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Fecal Continence is Important: KocK Pouch or BCIR?

Medical conditions exist that can only be cured with removal of the large intestine. When this is the case, a new way to eliminate bowel waste must be considered. Once upon a time, the only way to achieve this was to bring the end of the small bowel through an opening in the abdominal wall creating a protruding stoma to which an external device was fashioned to collect your bowel waste. This was called an ileostomy.

With medical advances, we now have options that address continence of fecal waste. These include a rectal pouch know as a j-pouch, s-pouch or a w-pouch. However, due to poor rectal sphincter muscle control or lack of rectal muscles (someone that already had a proctocolectomy) there is a subset of the population that is not a candidate for such a surgery but still can achieve continence with a "pelvic pouch referencing the Kock Pouch and the Barnett Continent Intestinal Reservoir.

Dr. Nils G. Kock published a landmark article in 1969 describing a surgical method where a reservoir (pouch) was created with 2 feet of the individuals own small bowel leading to a flush stoma on the lower abdominal wall. Several times a day, the individual would insert a silicone catheter into this flush stoma which would facilitate bowel elimination. In between the insertion of the catheter, a small absorbent pad was needed to absorb clear colored mucus that was produced by the lining of the intestine.

In the early studies the failure rate (defined as loss of continence) was reported between 25-40%. These studies showed that the major problem was maintaining the valve in the proper position. The symptoms of this "slippage" were difficulty inserting the catheter and leakage of fecal waste. This lead to a small number of dedicated surgeons improving the original technique.

Dr. William O. Barnett was one of those dedicated surgeons who looked at Dr. Kocks design and made three significant modifications. The first change was creating a "nipple valve" which involved taking a small segment of intestine and telescoping it back into itself making two layers of mucosa. This decreased the potential for the valve to prolapse. Another major modification involved wrapping a segment of bowel around the base of the valve referred to as a "living collar". This collar is in concert with the reservoir and creates a "draw string effect" as the pressure in the pouch fills. This modification reduced the tendency of the valve to move out of position and improve continence. Another significant modification was to eliminate a triangulated surgical line in the round shaped Koch pouch. With Barnett's modification, a lateral pouch design was created involving one midline incision thus reducing a potential fistula prone site.

Individuals who already have a Kock pouch and are experiencing difficulty can have their K pouch transformed into the Barnett version. We find that usually the pouch itself is large and healthy so to conserve small intestine, the reservoir is preserved. The weakness usually lies with the valve mechanism, so the efforts in the operating room involve creating a new valve, collar and stoma.

Because both the Kock pouch and BCIR procedures have passionate proponents, knowing the differences between the two and the benefits of each can help those considering be fully knowledgeable of their ostomy options. If you'd like to learn more about the BCIR, contact our team at the Palms of Pasadena Hospital to get a free information packet sent to your home. We can be contacted at 1.800.336.0789 or www.BCIR.com.

You have options when it comes to a traditional ileostomy or failed alternative surgery such as a J-pouch or Kock pouch. The BCIR may just be the solution you've been looking for.