The need to cure a disease or condition by removing the entire colon
(large intestine) and rectum requires creating a way to evacuate the
intestinal waste. The three options available include the conventional Brooke ileostomy, the ileoanal J-pouch, or the continent ileostomy.
Conventional Brooke ileostomy surgery
requires a permanent external appliance to collect the intestinal waste
because the small intestine is a continuous flow system. Material is
produced continuously, even when not eating. The end of the small
intestine is brought through an opening in the abdominal wall and sewn
to the skin to form a spout or nipple-like projection. This allows the
waste to flow into the appliance without contact with the skin. The
waste from the small intestine is corrosive to skin, so the appliance
must be cemented onto the skin and worn at all times. While most people
with a Brooke ileostomy lead a normal life, a
significant number will have episodes of leakage with skin irritation,
allergies to the adhesives, problems with "bag bulge", limitation in
activities, and difficulty making the emotional adjustment to life with
an appliance especially regarding intimate relations and dating. In
fact, 11% of people with a Brooke ileostomy will require a surgical revision during their lifetime. This may be for retraction of the stoma with inability to maintain a seal, prolapse (a stoma that becomes very long and rubs against the bag), or hernia.
The ileoanal J-pouch procedure allows the patient to
evacuate waste the normal way, but it can never be the way it is with a
normal colon. Most people with a J-pouch have 4-7 movements a day. From 5-15% of J-pouch
patients have a poor outcome, either due to many evacuations each day
and/or incontinence (leakage of gas and stool when not intended).
It is important to understand that a patient with a failed J-pouch does not need to have a standard Brooke ileostomy with the external appliance! That is because the third option is the "continent ileostomy", originally devised as the Kock pouch and then modified to the Barnett continent intestinal reservoir (BCIR).
This procedure creates a reservoir or storage chamber made from the
small intestine, together with a valve also made from the small
intestine, and a passageway (the access segment which is brought to the
skin through the abdominal wall), ending as the stoma.
This gives the patient control over the evacuation of their intestinal
waste. Several times daily (usually from 2-5 times depending on the
individual's system), while seated on the toilet, a tube (catheter) is
painlessly inserted to drain the internal pouch. There is no urgency to
doing this and evacuation can be delayed until a convenient time (much
longer than with a J-pouch). Since no appliance is required, the stoma of the BCIR is flat (flush to the skin) and only requires a small covering patch to collect mucous that is produced by the stoma tissue.
BCIR (Barnett Continent Intestinal Reservoir)
The Kock pouch was designed by Dr. Nils Kock in Sweden in 1969 and was met with much enthusiasm, as it was the very first ileostomy
that did not require wearing an external bag (appliance). However, the
failure rate was nearly 50%. Many surgeons and gastroenterologists
stopped recommending the Kock Pouch procedure to their
patients. Fortunately, a small number of surgeons in the United States
continued to work on Dr. Kock's original technique, modifying it to
reduce failures such as slipped nipple valve and fistula. Dr. William
O. Barnett made the most substantial changes to the Kock pouch.
He created the pouch with a single long suture line instead of a
triangulation. He made the intestinal valve in the same direction as
peristalsis. Most importantly, he created the "intestinal collar" that
helps to reduce the incidence of slipped valves. So the Barnett
version of the Kock Pouch is an internal reservoir,
with a self-sealing valve also made from the person's own intestine.
External water cannot get into the pouch even with Scuba diving, and
waste and gas do not come out of the stoma in-between when the pouch is drained.
People who are unhappy or dissatisfied with the results of their procedure - whether it be a conventional Brooke ileostomy, a malfunctioning Kock pouch or malfunctioning ileoanal J pouch - may be candidates for the appliance -free internal pouch known as the Barnett version of the Kock pouch --- the BCIR or Barnett Continent Intestinal Reservoir. A malfunctioning Kock pouch can be revised, including transforming it into the BCIR design.