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Biographical entry Kock, Nils Gustav Johannes (1924 - 2011)

MD Helsinki 1951; MD Gothenburg 1955; PhD Gothenburg 1959; Hon FRCS 1977.

Born
29 January 1924
Jakobstad, Finland
Died
24 August 2011
Gothenburg, Sweden
Occupation
Colorectal surgeon and Urological surgeon

Details

Nils Kock, professor of surgery and chief of the department of surgery II, Sahlgrenska University Hospital, Gothenburg, was an eminent colorectal surgeon, widely known for his development of the 'Kock pouch', a continent pouch formed by using the terminal ileum after colectomy.

Known as 'Nicke' to his friends, Nils Kock was born on 29 January 1924 in the Finnish town of Jakobstad ('Jacob's city'), to use its Swedish name, and Pietarsaari ('Peter's Island') in Finnish. This town in Ostrobothnia, western Finland, on the Gulf of Bothnia, is an important Finnish port and industrial centre with some 20,000 inhabitants. Nils Kock's family were Finnish-Swedish in origin. His father, Emil Kock, owned an equipment store in Jakobstad: his mother, Aili Kock née Lönnmark, was a housewife. Nils had one older brother, Sven, who became a professor of economics, and an older sister, Auda Andersson, a language teacher.

The first four years of Nils' school life were spent in the Jakobstad Folkskola, or elementary school, followed by eight years at the Jakobstad Samlycéum or secondary school. His teenage years were interrupted by the Second World War. Drafted into the Finnish Army, he was involved in the confrontations between Russia, Germany and the Western Allies. Entering the Army as a private in the heavy artillery, by the end of the war he had been promoted to the rank of lieutenant. His home town of Jakobstad was bombed by the Russians during the war years. Nils Kock was always modest about his war-time experiences, but these years remained important to him for the rest of his life: he was very proud of belonging to the Finnish Second World War veterans.

Demobilised after the war, Nils applied for entrance to Helsinki University to study medicine. As his school grades were not all that outstanding, even after being given extra marks for exemplary military service, his first application was turned down. Clearly disappointed at the outcome, he entered what he felt was the second best option, the dental school. Within a year he re-applied for a place on the medical course at Helsinki University and was successful. He was further compensated for this early upset by meeting his future wife, Birgit Bretenstein (known as 'Bie'), a student of languages. She was born in Tampere in southern Finland. Their romance led to their wedding in 1950 at a small family ceremony. They had a very happy and successful life together. The first of two daughters, Anki, was born in Helsinki in May 1952.

Nils graduated in 1951 and held post-qualification house appointments in Helsinki, but to realise his ambition of specialising in surgery, he decided to move to Sweden in the hope of gaining entrance to a residency programme. Travelling in the autumn of 1952 with his wife and daughter, he studied hard in order to pass the Swedish qualifying examination in the spring of 1955. By now the Kocks had another daughter, Maria, who was born in Gothenburg in January 1955. Having a Swedish licence to practice, he managed to get a foot on the first rung of the ladder as an assistant in surgery in the department of surgery I, Sahlgrenska University Hospital. The period of higher surgical training within the University Hospital was to last another five years or more. He was to remain in Gothenburg for the rest of his professional life: from 1974 to 1990, when he retired as professor of surgery and chief of the department of surgery II, Sahlgrenska University Hospital.

He formed the opinion that to progress in his chosen career of surgery, basic science education must work hand-in-hand with clinical work. Supervised for two to three years by Bjorn Folkow, head of the department of physiology at Gothenburg, Nils worked towards a PhD thesis. Entitled 'An experimental analysis of mechanisms engaged in reflex inhibition of intestinal motility', he defended his thesis before the adjudicating panel, receiving his doctorate in 1959.

At this early stage of his training he had established a laboratory for 'urodynamic' studies, and adapted the apparatus for pressure studies on intestinal segments as bladder substitutes on both canine and feline models. This was just the beginning of his future clinical research, with projects that led to innovations in continence-preserving urological and colo-rectal techniques in patients undergoing cystectomy and procto-colectomy.

For years those patients with conditions requiring radical colectomy accepted the need for a permanent opening or ileostomy, for which external appliances/bags were required over the stoma to collect faecal waste. There was still a degree of patient satisfaction of 'conventional ileostomy', as popularised by Bryan Brooke of Birmingham, who had founded the Ileostomy Association in 1956 in the UK. Similarly, urine drainage bags were acceptable in patients after total cystectomy with ileal conduits, and continued to prove satisfactory. However, in 12% of patients the continuous flow of faecal material/urine over the abdominal wall caused skin erosion, and prolapse of the ileostomy and para-stomal hernias were also significant problems. Clearly, other approaches were needed.

During his animal experiments that were part of the evolution of the 'continent ileostomy', Kock discovered that graded filling of the sigmoid colon as well as small bowel segments induced strong pressure waves, even when low volumes of fluid were introduced. Such pressures were sufficient to overcome sphincter tone and allow leakage of fluid. But by detubularising of the intestinal segments using a new double folding technique and suturing together the opened terminal ileum, a spherical 'reservoir' could be constructed virtually free of pressure on filling. A satisfactory 'bladder/reservoir' capacity with minimal leakage therefrom resulted after years of experimental work. This unique invention meant that patients whose colon and rectum had been removed could be offered an alternative to an external appliance. Stimulated by these promising experiments, in 1967 Kock began a clinical study using low-pressure reservoir continent ileostomy after procto-colectomy in patients with ulcerative colitis. The reservoir was constructed on a distal 15cm of ileum and the outlet or stoma from the pouch passed through the rectus abdominis muscle at an acute angle to form a flat cutaneous ileostomy. It was hoped that rectus muscle tone would be sufficient to gain continence. Sadly, in many cases it proved insufficient to stop leakage from the internal pouches, and alternatives were sought.

In 1969, Nil Kock published a landmark article on this, the 'Kock pouch', or continent ileostomy ('Intra-abdominal "reservoir" in patients with permanent ileostomy. Preliminary observations on a procedure resulting in fecal "continence" in five ileostomy patients' Arch Surg. 1969 Aug;99[2]:223-31), describing a surgical method for achieving continence by creating an internal reservoir in the form of a sphere. Fashioned from the lower end of the patient's own small intestine it led to an opening or stoma on the patients' abdominal wall. Several times a day the patient would sit on the toilet, insert a catheter via the stoma and into the pouch and drain out waste material. It was only necessary to place a small dressing over the stoma to absorb mucus in between regular self-catheterisations.

A 'nipple valve' constructed by intussuscepting a short outer segment of the efferent limb at the stoma achieved a greater degree of continence: some valves required stapling in order to increase stability. But evacuation difficulties, stenosis, slippage of the valve or leakage still remained the Achilles heel. None of these problems and complications were ignored by Kock and the many other investigators who were attracted to this revolutionary concept. Solutions were found whenever possible. Needless to say, long-term studies are being done on continent ileostomies, with or without valve mechanisms. The incidence of pouchitis, improvements on the nipple valve and, most important of all, pouch durability and need for revisions are being researched. Many studies were done by Nils Kock himself, assessing quality of life and patient satisfaction.

Kock's method spread world-wide, and specialist centres in North America and other parts of Scandinavia began to report good or improved results. A Canadian devotee, Zane Cohen, set up a clinic at the University of Toronto after first visiting Kock at St Mark's Hospital, London, where he held a fellowship. He described him as 'an amazing individual who was kind, clever, committed and creative'. Cohen and his colleagues modified and worked on the Kock pouch procedure at the University of Toronto, and the Scandinavian experience has been shared and improved throughout other parts of the world.

Nils was a charismatic tutor and skilled clinician who generously shared his skills and ideas with others: he also very much preferred to 'go his own way'. In so doing he expressed a slight distrust of hospital administration and bureaucracy in general. On joining the permanent staff of his old medical school, he set up a private clinical and experimental gastroenterological research unit with a staff of research nurses and graduate assistants, who constituted the cornerstone of his research activities. From this laboratory emanated a large number of original papers and academic theses in gastroenterology and urology. Over the years he himself had over 300 publications, including those detailing modifications necessary to overcome problems with the Kock pouch.

As an early part of his own training, and to broaden his experience of other systems of healthcare, in 1968 he and his family went for a year to the USA. In Buffalo, New York, he worked with Bud Schenk in laboratories attached to the Edward J Meyer Memorial Hospital, doing research work on intestinal circulation. No doubt he imbibed the cut and thrust of discussions on 'grand rounds', so common in USA institutions.

Nils had numerous invitations to lecture and demonstrate his techniques abroad. In 1973 he was asked by the thoracic surgeon, Ake Senning, to spend a sabattical year and to establish a new clinic for gastrointestinal surgery in Zürich, Switzerland. In 1986 he went to work in the urological department of the University of Mansoura, Egypt, for several short periods. A common problem in this country is the development of carcinoma in bladders infested with bilharzia. Working with Mohammed Ghoneim, who became a great friend, he developed a Kock reservoir which would avoid a stoma after cystectomy. They started a trial using the low pressure pouch provided with an anti-reflux valve that was anastomosed directly to the urethra, a technique which is now used widely.

Nils Kock was made an honorary fellow of the Royal College of Surgeons in 1978, at an annual general meeting held in Swansea. At the meeting he also gave a Moynihan lecture entitled 'A new look at faecal and urinary diversion procedures'. Throughout his career he was presented with numerous awards, including, in1988, the Söderberg prize in medicine - the so-called 'small Nobel prize' - for his ground-breaking research and clinical development of continence-preserving surgery. In 1997 he received the Société Internationale d'Urologie award in recognition of his great contributions to urology.

Although he was in many ways a workaholic, Nils had many interests outside medicine. He was fond of sailing his yacht round the islands of southern Sweden. In 1969 he, with two other surgeons, bought properties and land on Ljusterö, an island located in the northern part of the Tjust archipelago on the east coast of Sweden. It became a favourite place to which he could escape with his closely-knit family. His original mind led him to carpentry for relaxation, befitting a surgeon who was a good technician. He was widely read on diverse subjects, and visited the library near his home in Gothenburg on a regular basis to borrow books to read at home.

Following his retirement in 1990, he and his wife lived for part of the year in southern France, where they enjoyed the French cuisine and wine. In addition they and the members of the family were able to meet up more frequently on Lustjerö. Anki, the older of the two daughters, is married and has two children, My Ernevi and Jonas: she followed her mother into the study of languages. The second daughter, Maria, has followed her father into medicine. She is an anaesthetist and specialist in intensive care at the Sahlgrenska University Hospital, Gothenburg. She is married and has three children - Björn, a trainee cardiologist, Olaf, an intern in medicine, and Tove, who is studying psychology.

Nils Kock died as he would have wished, peacefully, on 24 August 2011, at his home in Gothenburg whilst waiting to go out for lunch. He was 87. He did not wish for any fuss at his memorial service, which was non-religious. He was known to have cardiac problems, so this was presumably the cause of his sudden death. He was survived by his wife of 61 years, their two daughters and five grandchildren.

As the coloproctologist Sir Alan Parks described him at the time of his election to the honorary fellowship of the Royal College of Surgeons, he was 'A giant of a man in all ways, a great Scandinavian, and a great European'. His colleagues, Leif Hultén and Helge Myrvold, end their tribute: 'We who had the privilege to work and interact with "Nicke" have a lot to thank him for and have great memories to look back on. We remember him for his dedication, his curiosity, his thoughtfulness and humour.'

N Alan Green

Sources used to compile this entry: [Maria Kock-Redfors; tributes by Helge E Myrvold, Trondheim, and Leif Hultén, Gothenburg; 'The management of an ileostomy, including its complications.' Brooke, BN. Lancet 1952 Jul 19;2(6725):102-4; 'Proctocolectomy without ileostomy for ulcerative colitis.' Parks, AG, Nicholls RJ. Br Med J 1978 Jul 8;2(6130):85-8; 'Cystectomy + diversion for carcinoma of the bilharzial bladder.' Ghoneim MA, Adhmallah AK, Awaad HK, Shehab el-Din AB, Kock NG, Whitmore WF Jr. Prog Clin Biol Res. 1988;260:315-9; 'Nils Kocks adelsmärke var den kontinensbevarande kirurgin' Svensk Kirurgi 2011 Vol 69 6:312-4; 'A tribute to Nils G Kock, 1924-2011.' Cohen Z. Can J Surg. 2012 Jun;55(3):153-4].

The Royal College of Surgeons of England