This topic revolves around the challenges and decisions faced by an 83-year-old man who had a total colectomy 30 years ago and has been living with a Koch pouch, a type of continent ileostomy. Recently, he has been experiencing severe abdominal pain due to a stricture near the pouch, leading to a diversion to a conventional ileostomy. This change has brought about significant difficulties, and now there is a proposal to reconnect the Koch pouch. Here are some insights and advice shared by others:

- The husband has been dealing with unintended weight loss, the need to flush the unused Koch pouch regularly, and recurrent severe abdominal pain. Despite no obstruction found in the pouch, the situation has been challenging.
- After the reconnection surgery, the Koch pouch is functioning, but new issues have arisen, such as the inability to eat and reliance on high-dose pain medications. Exploratory surgery is being considered to find a suspected blockage.
- Internal pouches like the Koch pouch can have a limited lifespan, with issues such as strictures, failures, and pain becoming more common over time.
- Age plays a significant role in decision-making. At 83, opting for the simplest solution that reduces surgeries and enhances comfort, like continuing with an external ileostomy, might provide the best quality of life.
- Seeking multiple surgical opinions is crucial. Consulting with high-volume centers or experienced colorectal/IBD teams can provide valuable insights.
- Some European surgeons have moved away from using continent pouches due to long-term complications, and many patients adapt well to conventional ostomy bags.
- It's important to carefully consider the risks and benefits of additional surgery, potential short-bowel syndrome, prolonged use of an NG tube, chronic pain, and nutritional issues versus managing life with an external appliance.