Wednesday, March 28, 2012

BCIR - The Barnett Continent Intestinal Reservoir - Information

Barnett Continent Intestinal Reservoir   otherwise called:


I just learned of this kind of intestinal pouch for people that must undergo the removal of their large intestine or for people that are having complications from previous surgeries OR for people that have had an external bag and would like to have more freedom to live a more normal life.  I posted this video because the patient previously had an external bag and she discusses her life after the BCIR surgery.  From what I gather, she talk about the freedom she now has compared to the restrictions she had living with the external option.  I know of the internal pouches and the various kinds of surgeries, but never heard of this method before.  
Any surgery that allows a person to function and feel "normal"; living their life in a way that is the closest to the way they previously lived when they did not have a disease is a blessing.  This is a pretty good alternative for people that are good candidates for this type of surgery.   

Just what is a BCIR anyway?

A BCIR, (Barnett Continent Intestinal Reservoir) is an intra-abdominal continent pouch - all constructed from your small intestine. Also, you will have a very small skin-flush stoma on your lower right abdomen. No external appliance is necessary. The late Dr. William O. Barnett devised the BCIR in 1979 based on the Kock pouch. 

Who is a candidate for the procedure?
1. Individuals who have problems associated with the conventional ileostomy.
2. Individuals who have a failed continent (Kock) pouch, failed ileal pouch anal anastomosis (IPAA) or other similar procedure.
3. Individuals with poor anal sphincter control and are therefore judged not to be a candidate for the IPAA or who elect not to have the IPAA.

How do you decide when it is time to have surgery, especially if colitis is controlled?
Determining whether or not you should have surgery will depend upon you and your physician. The usual indications for surgery would be:
1. If you are one of the people who are no longer responding to medical therapy.
2. You are experiencing complications associated with the disease or medications.
3. You are experiencing tissue changes, or dysplasia, a pre-cancerous condition.

What is the success rate of the BCIR procedure?
Success can be defined in many ways since it can mean different things to different people. In our series of 510 patients with diagnosis of ulcerative colitis or familial polyposis, 477 patients had their BCIR pouches intact at the end of the study period. 

What is the mortality rate for the BCIR procedure?
The risk of death for the BCIR procedure is no different than the risk of similar major surgery. Potential complications are dependent upon the particular patient's history. You should discuss your entire medical history with your surgeon to be fully informed.

Is there a large blood loss during the BCIR surgery?
No, it is rare for a patient to require transfusions for surgery to convert a malfunctioning Brooke ileostomy to a continent ileostomy. However, if a person desires, one or two units (pints) of blood can be donated in the three to four weeks prior to surgery, as long as the patient takes iron to restore their blood count.

What are the ages of your patients?
A person needs a certain amount of maturity to have a continent ileostomy and the growth period of adolescence should be finished before surgery. The youngest patient was 13, the oldest patient was 74.

Are there any contraindications for having this surgery?
The two absolute contraindications are active Crohn's disease or an inadequate length of small intestine. Also, if you have a permanent colostomy, you would not be a candidate for a BCIR.

How long would I be in the hospital for a BCIR?
The average length of stay varies, depending on the individual circumstances and details of surgery. Generally it is between 16 and 21 days.

How can you tell the difference between ulcerative colitis and Crohn's?
In the majority of patients, the difference between ulcerative colitis and Crohn's disease can be made upon the basis of a colonoscopy and biopsies. However - as you probably know - it is sometimes difficult to render a 100% definite diagnosis between Crohn's and ulcerative colitis.

What is pouchitis and is it a major problem?
Pouchitis is a nonspecific inflammation occurring in the pouch. The true incidence of pouchitis is difficult to identify because of variable criteria for diagnosis and severity. However, 73% of the 510 surveyed patients said that they did not consider pouchitis to be a major problem. It is fair to say that most patients experience pouchitis to some degree. However, in a majority of these cases, the symptoms are managed at home with oral antibiotics.

Will I be able to eat anything I want after the BCIR?
When you first leave the hospital, you should avoid fruits, nuts and vegetables that may clog the catheter. Once you are all healed and your pouch has expanded in size, you will be able to eat most any food.

If you chew your food very well, you should be able to eat just about anything. However, many of our patients avoid the tough 'skins' of apples, potatoes and tomatoes, and foods which do not digest well like corn, mushrooms, and peanuts, simply because of the difficulty in passing them through the catheter. Each individual seems to have a somewhat different tolerance for these types of foods.

Will I have to get up in the middle of the night to drain the BCIR?
Once your pouch is matured there should be no need to get up in the middle of the night unless you have eaten late or had a large meal which you are not accustomed to.

Where is the stoma located?
The stoma is small and skin-flush with the abdominal wall. It is usually located low on the abdominal wall. It can be located in close proximity to bony structures since one does not have to secure an external appliance.

Is there pain involved with intubation (process of draining) the BCIR pouch?
There should not be any pain with intubation because the BCIR pouch does not have any nerve endings. Using adequate lubrication helps with the process. Some patients use a little bit of K-Y jelly and some just use a bit of tap water on the catheter before intubating.

What happens if you lose a catheter or forget to take one on a trip?
Many hospitals in the world have Foley catheters of various sizes which can be used temporarily instead of the usual '30 French' silicon type intubation catheters. The standard catheters you will use are easily attained through medical supply houses. They can be used over and over and most cost about six dollars each.

What do you wear to cover the stoma?
This varies greatly with individual patients. Depending on your body's individual tendency to produce mucus, the amount of mucus drainage varies greatly. Some patients use something as small as an adhesive bandage, or a small gauze pad, while others use maxi-thin pads cut in half or small absorbent towels to contain the mucus.

Will I be able to wear tight fitting clothing with my BCIR? And what kinds of activities can I engage in?
Yes to the first question. This is one advantage of the continent ileostomy. Our patients wear tight bathing suits, sports wear and the like. Once your doctor and surgeon give you the green light after surgery, you should be able to resume activities you enjoyed before the surgery, such as swimming, biking, exercising and most all sports. (You might want to wear a protective device to cover the stoma area if you play softball, etc.)

What happens if I get a GI bug and have diarrhea?
The BCIR should remain continent. However, you may experience cramps which is your body signaling that you have to go to the bathroom.

During a normal day, how will I know when I need to go to the bathroom?
When you first leave the hospital, you will be on a schedule of intubating every couple of hours or so and gradually extending the time between intubations in order to let the pouch expand in size gradually. When the pouch has matured, you may go to the bathroom when you feel the need.

Most patients say they experience a 'full' feeling. It is similar to the signal you get when you have to urinate. You'll know when it's about time to empty the pouch, but most times you can wait until it's convenient for you to intubate. If you wait too long, you may have a more intense feeling or slight ache in the pouch area.

What is the recovery time?
The recovery time after major abdominal surgery is 12 weeks to return to strenuous activity and to have normal energy levels. Many people recover much sooner than 12 weeks and return to non-strenuous employment within four to six weeks of surgery.

Do you have to take any supplements or routine medications after the surgery?
Most patients do not require supplements or routine medication after surgery. Just eat a well-balanced diet and you should be fine.

Can you have children after you have the BCIR procedure?
A women may have children through normal vaginal delivery or by Caesarian section with a BCIR. During the pregnancy we request your OB doctor be in contact with the BCIR surgeon.

Are blockages as common as with other surgeries?
Blockages can occur from adhesions after any abdominal surgery, but are no more common with the BCIR.

If you are unhappy with the BCIR, can you revert back to any other surgery?
If the BCIR is not satisfactory for a given person, and this can happen for a variety of reasons, then it may ultimately be removed, reverting to a permanent, conventional Brooke ileostomy with an external appliance.

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