Barnett Continent Intestinal Reservoir (modified continent ileostomy) to restore continence after colon and rectum removal

Evidence-based recommendations on Barnett Continent Intestinal Reservoir (modified continent ileostomy) to restore continence after colon and rectum removal in adults. This involves using the ileum to create a pouch on the inside of the abdominal wall to collect waste.

# Recommendations
The evidence on the safety of Barnett Continent Intestinal Reservoir (modified continent ileostomy) to restore continence after colon and rectum removal shows that there are serious but well-recognised safety concerns. Current evidence on its efficacy is limited in quantity and quality. Therefore, this procedure should only be used with special arrangements for clinical governance, consent, and audit or research.
Clinicians wishing to do Barnett Continent Intestinal Reservoir (modified continent ileostomy) to restore continence after colon and rectum removal should:
Inform the clinical governance leads in their NHS trusts.
Ensure that patients understand the procedure's safety and efficacy, as well as any uncertainties about these. They should provide them with clear written information to support shared decision making. In addition, the use of NICE's information for the public is recommended.
Audit, review and publish clinical outcomes of all patients having Barnett Continent Intestinal Reservoir (modified continent ileostomy) to restore continence after colon and rectum removal. This guidance requires that clinicians doing the procedure make special arrangements for audit. NICE has identified relevant audit criteria and has developed an audit tool (which is for use at local discretion).
The procedure should only be done by experienced colorectal surgeons with training and mentoring in the specific technique.
Further research should include details of patient selection, durability and the incidence of complications. Outcomes should be published.# The condition, current treatments and procedure

# The condition
Various groups of patients may need surgery to remove the colon and sometimes the rectum. They include patients with: ulcerative colitis that is unresponsive to medical treatment or who cannot tolerate the treatment; familial adenomatous polyposis; Crohn's disease; or cancer-related problems. An ileostomy is then needed to allow intestinal contents to exit the body through a stoma on the abdominal wall.

# Current treatments
There are different surgical techniques for creating an ileostomy, including: a Brooke ileostomy (this involves creating a standard stoma that empties intestinal contents continuously into an external ileostomy bag); or a Kock continent ileostomy (this involves creating an internal ileal reservoir connected through the abdominal wall, which is drained intermittently by the patient). In patients with good anal sphincter control, a long-term ileostomy may be avoided by creating an ileal pouch reservoir connected directly to the anus (ileal pouch-anal anastomosis).
The Barnett Continent Intestinal Reservoir is a type of continent ileostomy and may be considered as an option for some patients.

# The procedure
The Barnett Continent Intestinal Reservoir procedure is done under general anaesthesia, usually through a midline incision. It may be done as a primary procedure, when the colon and rectum are removed, or to modify a pre-existing ileostomy. A pouch incorporating a collar and an isoperistaltic valve is created using the last 60 cm of the ileum. The valve is made by intussuscepting a segment of small bowel and fixing it to the pouch wall with staples. This valve functions in the opposite direction to that in a Kock pouch, ensuring the bowel's normal peristaltic action keeps intestinal contents in the pouch rather than expelling them. The collar is formed by wrapping a segment of small bowel around the top of the pouch and valve. It holds the valve in place and provides further continence when the pouch is full and under high pressure. The flat stoma opening is located just above the pubic area and covered with a small adhesive dressing.
When there is a sensation of fullness, the patient drains the pouch by inserting a catheter through the stoma and valve into the pouch. This is typically done 2 or 3 times a day, but the patient determines the exact frequency.