The original internal continent ileostomy pouch was devised by a surgeon in Sweden Dr. Nils Kock in 1969. In 1972 Dr. Kock developed the intestinal valve to insure continence. There was great initial enthusiasm among American surgeons and gastroenterologists with this surgical option to the Brooke ileostomy and its need for an external appliance.
I personally began to perform the Kock pouch when I began my private practice in Surgery in 1977. However, the Kock pouch design had an unacceptably high incidence of complications and failures, leading to removal of the pouch returning the patient to a conventional ileostomy. A small number of dedicated surgeons modified the original technique. The most significant modification was made by Dr. William O. Barnett, involving three changes:
- design of the pouch to minimize fistula formation (leakage of intestinal waste through a weak point in the pouch coming out of the skin or stoma),
- orientation of the intestinal valve component to minimize mucous coming out of the stoma, and
- creation of the intestinal collar to minimize any chance of the valve slipping. A slipped intestinal valve causes difficulty with inserting the drainage catheter and also incontinence (leaking of gas or waste out of the stoma in-between intubations).
I learned the BCIR (Barnett Continent Intestinal Reservoir) technique from Dr. Barnett in 1989 and have been performing it ever since. It should be understood that no operation is perfect. Even a routine simple repair of a hernia can fail, leading to the development of a recurrent hernia and need for another operation.
When a complex intestinal operation is performed like the BCIR, problems can occur despite the latest technology used. There are patients who will require reoperation to repair a fistula or a slipped valve, but this occurs much less frequently than with the original Kock pouch technique. For people with a Kock pouch that is not functioning properly, there are techniques available to transform the pouch to the BCIR, preserving the original pouch itself so no intestine is removed or lost. This is also done for people who have undergone the ileoanal J-pouch procedure who suffer with frequent bowel movements and/or incontinence. Most of these pouches can be saved, converting them to the BCIR instead of removing them and creating a conventional ileostomy with the external appliance.