Kock Pouch

The first continent intestinal reservoir or Kock pouch was pioneered in 1969 by Swedish surgeon Dr Nils Kock.

While the procedure originally had about a 40% failure rate due mostly to valve slippage, over the last 25 – 30 years,  the procedure has been improved and perfected and is now a very reliable and life changing option.

Dr. William Barnett, developed The Barnett Continent Intestinal Reservoir or BCIR procedure that modified the Koch pouch by adjusting the length of the valve and developing a “living collar” to keep the valve from slipping.  The BCIR has decreased the occurrence of CIR valve slippage to less than 10 percent.

Studies show a significant reduction in complications when the surgery is performed by a board certified colon-rectal surgeon who specialized in pouch surgery.

If you are a patient with an ileosotmy and want to know if you are a candidate for a Kock or Barnett (BCIR) pouch, you should discuss it with your surgeon.  But the generalized criteria would be that:

  • You presently have an ileosotmy and your rectum has been removed.
  • Your have a J pouch that has failed, or if you are not a candidate for a j pouch.
  • You have a minimum of 14 feet of small bowel, if your pouch fails and needs to be removed, an adequate amount of bowel must remain to prevent short bowel syndrome.
  • A very select group of patients with Crohn’s disease may be considered.

Patients with a colostomy frequently ask if they are candidates.  The pouch is made from small bowel.  In order to have a CIR, any remaining large intestines (colon) would have to be removed.  If only a couple of feet remain, this is not an issue.  But if the majority of your colon is intact, this is a rather radial surgery.  If your primary doctor states that it is medically necessary to remove your entire colon, then you would be a candidate.

How is the CIR Made?

Approximately 2 feet of the small bowel is used to create the CIR.  It sits in the lower pelvis: the stoma is flush in the right lower quadrant, usually parallel with the hip bone.  Postoperatively, the pouch is allowed to rest by an indwelling catheter for three weeks.  This allows the new reservoir suture line to heal properly to prevent leakage problems.  Some patients will need to be on suction in the hospital for a couple of weeks, but others may be discharged within a week with the catheter sutured to the skin and connected to a leg bag.
After 3 weeks, “self intubation” begins at 2 hour intervals, gradually working up to draining 3 to 4 times a day.  A small pad is needed to absorb mucous over the stoma. Change in diet is minimal provided you chew your food well and increase your fluid intake to keep your stool thin. There are very few lifestyle restrictions with a CIR, although vigorous physical activity should only be performed with an empty pouch.  Direct trauma to the pouch may cause problems especially if the pouch is full.

Complications

Pouchitis: This refers to an inflammation of the pouch.  It is generally a condition wherein the patient will develop abnormal cramps, feeling poorly, frequent stool, and possible fever.  Normally responds to antibiotics.

Stoma stenosis:  This is the narrowing of the stoma that may occur during healing.   This can be repaired with a simple outpatient surgery procedure.

Slipped valve: The valve has become desusscepted.  The valve is coming apart and returning to its original state.  When this occurs, it will come apart and returning to its original state.  When this occurs, it will become shorter, the access segment will become longer and not straight.  Therefore, intubations will become difficult and the pouch will leak.  This will require surgery to repair.