Ileostomy

In a temporary or loop ileostomy, a loop of the ileum is surgically brought through the skin creating a stoma, but keeping the lower portion of the ileum for future reattachment in cases where the entire colon and rectum are not removed but need time to heal. Temporary ileostomies are also often made as the first stage in surgical construction of an ileo-anal pouch, so fecal material doesn't enter the newly made pouch until it heals and has been tested for leaks—usually requiring a period of eight to ten weeks. When healing is complete the temporary ileostomy is then "taken down" (or reversed) by surgically repairing the loop of intestine which made the temporary stoma and closing the skin incision.[3]

The Barnett continent intestinal reservoir (BCIR) is a type of an appliance-free intestinal ostomy. The BCIR was a modified Kock pouch procedure pioneered by 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),[9] 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.

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.[10][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.

Finnish 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,[11] 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.[11][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.[10][Note 3] In addition, he used a plastic material called Marlex to form a collar around the valve.[11] 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 itself. This technique made the valve more stable and eliminated the problems the Marlex collars had presented.[11]

After a test series of over 300 patients, Dr. Barnett moved to St. Petersburg, Florida where he joined the staff of Palms of Pasadena Hospital, where he trained other surgeons to perform his continent intestinal reservoir procedure. With the assistance of Dr. James Pollack, the first BCIR 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); and creating a serosal patch over the suture lines which prevented leakage.[10][Note 4] The end result of these developments has been a continent intestinal reservoir with minimal complications and satisfactory function.[12]

Ulcerative colitis[13] and familial adenomatous polyposis[14] are the two main health conditions that lead to removal of the entire colon (large intestine) and rectum, which leads to the need for an ileostomy.[15][16][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/failed Kock pouch or IPAA/J-pouch; and individuals with poor internal/external anal sphincter control who either elect not to have the J-pouch (IPAA) or are not a good candidate for IPAA.[17]

There are, however, some contraindications for having the BCIR surgery. BCIR is not for people who have or need a colostomy, people with [active] Crohn's disease, mesenteric desmoids, obesity, advanced age, or poor motivation.[18]

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).

A patient must have an adequate length of small intestine to be considered a potential candidate.

ASCRS study, 1995

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.[17] 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 (with the majority of these having occurred within the first year (63.6%);
• Re-operation rate for major pouch-related complications (other than pouch removal) was 12.8% (including: 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; with the most frequent being 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;[17] Over 87% of the patients in this study feel their quality of life is better after having the BCIR.

The study concluded: "BCIR represents a successful alternative to patients with a conventional Brooke ileostomy or those who are not candidates for the IPAA."[17]

ASCRS special study, 1999

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 noted that their study was significant in the very large number of patients,[19] approximately 6 times more than studied by any previous author.[20] The study was published in Diseases of the Colon and Rectum in April 1999.[20] The study found:

• that forty (95.2%) patients of the failed IPAA population reported fully functioning pouches;
• that two pouches had been 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;
• 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."[20]

The study concluded: "The continent ileostomy offers an alternative with a high degree of patient satisfaction, to those patients who face the loss of an IPAA."[20]