Barnet Continent Intestinal Reservoir

The Barnett Continental Intestinal (BCIR) is a modified version of the continent (Kock pouch) ileostomy which was pioneered by Dr. Nils Kock in the 1960's. The major modifications are a collar made from a piece of the patients intestine, an isoperistaltic valve an a lateral pouch design. These design modifications attempt to reduce incidence of the most serious complications of continent slipped valves and fistulae.

A general surgeon, William O. Barnett, M.D., F.A.C.S., began making these modifications to the original Kock technique in 1979 and accumulated a personal series of over 300 cases. Since 1988, surgeons affiliated with the Continent Ostomy Centers have learned the modified procedure in a structured program including observation of Dr. Barnett's technique and proctoring by a surgeon experienced in the procedure. Since 1988, more than 1,300 patients have had BCIR surgery in these centers.

Indications for the Continent Intestinal Reservoir are:

• Patients who have problems associated with the conventional (Brooke) ileostomy.
• Patients who have a failed continent (Kock) pouch, failed Ileal Pouch Anal Anastomosis (IPAA) or other similar procedure.
• Ulcerative colitis patients who have poor anal sphincter control or other conditions precluding their being candidates for the IPAA or who elect not to have the IPAA.

Construction of the BCIR involves taking down a pre-existing ileostomy or removing the colon and rectum if this has not been previously done. The pouch itself is formed from about two feet of the patient's intestine including the valve and collar which are also made of intestinal tissue.

A sensation of fullness will occur when the pouch is ready to be drained. This sensation is not an urgent one and many patients report draining their pouch three to five times a day. The pouch is drained by inserting a catheter through a button hole shaped opening stoma located just above the pubic area.

The hospital stay varies and can range from 13 to 21 days, principally due to the time necessary for the pouch to heal sufficiently. During a portion of this time period the patient is treated post-operatively with suction and intravenous nourishment. Hyperalimentation and antibiotics may be a part of the post-op care as well. Since most patients travel considerable distances to the centers, the extended length of stay is necessary to promote satisfactory patient outcomes, although efforts are now ongoing to reduce the of stay post-operatively.

The surgeons who perform the procedure at the Continent Ostomy Centers collaborated on the design of an outcomes monitoring program which enables them to monitor their surgical outcomes on an ongoing basis, including the impact of surgery on the perceived quality of life of patients who undergo the procedure. A department has been created to collect, monitor and report surgical outcomes. These activities are performed with the assistance of eminent physicians and researchers affiliated with major teaching institutions.

Functional BCIR Pouches Following Surgery
Pouch Related Complications
Quality of Life after the BCIR

A retrospective outcome analysis was performed in 1994 on 510 patients who received the BCIR procedure between January 1988 and December 1991. The study was published in the The Diseases of the Colon and Rectum, June 1995. All patients in this study were between one and five years post-op with an admitting diagnosis of ulcerative colitis or familial polyposis. Approximately 73% were conversions from conventional (Brooke) ileostomies, 9% were conversions from failed alternative procedures and 18% were primary proctocolectomies.

The study found that approximately 92% of the patients have functional BCIR pouches at least one year following surgery. As illustrated in the table, a total of 87.2% of patients required no or minor subsequent surgery to ensure a functioning pouch. Only 6.5% of the 510 patients required subsequent removal of the pouch. The majority of these pouch excisions (removals) occurred within the first year (63.6%).

Major complications included valve slippage, fistula formation, and pouch leakage. Of the 32 patients treated for valve slippage, 23 achieved a fully functioning pouch. Pouch or valve fistulas effected 52 patients, 39 ultimately achieved successful results. Pouch leaks occured in 11 patients, of these 7 have functioning pouches. The incidences of complications are listed in the tables.

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.

The retrospective study further evaluated the impact of the operation on each patients perceived quality of life. As the chart indicates, over 87% of the patients feel their quality of life is better after having the BCIR