Barnett continent intestinal reservoir
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The Barnett continent intestinal reservoir (BCIR) is one type of an appliance-free intestinal ostomy. The BCIR was modified from the Kock pouch by Dr. William O. Barnett. It is a surgically created pouch, or reservoir, on the inside of the abdomen, made from the last part of the small intestine (the ileum), and is used for the storage of intestinal waste. The pouch is internal, so the BCIR does not require wearing an appliance or ostomy bag.
How it works
The pouch works by storing the liquid waste, which is drained several times a day using a small silicone tube called a catheter. The catheter is inserted through the surgically created opening on the abdomen into the pouch called a stoma. The capacity of the internal pouch increases steadily after surgery: from 50ccs, when first constructed, to 600–1000ccs(about one quart) over a period of months, when the pouch fully matures.
The opening through which the catheter is introduced into the pouch is called the stoma. It is a small, flat, button-hole opening on the abdomen. Most patients cover the stoma site with a small pad or bandage to absorb the mucus that accumulates at the opening.[Note 1] This mucus formation is natural, and makes insertion of the catheter easier. The BCIR requires no external appliance and it can be drained whenever it is convenient. Most people report draining the pouch 2–4 times a day, and most times they sleep through the night. This can vary depending on what kinds and quantities of food eaten. The process of draining the pouch is simple and quickly mastered. The stoma has no nerve endings, and inserting the catheter is not painful. The process of inserting the catheter and draining the pouch is called intubation and takes just a few minutes.
History of BCIR
Swedish surgeon Dr. Nils Kock developed the first intra-abdominal continent ileostomy in 1969. This was the first continent intestinal reservoir. By the early 1970s, several major medical centers in the United States were performing Kock pouch ileostomies on patients with ulcerative colitis and familial polyposis. One problem with these early Kock pouches was valve slippage, which often resulted in difficulty intubating and an incontinent pouch. As a result, many of these pouches had to be revised or removed to allow a better quality of life.
The late Dr. William O. Barnett began modifying the Kock pouch in 1979. He believed in the concept of the continent reservoir, but was disappointed with the valve's relatively high failure rate. Barnett was intent on solving the problem.[Note 2] His first change was in the construction of the nipple valve. He changed the direction of flow within this segment of intestine to keep the valve in place. This greatly improved the success rate.[Note 3] In addition, he used a plastic material called Marlex to form a collar around the valve. This further stabilized and supported the valve, decreasing valve slippage. This technique worked well, but after several years, the intestine reacted to the Marlex by forming fistulae (abnormal connections) into the valve. Dr. Barnett continued his investigation in an effort to improve these results. After much effort, the idea came to him—a "living collar" constructed from the small intestine. This technique made the valve more stable and eliminated the problems with the Marlex collar.
After a series of over 300 patients, Dr. Barnett moved to St. Petersburg, Florida where he joined the staff of Palms of Pasadena Hospital. Dr. Barnett's goal was to train other surgeons to perform the continent intestinal reservoir.
With the assistance of Dr. James Pollack, the first BCIR (Barnett Continent Intestinal Reservoir) program was established. Both surgeons further enhanced the procedure to bring it to where it is today. These modifications included reconfiguring the pouch to decrease the number of suture lines from three to one. This allowed the pouch to heal faster and reduced the chance of developing fistulae. Creating a serosal patch over the suture lines prevented leakage.[Note 4] The end result of these efforts has been a continent intestinal reservoir with minimal complications and satisfactory function.
Ulcerative colitis and Familial adenomatous polyposis are the two main health conditions that lead to removal of the entire colon (large intestine) and rectum leading to an ileostomy.[Note 5]
Candidates for BCIR include:
- People who are dissatisfied with the results of an alternate procedure, whether a conventional Brooke ileostomy or another procedure
- Patients with a malfunctioning or failed Kock pouch or IPAA/J-pouch
- Individuals with poor anal sphincter control who either elect not to have the IPAA (J-pouch) or are not a candidate for IPAA
Contraindications for having the BCIR surgery
- The BCIR is not for people who have or need a colostomy.
- "The BCIR is not recommended for people with [active] Crohn's disease, mesenteric desmoids, obesity, advanced age, or poor motivation."
- When Crohn's disease only affects the colon, it may, in select cases, be appropriate to perform a BCIR as an alternative to a conventional ileostomy. If the small intestine is affected, however, it is not safe to have the BCIR because the internal pouch is created out of the small intestine, which must be healthy.
- Candidates must have an adequate length of small intestine.
Success Rate & Case Studies
A 1995 study by the American Society of Colon and Rectal Surgeons included 510 patients who received the BCIR procedure between January 1988 and December 1991. All patients were between 1–5 years post-op with an admitting diagnosis of ulcerative colitis or familial polyposis. The study was published in Diseases of the Colon and Rectum in June 1995.
- The study found that approximately 92% of the patients have functional BCIR pouches at least one year after surgery.
- 87.2% of patients required no or minor subsequent surgery to ensure a functioning pouch.
- 6.5% of patients required subsequent excision (removal) of the pouch. The majority of these pouch excisions occurred within the first year (63.6%).
- Re-operation rate for major pouch-related complications (other than pouch removal) was 12.8%. These complications included slipped valve (6.3%), valve fistulas (4.5%), and pouch fistulas (6.3%). Of the 32 patients treated for valve slippage, 23 achieved a fully functioning pouch. Pouch or valve fistulas affected 52 patients, 39 ultimately achieved successful results. Pouch leaks occurred in 11 patients, of these 7 have functioning pouches.
- Complications not related to the pouch itself parallel those that accompany other abdominal surgeries. The most frequent is small bowel obstruction, which occurred in 50 patients, 20 of whom required surgical intervention.
- "Several questions were administered to patients whose responses revealed a significant improvement in general quality of life, state of mind, and overall health. Over 87% of the patients in this study feel their quality of life is better after having the BCIR.
- Conclusion: "The BCIR represents a successful alternative to patients with a conventional Brooke ileostomy or those who are not candidates for the IPAA."
In 1999 American Society of Colon and Rectal Surgeons published a unique study on 42 patients with a failed IPAA/J-pouch who converted to the Barnett modification of the Kock pouch (BCIR). The authors note that their study is significant in the very large number of patients, approximately 6 times more than studied by any previous author. The study was published in Diseases of the Colon and Rectum in April 1999.
- The study found that forty (95.2%) patients of the failed IPAA population reported fully functioning pouches.
- Two pouches were excised, one after development of a pouch vesical fistula, the other after emergence of Crohn's disease, which had not been diagnosed at the time of the original colectomy.
- The study found that "Forty (100%) of the patients with failed IPAAs who retained their pouch rated their life after the continent ileostomy as better or much better than before."
- Conclusion: "The continent ileostomy offers an alternative, with a high degree of patient satisfaction, to those patients who face the loss of an IPAA."
- Patients may place a simple dressing over the flush stoma.
- Dr. Barnett states that over a period of 9 years (and 315 patients) they strove to decrease malfunctioning pouches and the need for additional operations.
- The intestinal collar communicates with the pouch in such a way that buttresses the nipple valve and conduit, providing increased security against leakage.
- Leakage through one of the reservoir suture lines used to be a much more common complication than it is today, thanks to improved construction of the reservoir and careful selection of patients.
- There is no cure for ulcerative colitis, but surgery may be recommended in chronic cases where medical therapy fails. Surgical options include a proctocolectomy, or creating a Brooke ileostomy or continent ileostomy.
- "Ostomy". ASCRS. http://www.fascrs.org/patients/treatments_and_screenings/ostomy/. Retrieved 16 December 2012.
- Corman, Marvin (1993). Colon and Rectal Surgery. Philadelphia: Lippincott Williams & Wilkins. pp. 966–973. ISBN 0397511787.
- Barnett, William. (January 1989), "Current Experiences with the Continent Intestinal Reservoir", Surgery, Gynecology & Obstetrics, 168:1-5.
- Lian L, Fazio VW, Remzi FH, Shen B, Dietz D, Kiran RP. (August 2009) "Outcomes for patients undergoing continent ileostomy after a failed ileal pouch-anal anastomosis", Diseases of the Colon & Rectum (American Society of Colon and Rectal Surgeons) 52(8):1409-14; discussion 4414-6, doi: 10.1007/DCR.0b013e3181ab586b
- "Ulcerative Colitis". ASCRS. http://www.fascrs.org/patients/conditions/ulcerative_colitis/. Retrieved 16 December 2012.
- Dietz, David. "Familial Adenomatous Polyposis (FAP)". ASCRS. http://www.fascrs.org/physicians/education/core_subjects/2006/fap/. Retrieved 16 December 2012.
- McLeod RS. (2003), "Surgery for inflammatory bowel diseases", Dig Dis. 21(2):168-79.
- "Colorectal Diseases and Treatments". ASCRS. http://www.fascrs.org/aboutus/press_room/backgrounders_and_tip_sheets/colorectal/. Retrieved 16 December 2012.
- Mullen, Patrick; Behrens, Donald; Chalmers, Thomas; Berkey, Catherine; Paris, Martin; Wynn, Michael; Fabito, Daniel; Gaskin, Ronald; Hughes, Tyler; Schiller, Don; Veninga, Francis; Vilar, Pio; Pollack, James. (June 1995), "Barnett continent intestinal reservoir: Multicenter experience with an alternative to the Brook ileostomy", Diseases of the Colon & Rectum (American Society of Colon and Rectal Surgeons) 38(6):573-582, doi: 10.1007/BF02054114>
- Vernava III, A. M.; Goldberg, S. M. (1 June 1988), "Is the Kock pouch still a viable option?", International Journal of Colorectal Disease (Springer-Verlag) 3(2):135-138, doi: 10.1007/BF01645320, ISSN: 0179-1958
- Behrens, Donald T.; Paris, Martin; Luttrell, Josiah. (May 1999), "The Authors Reply", Diseases of the Colon & Rectum (American Society of Colon and Rectal Surgeons) 42(5)
- Behrens, Donald T.; Paris, Martin; Luttrell, Josiah. (April 1999), "Conversion of failed ileal pouch-anal anastomosis to continent ileostomy", Diseases of the Colon & Rectum (American Society of Colon and Rectal Surgeons) 42(4):490-6.