified. The stoma was enlarged, engorged and rigid. Emergencyroom treatment was required to cut the faceplate away. Reparative surgery was advised. The theme of being the fair-haired boy of a successful older man was exemPlified in the relationship with his first surgeon to whom he returned for reoperation. Initially, he recalled reciprocated tender feelings toward this man who, he had surmised, was disappointed in his own son and whom the patient sought to replace in fantasy. On the vaguest hearsay, the patient had assumed the son to be a homosexual. On this second occasion, efforts to reestablish his favored position antagonized the surgeon who, the patient alleged, therefore performed an inferior operation. Following the second operation, over 20 hospitalizations for medical and surgical treatment occurred. During this time, his marriage deteriorated. Although he feared leakage, he described his wife as messy and sexually disinterested. Divorce soon followed. Subsequently he became depressed and then addicted to a variety of illicitly obtained mood-evaluating drugs. His practice suffered, and he sought hospitalization for detoxificati0n, again for ECT, and finally for psychotherapeutic treatment. He complained constantly about his new fiancde's sexual unresponsiveness and her small breasts. On discharge, the patient was referred for private psychiatric treatment. Within months, he terminated efforts at treatment with a number of competent psychiatrists. When he heard of the Kock ileostomy, he was certain that his sexual difficulties would be alleviated. The surgeon's misgivings based on the patient's psychiatric history were offset by his hope of ending the prolapse-surgery cycle. The revision was performed successfully, but the hostile, dependent relationship with the fiancde remained Digestive Diseases, Vol. 21, No. 11 (November 1976)

C A S U A L T I E S O F T H E K O C K ILEOSTOMY unchanged. Immediately after her termination of the engagement, the patient made the suicide attempt that resulted in his last hospitalization. In discussing the upcoming surgical repair, the patient vacillated obsessively over which was the preferable operation. In retrospect, the only disadvantage to the conventional ileostomy that he recalled was an inordinate sense of v u l n e r a b i l i t y . He had f r e q u e n t l y imagined being mugged or attacked at knife-point, and he remembered anxious concern about protecting the stoma from harm. In contrast, his handling of the new ileostomy was bizarre from the start. He irrigated the reservoir frequently, and found it strangely repellent to insert the catheter into " a hole in the front of the b o d y . " He never emptied the reservoir while sitting on the toilet but rather while standing. When offered a tentative interpretation that introducing a long, rigid object into a hole in the front of his body might have uncomfortable feminine connotations, he acknowledged his long-standing belief that the sexual experience of the female was more voluptuous. He then spoke movingly of his wish for a female child so as to present his mother at last with the daughter she so desired.

Case 2 This 30-year-old unmarried schizophrenic male was referred for psychiatric assistance when his surgeon became concerned over his refusal to deal with a complication of his recent Kock revision. During the course of the interviews in which the following history was obtained, he grew increasingly depressed, nihilistic about his declining health and, during an emergency hospitalization for unexplained fever, diarrhea, and weight loss, overtly paranoid. At the time of the last interview, while in the hospital, he said he regretted having had the revision. He felt terror toward his surgeon and had the delusional belief that he was a victim of medical experimentation. He signed himself out of the hospital against medical advice and moved into his parents' home. The patient was an unplanned child and was always compared invidiously with his more successful older sister. His first episode of colitis was in the sophomore year of high school in conjunction with worry over his father's disappointment that he had failed to make a ball team. He was hospitalized for several weeks and spent the remainder of the school year on home instruction, a period recalled with pleasure. Minor exacerbations the following year led to some absence from school. Thereafter, his colitis was quiescent for 10 years. The patient had a single serious although nonsexual relationship with a girl during college. He was vague about its termination, but focused on her father's violent attitude toward him. Following graduation he had a brief succession of preprofessional jobs but soon drifted into a drug-using milieu. He engaged in homosexual activity with much guilt. During this period he was jailed for vagrancy, " a t t a c k e d " in ways he could not clearly recall, and psychiatrically hospitalized under an assumed feminine name. The patient was treated with ECT and made a good recovery. He began working with greater success and made a conscientious effort to meet women with the explicit although naively conceptualized goal of marriage. He reDigestive Diseases, Vol. 21, No. 11 (November 1976)

ported a single sexual experience with a woman his mother's age. At 27, while his parents were on vacation, he had a sudden and serious attack of colitis that required hospitalization. When surgery was advised he became acutely depressed and withdrew from all participation in his treatment. He remained depressed postoperatively and was unable to resume work. All his time was devoted to the care of his stoma and appliance. Six months later he was hospitalized for psychiatric treatment of his depression. The patient gradually adjusted to his ileostomy and was able to resume work at a higher level than before, despite subjective feelings of abnormality, freakishness, and difference from others. Two years after the initial surgery he learned of the Kock procedure. His surgeon was persuaded by the patient's feelings of abnormality and his strong desire to marry and lead a " n o r m a l " life. Although his initial response to the revision was good, he soon began having difficulty inserting the catheter and gave up with relief. He had no objection to reverting to the appliance to deal with his increasing incontinence. Simultaneously, however, he felt an oppressive sense of retribution for his wish to be like others. He began to mistrust his perception of his parents and frequently intoned, " M y father works for _ _ . My mother works at _ _ . They are normal people, not bums and freaks." But this incantation tailed to stabilize his perception, and he suffered terrifying spells of hatred toward these people whose identity wavered so alarmingly. He half believed that the woman had been raped and the man murdered. The idea of sex became abhorrent to him, and his wish for marriage now included the adoption of a baby. Several months after his paranoid flight from the hospital, the patient was seen again. He was in fair psychiatric remission and vacillated over repair of his Kock ileostomy. He regretted having had the revision. DISCUSSION It is difficult to o v e r e m p h a s i z e t h e i m p o r t a n c e o f understanding the less-apparent motives behind any request for revision of a conventional ileostomy. T w o d i s a p p o i n t i n g r e s u l t s a r e r e p o r t e d in t h e o n l y papers which specifically describe negative outc o m e (16, 17). T h e h i s t o r i e s o u t l i n e d h e r e s h o u l d rei n f o r c e t h e f a c t t h a t t h e prima facie r e a s o n s o f f e r e d by the patient may hide a hornet's nest of serious p s y c h o p a t h o l o g y a n d p l a c e an u n d u e b u r d e n on t h e i n t e r n i s t o r s u r g e o n w h o is c o n f r o n t e d with s u c h requests. D r u s s et al (l 1) h a v e p o i n t e d o u t t h a t s u r g e r y f o r u l c e r a t i v e colitis m a y l e a d to p r o f o u n d c h a r a c t e r o l o g i c a l c h a n g e s a t t r i b u t e d to feelings a b o u t t h e ileostomy itself and the ensuing altered body image. In d i s c u s s i n g f o u r w o m e n w h o s e f a n t a s i e s c e n t e r e d a b o u t p e r c e i v e d p h a l l i c c h a r a c t e r i s t i c s o f t h e i r stom a s , it w a s n o t e d t h a t t h e s e f a n t a s i e s w e r e reinf o r c e d b y life-long w i s h e s to h a v e b e e n b o r n m a l e . A

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GOLDEN psychiatric evaluation of the patients presented here would have demonstrated that each had serious problems with masculine sexual identification and would have contraindicated or deferred further surgery pending a psychotherapeutic resolution of their conflicts. Hindsight ensures 20-20 vision, and the consequences described in these anecdotal reports are not intended to downgrade the importance o f an operation of immense appeal. However, controlled studies are clearly needed to determine the relevant criteria, both psychological and medical, to which one must attend in striving for optimum individual outcome. The psychological problems of patients requesting revision of a conventional ileostomy are undoubtedly different from those of patients facing ileostomy surgery for the first time. One might hypothesize that the motives of the former group are more akin to those of patients seeking cosmetic surgery. Both procedures are generally elective and are ostensibly sought out of a desire to improve appearance. In both instances, however, the conscious wish may o b s c u r e h a z a r d o u s psychopathology. The expectation that the operation will eliminate deep-seated dissatisfactions that have been displaced onto a particular body part is well known to plastic surgeons. Any procedure performed on the basis of unconscious motives runs the risk of profound disappointment with the inevitable frustration of conscious expectations. Druss et al (18) have succinctly stated that "operating on a delusion" stands little chance of success. The following suggestions are offered to those confronted with urgent pleas for revision when there is no medical indication for further surgery. 1. Every patient with a serious psychiatric history should be carefully evaluated. Shock treatment, extended use of psychotropic medications, drug or alcohol abuse, attempted suicide, or psychiatric hospitalization are included here. Patients who use any illness self-destructively or for secondary gain present particular risks in a surgical procedure where responsible management by the patient is crucial to safety and success. A diabetic who was suicidally reckless in his handling of insulin was equally foolhardy in observing dietary restrictions and scheduled emptying of the reservoir during the postoperative phase of his Kock revision. Emergency surgery w a s soon required for obstruction. The patient now possesses a second covert instrument for life threatening behavior and the attendant benefits he derives therefrom.

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2. Elective surgery when sought as a solution to life-long conflicts that are generally out of awareness may precipitate a psychotic reaction or depression of dangerous proportion. Careful inquiry into the patient's expressed motives may elicit evidence of perilous unconscious wishes frequently related to sexual concerns. A middle-aged man was referred for psychiatric evaluation when he requested revision of a 20-year-old well-functioning ileostomy for the sole purpose of joining a nudist colony. The wish to marry expressed by the second patient discussed here must be viewed as an unrealistic solution to his guilt-evoking homosexual impulses. 3. Druss et al (18) emphasize that when a patient blames all his problems on any single aspect of himself that he wishes changed, he may be using the psychological mechanism of projection, that is, attributing to outside sources (which may include parts of his own body) the reasons for his dissatisfaction. This is clearly seen in the first patient's projection of his messiness and decreasing potency onto his wife and fianc6e, and in the second, in attributing to the surgeon the "persecuting" stings of his own guilty conscience. 4. As in the case for cosmetic surgery, complaints that are grossly exaggerated or couched in language that evokes surprise or unusual imagery may allude to unconscious ideas. The first patient's description of his prolapsed stoma in disparaging and obscene phallic terms was a clue to his symbolic associations as well as to his sense of devalued masculinity. 5. Response to previous surgery often has predictive value. The first patient's addiction to surgery suggests an ominously masochistic and dependent individual for whom surgery serves ulterior motives that undermine success. Boyd et al (19) point out that an active, inquiring, forward-looking preoperative stance is highly correlated with good physical and psychological recovery, independent of the inherent risks of the surgery. The second patient's emotional disengagement at the time of his initial operation predicted the decompensation he suffered then and at reoperation. It is hoped that psychiatric consultation will become routine in the presence of any of the above indications, and indeed, in all cases where surgery is requested for consideration of body image alone. The willingness of a patient to agree to such an evaluation is, in itself, indicative of an inner flexibility that is prognostically favorable. Digestive Diseases, Vol. 21, No. l 1 (November 1976)

CASUALTIES

OF THE KOCK ILEOSTOMY

ACKNOWLEDGMENT Personal appreciation is e x t e n d e d to Irwin M. Gelernt, MD, Assistant P r o f e s s o r of Surgery at the M o u n t Sinai Medical Center, N e w Y o r k City, for his critical reading of this paper.

REFERENCES 1. Daniels GE, O'Conner JF, Karush A, Moses L, Flood CA, Lepore M: Three decades in the observation of ulcerative colitis. Psychosom Med 24:85-93, 1962 2. O'Conner JF, Daniels G, Karush A, Flood C, Stern LO: Prognostic implications of psychiatric diagnosis in ulcerative colitis. Psychosom Med 28:375-381, 1966 3. Bon6 J, Sorenson FH: Life with a conventional ileostomy. Dis Colon Rectum 17:194-199, 1974 4. Claman L, Trieschman A: Adjustment to surgery of children with ulcerative colitis. Am J Dis Child 107:131-137, 1964 5. Daly DW: The outcome of surgery for ulcerative colitis. Ann R Coil Surg Eng142:3%57, 1968 6. White B J: The effect of ileostomy and colectomy on the personality adjustment of patients with ulcerative colitis. N Engl J Med 244:537-540, 1951 7. Stahlgren LH, Ferguson LK: Influence on sexual function of abdominoperineal resection for ulcerative colitis. N Engl J Med 259:873-879, 1958 8. Lennenberg E, Rowbotham JL: The Ileostomy Patient. Springfield, Illinois, Charles C Thomas, 1970

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9. Dlin BM, Perlman A, Ringold E: Psychosexual response to ileostomy and colostomy. Am J Psychiatry 126:374-381, 1969 10. Druss RG, O'Conner JF, Stern LO: Changes in body image following ileostomy. Psychoanal Q 41 : 196-206, 1972 11. Druss RG, O'Conner JF, Prudden JF, Stern LO: Psychologic response to colectomy. Arch Gen Psychiatry 18:53-59, 1968 12. Kock NG: Intra-abdominal "reservoir" in patients with permanent ileostomy. Arch Surg 99:223-231, 1969 13. Kock NG: Ileostomy without external appliances: A survey of 25 patients provided with an intra-abdominal intestinal reservoir. Ann Surg 173:515-520, 1971 14. Kock NG: Continent ileostomy. Prog Surg 12:190-201. 1973 15. Cameron A: The continent ileostomy. Br J Surg 60:785-790, 1973 16. Kock NG, Darle N, Kewenter J, Myrvold H, Philipson B: The quality of life after proctocolectomy and ileostomy: A study of patients with conventional ileostomies converted to continent ileostomies. Dis Colon Rectum 17:287-292, 1974 17. Beahrs OH, Kelly KA, Adson MA, Chong GC: Ileostomy with ileal reservoir rather than ileostomy alone. Ann Surg 179:634-637, 1974 18. Druss RG, Francis CS, Cirkelair GF: The problem of somatic delusions in patients seeking cosmetic surgery. Plast Reconstr Surg 48:246-250, 1971 19. Boyd I, Yeager M, McMillan M: Personality styles in the postoperative course. Psychosom Med 35:23-40, 1973

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