What Is the Barnett Continent Intestinal Reservoir (BCIR) Procedure?

Treats Ulcerative Colitis or Familial Polyposis

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An ostomy is created when a person has part or all of their large intestine (colon and rectum) removed due to disease or injury. Without a colon and rectum, a different way for stool to leave the body must be created. In a traditional ostomy, an opening is made in the abdomen and a small piece of the intestine is exposed (which is called a stoma) so that stool can leave the body.

An appliance (usually a bag or a pouch) is worn over the stoma to collect the stool and it's emptied manually several times a day. A Barnett Continent Intestinal Reservoir (BCIR) is a type of ostomy that is internal, so there is no external appliance worn on the abdomen. The stool is emptied out of the internal reservoir by inserting a catheter into the stoma several times a day.

The surgery has gone through several changes since it was first described in the 1960s (as the Kock pouch).

Candidates for BCIR

Some of the conditions that might lead to colectomy surgery (removal of the colon and/or rectum) include ulcerative colitis, Crohn’s disease, other forms of inflammatory bowel disease, and familial adenomatous polyposis (FAP). A traditional ileostomy, called a Brooke or an end ileostomy, is the surgery that is usually done after the removal of the colon and/or the rectum.

In some cases, such as where there is disease in the area around the anus (perianal disease), the anal sphincter might also be removed during another surgery. Since every patient and every circumstance is different, there are several different types of surgeries that might be used as a treatment. Some of these are the traditional ileostomy, an ileal pouch-anal anastomosis (IPAA, or j-pouch), or an ileoanal anastomosis (pull-through). 

For some people, a traditional ileostomy might not fit their lifestyle. In other situations, the anal sphincter might need to be removed or it might not be healthy enough to hold stool, so making an internal reservoir and connecting it to the anus (which is what is done in the j-pouch and pull-through procedures) wouldn’t work well.

A failed j-pouch, which can occur for a variety of reasons, including repeated pouchitis, cuffitis, irritable pouch syndrome, or poor continence, is another reason patients may consider a BCIR.

The BCIR uses an internal reservoir, but it is emptied through the abdomen instead of through the anus.

Therefore, in the cases described, a BCIR may be considered.

Risks and Contraindications

There are some conditions for which the BCIR would not be considered a treatment option and some patients who might not fare well with the procedure.

  • Colostomy: A colostomy, which is when only part of the large intestine is removed through surgery, cannot be converted to a BCIR.
  • Crohn’s Disease: Those with this form of inflammatory bowel disease (IBD) are not considered candidates for the BCIR because of the potential for recurrence of the disease.
  • Obesity: Having abdominal fat may increase the risk of a complication where the valve of the BCIR might slip out of place.
  • Adaptive Needs or Intellectual Disabilities: Certain types of disability may make intubation or care of the BCIR challenging and therefore it may not be a good fit for these patients.
  • Short Bowel Syndrome: A certain length of small bowel is needed to create the BCIR, and those who already have a shortened length of bowel because of surgeries may not be a candidate for this surgery.

Complications that tend to occur soon after surgery include bleeding, leakage, perforation, or necrosis (tissue death) in the valve. According to a review of continent ostomy procedures, other complications that can occur as the pouch matures include valve slippage, prolapse, fistulas, volvulus, perforation hernia, valve stenosis, or pouchitis.

How the BCIR Is Done

The BCIR procedure is not done as often as other procedures such as the Brooke ileostomy and the j-pouch. There are only a few locations in the country where this surgery is actually offered. A BCIR is complicated to construct and therefore is performed by surgeons who are specialized in the procedure. The actual surgery done to create the BCIR will vary a bit based on any previous surgery a patient has had. 

For patients who have not had any previous bowel surgery, a colectomy (removal of the colon and rectum) will be performed during the BCIR.

If there is already an ileostomy or another type of internal reservoir in place, it will be “taken down,” meaning that the stoma for the ileostomy or the j-pouch will be removed or revised in order to create the BCIR. In some cases, the part of the small intestine used to create the j-pouch (which is the terminal ileum) might be reused to create the BCIR.

Placing the BCIR involves creating the internal pouch as well as the “valve" and “collar." The internal pouch will be created out of about two feet of the small intestine. The collar and the valve are also put in place and attached to the abdomen to avoid having the valve slip out of place and causing a complication.

Aftercare

Many people who receive this procedure travel in order to have it done, so hospital stays may be longer than with other types of internal pouches or an ileostomy. This is to allow for the healing of the BCIR and also to adjust to the intubation process. The hospital stay could be as short as seven days or as long as three to four weeks before being allowed to travel home.

After returning home, patients will have a need to carry a tube with them in order to empty the pouch when necessary. Emptying the pouch is called intubation. Intubation tubes can be ordered from medical supply sites.

A common complication with an internal pouch is pouchitis, which is an inflammation in the pouch that causes diarrhea, discomfort, and in some cases, bleeding. In most cases, this is a complication that can be managed at home with antibiotic treatment. Pouchitis usually starts to resolve within a few days of starting antibiotic treatment but for some patients, it can be recurrent.

Emptying a BCIR

During the BCIR surgery, a stoma is created on the abdomen, which is called an elliptical or a buttonhole stoma. It is flush against the skin, instead of projecting out like a stoma that’s created during a traditional ileostomy. A gauze pad or a bandage is worn over the stoma to collect any mucus. (This is because mucus is continually created by the small intestine and some will leave the body through the stoma.)

When it’s time to empty the pouch, a small catheter is inserted through the stoma and the waste is emptied into a toilet. The mucus that is created by the tissue of the small intestine can help in the insertion of the tube.

There should be no discomfort while draining the pouch. It’s estimated that most people drain their BCIR anywhere between two and five times a day. The pouch can be intubated whenever it is convenient, but this will vary with foods eaten and other factors that affect stool amount and consistency. Some people may need to intubate during the night, but others find that this is not necessary.

Success Rates

One study of more than 500 patients with a BCIR showed that after one year, 92 percent of BCIR patients had functional pouches. Approximately 13% had more surgery to treat a pouch complication. About 7% had the pouches removed due to complications. All patients included in this study had the surgery done to treat ulcerative colitis or FAP. (It should be noted that this study was published in 1995.)

Another small study from 2005 showed that of 24 patients receiving continent ostomy procedures showed that 29 percent needed revisions surgery within a year. However, the authors of the study note that most patients were satisfied with pouch function.

Similar results were shown in a 2009 study where 64 patients who received a continent ostomy after a failed j-pouch, with 30 percent having a complication within 30 days and a 45 percent revision rate. Even with the high complication rate, authors note that most patients were satisfied. 

Follow-Up

Surgical centers where a BCIR is performed often have detailed follow-up plans for patients that include multiple touchpoints, especially during the first year after surgery. This is largely because the rate of revision surgeries and complications tends to be higher than that for a traditional ostomy.

The specialized nature of the surgery will mean that keeping in close contact with the surgeons who understand how to treat potential complications is important.

A Word From Verywell

A BCIR procedure is not common and is usually only done for patients who are good candidates and are highly motivated. For those who have had other procedures for FAP or ulcerative colitis and have a strong desire to avoid a traditional ostomy, the BCIR may be a consideration.

Some of the drawbacks include needing to travel to have the surgery at a specialty center and the complication and surgical revision rates. Be sure to closely discuss your options with your doctor so that together, you can both make the right decisions for you.

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Article Sources

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