User:Cabedge/sandbox

/BCIR

Barnett Continent Intestinal Reservoir (BCIR)

File:BCIR diagram.jpeg

Diagram of the BCIR construction

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.

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. 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 pouch is attached to the wall of the abdomen, with a short segment of the intestine leading from the pouch to the stoma.
  The pouch is attached to the wall of the abdomen, with a short segment of the intestine leading from the pouch to the stoma.
• The external opening, called the stoma, is elliptical or button-hole in design.
  The external opening, called the stoma, is elliptical or button-hole in design.
• There is no projecting spout. The opening is covered with a small adhesive dressing.
  There is no projecting spout. The opening is covered with a small adhesive dressing.
• Because the BCIR stores waste internally, you control disposal by deciding when and where to empty the pouch.
  Because the BCIR stores waste internally, you control disposal by deciding when and where to empty the pouch.

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. 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.

File:Traditional BCIR Diagram.png

Comparison illustration of a conventional ileostomy to the BCIR

Most people report that they drain their pouch 2 to 4 times a day and most times they sleep through the night. Of course, this can vary depending on what kinds and quantities of food one eats. 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

File:BCIR History Dr. Nils Kock Dr. William Barnett.png

Dr. William Barnett (left) talks with Dr. Nils Kock (right) at the 1985 UOA Convention

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.

File:BCIR Dr. William Barnett.png

The late Dr. William O. Barnett began making modifications to the Kock pouch in 1979. He had tremendous faith in the concept of the continent reservoir, but was disappointed with the relatively high failure rate regarding the valve. Dr. Barnett was intent on achieving a satisfactory solution to the problem.   The first change that he instituted was in the method of construction of the nipple valve. He changed the direction of flow within this segment of intestine, in order to keep the valve in place. This resulted in a much better success rate. In addition, a plastic material called Marlex was utilized to form a collar around the valve. This was designed to further stabilize and support the valve and resulted in less valve slippage. This technique worked very well, but after several years, the intestine reacted to the Marlex with the formation of 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 not only enhanced the stabilization of the valve, it eliminated the problems associated with the Marlex collar.

After a series of over 300 patients, Dr. Barnett relocated 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.

File:BCIR Dr. James Pollack.png

With the assistance of Dr. James Pollack, the first BCIR (Barnett Continent Intestinal Reservoir) program was established. Together, both surgeons made further enhancements to the procedure to bring it to where it is today. These modifications included changing the configuration of the pouch so that the number of suture lines was decreased from three to one, allowing the pouch to heal faster and reducing the chance of developing fistulae, and the creation of a serosal patch over the suture lines to prevent leakage.   The end result of these efforts has been a Continent Intestinal Reservoir with minimal complications and satisfactory function.

Candidates

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. Candidates for BCIR include:

• People who are dissatisfied with the results of an alternate procedure, whether it be a conventional Brooke ileostomy
• 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 intended for persons who have or need a colostomy.
• The BCIR is not recommended for persons 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 following 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 which accompany other types of abdominal surgery. The most frequent is small bowel obstruction which was seen 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."