The History of the BCIR Procedure
What is an Ileostomy?
What is an ileostomy and who might need to have this type of surgery? An ileostomy is an operation in which the end of the small intestine (the ileum) is pulled up through an opening created through the muscles and skin of the abdomen, and waste then evacuates into a bag or appliance placed over the intestine (the ileostomy or stoma) and attached to the skin with adhesives. People can be affected by diseases or conditions that can only be cured by undergoing complete removal of the large intestine also known as the colon. This operation is called total colectomy or proctocolectomy meaning resection of the entire large intestine.
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What is an ileostomy and who might need to have this type of surgery? An ileostomy is an operation in which the end of the small intestine (the ileum) is pulled up through an opening created through the muscles and skin of the abdomen, and waste then evacuates into a bag or appliance placed over the intestine (the ileostomy or stoma) and attached to the skin with adhesives. People can be affected by diseases or conditions that can only be cured by undergoing complete removal of the large intestine also known as the colon. This operation is called total colectomy or proctocolectomy meaning resection of the entire large intestine.
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Dr. William O. Barnett (left) talks with Dr. Nils Kock (right) at the 1985 UOA Convention in Anaheim, California.
Past Treatments
Surgeons 100 years ago could remove the colon, but dealing with the waste was a major problem.
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Surgeons 100 years ago could remove the colon, but dealing with the waste was a major problem.
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The Continent Ileostomy
The continent ileostomy creates storage capacity and a continence mechanism, so no gas or waste comes out of the stoma until the patient goes to the bathroom and ...
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The continent ileostomy creates storage capacity and a continence mechanism, so no gas or waste comes out of the stoma until the patient goes to the bathroom and ...
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The Modern Day Ileostomy
The modern-day ileostomy was developed in 1952 by Dr. Brooke and then Dr. Turnbull. It has come to be known as the Brooke ileostomy. In this technique, the end of the ...
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The modern-day ileostomy was developed in 1952 by Dr. Brooke and then Dr. Turnbull. It has come to be known as the Brooke ileostomy. In this technique, the end of the ...
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| Surgery Options After Total Colon Removal |
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| Taking Back Control with the Freedom Option |
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| The BCIR - Replacing an External Bag with an Internal Pouch |
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| Diet with a Continent Internal Ileostomy |
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| Ileostomy Options |
Other Resources
Differences between the Koch Pouch and the BCIR
There are major differences between the Koch pouch and the BCIR. First, in the Koch pouch there is a triangulated suture line which can increase the likelihood of a fistula developing. This risk is minimized with the BCIR technique which has a lateral pouch design with a single longitudinal suture line. A fistula is a result of breakdown in the wall of the pouch with waste leaking out usually along a drain scar or an ...
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There are major differences between the Koch pouch and the BCIR. First, in the Koch pouch there is a triangulated suture line which can increase the likelihood of a fistula developing. This risk is minimized with the BCIR technique which has a lateral pouch design with a single longitudinal suture line. A fistula is a result of breakdown in the wall of the pouch with waste leaking out usually along a drain scar or an ...
Read more ...
The BCIR Procedure
As thousands of people have undergone the BCIR procedure, the name has become popularized. The BCIR can be referred to as the Barnett modification or the ...
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As thousands of people have undergone the BCIR procedure, the name has become popularized. The BCIR can be referred to as the Barnett modification or the ...
Read more ...
What is an ileostomy and who might need to have this type of surgery? An ileostomy is an operation in which the end of the small intestine (the ileum) is pulled up through an opening created through the muscles and skin of the abdomen, and waste then evacuates into a bag or appliance placed over the intestine (the ileostomy or ) and attached to the skin with adhesives. People can be affected by diseases or stoma conditions that can only be cured by undergoing complete removal of the large intestine also known as the colon. This operation is called total colectomy or proctocolectomy meaning resection of the entire large intestine. When this surgery is performed, a new way to evacuate intestinal waste must be created. The most common diseases that lead to this kind of surgery are Ulcerative Colitis and Polyposis Syndromes. Colitis causes frequent urgent movements with bloody diarrhea and the cause if unknown. It cannot always be controlled or put into remission with medications. Polyposis can be inherited or sporadic, but involves hundreds of polyps growing in the colon. Without surgery, colon cancer is certain to occur. Most people with Ulcerative Colitis or Polyposis are young and have surgery in their teens to early 30s.
Surgeons 100 years ago could remove the colon, but dealing with the waste was a major problem. The first "diverting" ileostomy was done in 1913 for a patient with ulcerative colitis. The idea was to prevent waste from getting into the colon to heal the inflammation. Still, the only way for someone to live without their colon was to have the end of the small intestine have a skin graft placed onto it and have it hang into a bag draped around the waist to drip into it continuously. This is because the small intestine is a continuous-flow system. Without the large intestine or colon the usual storage capacity and water absorption functions are now missing from the digestive tract. This old-fashioned ileostomy was life-saving but was not compatible with a proper quality of life. The modern-day ileostomy was developed in 1952 by Dr. Brooke and then Dr. Turnbull. It has come to be known as the Brooke ileostomy. In this technique, the end of the small intestine (the ileum) is brought through an opening in the abdominal wall as a straight tube. The opening must be made through the rectus muscle to reduce the incidence of hernia developing at the stoma site. The location of the stoma on the abdominal wall is carefully selected before the operation. This is usually done together with a nurse who specializes in stomas – an Enterostomal Therapy RN. Dr. Turnbull also helped develop the Nursing specialty of enterostomal therapist. The choice of location is usually to the right of the navel and just below the level of the navel. It will vary based on bady habitus and how the individual person likes to wear their clothing regarding their belt-line. The surgery involves taking the edge of the end of the intestine and folding it back on itself circumferentially, sewing the edge to the intestine and then the skin. This creates a nipple bud or spout so that the caustic intestinal material will flow directly into the external appliance (bag) and not contact the skin where it can cause a burn. Most people who live their lives with this kind of ileostomy, wearing an external appliance, report high patient satisfaction and have good quality of life. Unfortunately, some people have poor ileostomy function, develop hernias at the stoma (parastomal or peristomal hernia) – a torn muscle opening with a bulging, or prolapse (an extra long stoma develops) or retraction (the stoma pulls back in). A proper ileostomy must protrude an appropriate length above the skin to allow for the appliance to make a good seal around it. An alternative to the Brooke ileostomy is the "continent ileostomy". The continent ileostomy creates storage capacity and a continence mechanism, so no gas or waste comes out of the stoma until the patient goes to the bathroom and inserts a catheter or tube into the internal pouch and drains the waste into the toilet. This is usually done 3-4 times daily. With this operation, a person with an ileostomy regains control over the discharge of their intestinal waste. No appliance is worn, only a small covering over the stoma opening to absorb mucus. The stoma is flat and just above the pubic area because no appliance or bag will be worn over it. Essentially, an internal pouch or reservoir is created from the end of the small intestine (the ileum) and a segment of intestine is telescoped into itself creating a double layer called the nipple valve or continence mechanism.The earliest continent ileostomy was devised by Dr. Koch in 1969, but only some people were truly continent. In 1972 he added the intestinal "nipple valve" which made a significant difference. However, over the years, a large percent of people with a Koch Pouch had leakage or incontinence or difficulty inserting their catheters, and needed revision. Many had their internal pouch removed and went to a permanent conventional Brooke ileostomy. Small numbers of surgeons in the United States continued to modify the original Koch technique. Dr. William O. Barnett made very substantial changes to the design of the Koch pouch . Every pouch is a complex operation, and even with the Barnett version of the Koch pouch, called the BCIR or Barnett Continent Intestinal Reservoir, there is a chance of needing a surgical revision. These revisions are highly successful.
Differences between the Koch Pouch and the BCIR
There are major differences between the Koch pouch and the BCIR. First, in the Koch pouch there is a triangulated suture line which can increase the likelihood of a fistula developing. This risk is minimized with the BCIR technique which has a lateral pouch design with a single longitudinal suture line. A fistula is a result of breakdown in the wall of the pouch with waste leaking out usually along a drain scar or an incision until it reaches the surface as an abscess. When drained, the abscess resolves but waste material and/or gas escapes from the skin opening. This is called an enterocutaneous fistula. A fistula can sometimes heal by itself with proper care, but it can be a condition that requires corrective surgery to repair it.Secondly, the BCIR changes the direction of the nipple valve intussusception (the way it is created by grasping a segment of the intestine in the middle and telescoping it into itself, thereby creating a double layer of intestine – a self-sealing valve) from the Koch design so that it is isoperistaltic. This means that the normal intestinal muscle contractions that go along the intestine (including the intestine used to form the valve) moving material from upstream to downstream in the BCIR go towards the pouch. This encourages the flow of mucous towards the inside of the pouch instead of coming out of the stoma.
Thirdly, and perhaps most significantly, the BCIR has an intestinal collar that comes off of the pouch and wraps around the outside of the access segment where it transitions to the valve segment at the junction with the pouch. As the pouch fills with gas and waste, the collar also fills, tightening like a noose to help prevent the possibility of slipping of the nipple valve. Dr. Barnett met with Dr. Koch and used his surgical skills to think of these improvements or refinements of the Koch (sometimes spelled Kock) pouch.
The BCIR Procedure (Barnett Continent Intestinal Reservoir)
As thousands of people have undergone the BCIR procedure, the name has become popularized. The BCIR can be referred to as the Barnett modification or the Barnett version of the Koch Pouch, but has come to be called either the Barnett Pouch or the BCIR to highlight the technical variations involved so that patients receive appropriate care after surgery during their lifetimes. First Dr. Barnett changed the suture line from triangular to lateral (longitudinal). Then he addressed the issue of reducing the incidence of slipped valves. For a few years in the early 1980s, Surgeons had been creating a "collar" (like the BCIR intestinal collar) using synthetic mesh. The mesh was the same as used to repair a groin (inguinal) hernia. The mesh creates an intense scar reaction which is good when repairing a hernia, but bad when it touches the more delicate intestinal wall. Many patients with the mesh collar developed a fistula involving the access segment into the pouch or the pouch itself. This led to sickness and reoperations. However, the mesh collar was nearly 100% effective at preventing a slipped valve from occurring. Therefore, Dr. Barnett conceived of another, better and safer way to achieve the same effect. That became the intestinal or "living" collar, to distinguish itself from the inert mesh collars. By the end of the 1980s, Dr. Barnett had completed the final design of the BCIR. At the same time he, together with patients of his including an Enterostomal Therapy Nurse with a BCIR, founded a non-profit educational and support organization called the Quality Life Association.