Continent Intestinal Reservoir
Suzanne Moss Mullen
To fca...@aol.com
To John
To Barbara Diehl bdi...@msus1.msus.edu
To Larry Finch La...@Prolifics.com
To Eduardo Haddad Filho eha...@iis.com.br
I read all the posting on the net about the BCIR. I think there are some
misconceptions you have about the BCIR, and I will try to explain them
the best I can.
My qualifications to write about these things is I have done quite a few
of these. Until October, 1995, I was one of the BCIR surgeons at the
Continent Ostomy Center @ RHD Hospital in Dallas. Additionally, I was
the medical co-director of the centers nationally. I tired of life in
the fast lane, and in November of that year, I moved to Louisburg, NC.
This is a small town just north of Raleigh, NC. I set up a center here
in Louisburg for doing BCIR procedures completely outside of the
National Continent Ostomy Centers of Tenet Healthcare. I was the second
surgeon to leave the Dallas Continent Ostomy Center(COC). Dr. Tyler
Hughes is in McPherson, Ks, and he also is łopen for BCIR business.˛
Neither of us is affiliated with these centers other than being friends
with all the surgeons and other support staff of the centers.
First of all, Eduardo, the BCIR stands for the Barnett Continent
Intestinal(or Ileal) reservoir. It is an internal intestinal pouch for
those who have had their total colon and recutm removed for either
Ulcerative colitis or Familial Polyposis(a heriditary tendency for the
bowel and specifically the large intestine to form polyps which can
progress to malignancy.). There are essentially 3 alternatives for those
who have had their colon removed. #1 is to have a Brooke Ileostomy. This
means to wear an external appliance for the rest of your life. #2 is to
have one of the pull through pouch procedures. These are termed Ileal
Pouch Anal Anastamosis(IPAA). # 3 is to have an internal pouch
constructed of ileum(one of the three parts of the small
intestine-Duodenum, Jejunum, and Ileum). There are 2 basic types the
Kock pouch created by Dr. Nils Kock in Sweeden, and the later
modification of Dr. William Barnett the BCIR.
Larry Finch called the BCIR a scam. I think that might be a bit too
harsh. We have made no secret of the success rate of the BCIR. Dr.
Barnett had at least 5-6 reports over a 6-8 year period of time. His
report was the lead article of the journal Surgery, Gynecology, and
Obstretics(SGO) in about Jan, 1989. Dr. Barnett was not well liked by
his opponents. Much of his work was completely discounted by his
competitors. Notice I did not say discredited. He was relentless in
trying to improve the Kock pouch to be more successful, and when he
succeeded and reported it, many accused him of inaccuracy in reporting
his data. Dr. Barnett responded by retreating to his work and just
taking care of patients. After about 1985-86 he never presented anything
at medical meetings. While I will admit Dr. Barnett was a zealot, and he
put his heart and soul into the operation and the patients, I knew him
personally, and found him to be accurate, honorable and honest.
Larry Finch also stated there have been no long term follow up studies.
The Brooke Ileostomy has been with us since 1952, the Kock Pouch since
1969, the first IPAA pouch was constructed in 1978, and the Barnett
reservoir since 1979. Face it, there is no real łlong term˛ to any of
these procedures other than the Brooke. The only reason the Kock, IPAA,
and BCIR are even around is because there is a significant number of
patients out ther who will not/can not/wish not to wear an exernal
appliance.
Almost all studies have a bias. The bias is called the thesis. It is the
thesis which is either proved or disproved in a study. Even though all
studies have certain biases, someone reading a report or a study has to
hope the researchers are fair and honest enough to report things
truthfully. The Adjuvant Breast Cancer study which was under a cloud for
so long because one of the Canadian centers łcooked the books˛ just a
bit, in the final analysis came out with just about the same results as
the original assumptions because the rest of the researchers were
meticulous in their honesty. I can not talk with authority about any of
the other COC (St. Pete, Boca Raton, LA, St. Louis, and San Ramon), but
while Dr. Hughes, Dr. Veninga, and I were in Dallas, we bent over
backwards to make sure our results were honest, and we never łhid˛ our
bad results. There was never any secret about what was happened in the
Dallas center. We felt strongly this was a legitimate procedure, and as
such we reported on the results we were having. Our numbers were smaller
than some of the centers, but they were always well studied. We reported
at any forum in which we could get a fair shake, and we even reported at
places we knew our results would be questioned. We invited other
surgeons to look at the procedure, and gave them hints on doing the
procedure themselves. It was the opinion of the surgeons at the Dallas
COC the more surgeons doing the BCIR, the more it had to become accepted
into the medical community. That was a minority opinion amongst the
other centers.
The Tenet Healthcare website points out whose point of view has won out
at the COCąs. There are little catch words or phrases like łwe canąt
make promisesŠ˛ and other such statements. The fact is there are really
many who can do the procedure of the Kock pouch or the BCIR. Really
quality centers like the Cleveland Clinic or the Mayo Clinic(there are
many others) can do the Kock pouch, but because they are so convinced
the IPAA(mostly the J-pouch) is superior few Colo Rectal surgeons would
ever recommend the procedure. The Tenet webpage on the BCIR and some of
the statements made in the alternative ostomy support group point out
the inherent weakness of the internet. Anyone can make any statement,
and it requires no validation. My response has the same inherent
weakness, but with facts I hope to persuade to my way of thinking about
the BCIR.
Babara Diehl had many criticism of the BCIR. Some of them I am in
agreement. The nationwide advertising and the hard sell on the BCIR the
telemarketing division of the Tenet Corporation was always a problem
with the Dallas COC. On the other hand, it did bring us patients who
would have otherwise never heard of the BCIR and some of the benefits.
Many patients came from cities and towns outside of the large
metropolitan areas. We often had to answer the question: Why will no one
tell us about the BCIR? Or even, Why did my doctor not tell me about the
BCIR before I had the Brooke? Here is the classic dilemma: What is the
best way to get out information? Advertising in medicine is all around
us. Barbara Diehl is in Minnesota, and I would bet there is fierce
advertising and competition between the University of Minnesota, Mayo
Clinic, and the larger hospitals in Minneapolis/St. Paul. The same is
true all across the country. I do not like this, but it is the facts of
life in the 90ąs.
The failure rate of the BCIR is not high. I was the lead author of the
report in the Disease of Colon and Rectum which detailed our results.
The pouch failure rate was about 6%, and there were major complications
etc which brought the total problems with pouch loss,complication/major
operative reoperation rate to a little over 13% total. There were minor
stoma revisions in about 7% of patients, and there were a total of >75%
of patients which never needed reoperation for BCIR or Intestine related
problems. There were patients who needed masectomy, gallbladder, liver
transplant and other operations which we defined as non-BCIR related
operations, and they were included in the 75% group. The patients were
overwhelming Brooke Ileostomy patients(72), 19% were patients who were
candidates for a total colectomy and either were not candidates for an
IPAA or chose not to have an IPAA, and 9% had failed IPAA or Kock
pouches. Additionally we had Quality of Life parts of our post op
questionairre, and the improvements, better feeling, etc were in the 90%
range. The total group was 510 patients done between 1988-1992, and had
a minimum of 2 years follow up(some had up to 6 years follow up). We had
about 86-88% followup by the patients.
This report was presented at the 1994 meeting of the Society of Colon
and Rectal Surgery in Orlando, Fl at their national meeting. These
surgeons are our harshest critics, and it was my thought we needed to
present our data to our harshest critics. I had to compress what should
have been a 15+ minute report into about a 5 min. presentation. After
the presentation, there is always a chance for questions and answers.
The questions I can remember: 1) Why did you not report on your cases
with Crohnąs disease(in the presentation we had said we were not
reporting on the Crohnąs patients as part of our report because we
wanted that report to be its own report)? 2) Why will you not report on
Crohnąs disease? 3) Why do you advertise, and in particular why do you
advertise for patients with Crohnąs disease? 4) Why did you not report
about pouchitis? Now this was a legitimate question because this was in
the text of our article, but it was one thing I had to cut out for the
sake of the presentation. I had slides to look at that, and I took about
60 secs. to tell about our results. The last question I remember was: 5)
Do your complications include the 3 patients I have seen in my practice
in Houston, Tx.? There were parts of my report which should have
stimulated really significant questions, but the colon and rectal
surgeons were not interested in asking the questions. They were just
interested in throwing stones! I ask you: Who is interested in the truth
here?
The cost of medicine is very expensive. We can complain or we can accept
that as a fact. I would assume all who have had the total colectomy have
had significant expenses. The IPAA and the BCIR are difficult to do
technically, and the patients require follow up. I think the doctors
charges are in line especially since all these patients are patients we
take care of for a long time if not for the rest of their life as long
as they have the IPAA and the BCIR. BOTH groups of patients have
problems, complications and have need for long term follow up. There are
few surgeons who are willing to take on the responsibility, and
therefore people do have to travel a long way to get there. It is better
for those wanting IPAA than it is for BCIR patients. With Dr. Hughes in
McPherson, Ks, and me in Louisburg, NC that problem just got a little
bit better. Both Dr. Hughes and I are in small towns, and patients have
to decide whether they want to be in the łbig centers˛ or in a smaller
setting. There are other options out there. The Mayo Clinic, the
Cleveland Clinic and other places are doing the Kock pouch or even the
BCIR in other places like Dallas(not at the COC).
I have taken a lot of time to explain this field. It is difficult to do
because it is complex. There is a lot of controversy about the field
which goes beyond the ability to talk about it here. I hope to soon have
a web site for my center on the webpage by Franklin County(NC) Chamber
of commerce. In the meantime I can be reached at:
Patrick D. Mullen, M.D.
122 Jolly Street, Suite 102
Louisburg, NC
27549
919-496-2124
My home E mail is spmu...@ral.mindspring.com
Patrick D. Mullen, MD
LarryFinch
Patrick D. Mullen, M.D. <spmu...@ral.mindspring.com> wrote:
>I read all the posting on the net about the BCIR. I think there are some
>misconceptions you have about the BCIR, and I will try to explain them
>the best I can.
-------------------------long post snipped ------------------------------
Dr. Mullen, thank you for that very informative summary of the BCIR. I was
not aware of all of the internal issues among BCIR surgeons. I was
generally aware of the view of BCIR by other surgeons, and to some degree
I think it's a case of what we engineers call NIH Syndrome (Not Invented
Here). The more interesting question is how less biased observers
(gastroenterologists, for example) view BCIR vs. IPAA vs. Brooke
ileostomy. Do you have any information on this?
One of the problems, which you addressed, is the slick marketing of the
BCIR, which makes one wonder what the real story is, and the appearance
that it's practiced by a secret society.
I have no doubt that the BCIR is an improvement on the Kock Pouch; I'm
less sure how BCIR fares against IPAA, as both of them avoid a Brooke
Ileostomy.
To reveal my own bias, I have had a Brooke ileostomy since 1967 (when it
was the only choice, as you correctly pointed out). It's impossible to say
what I would have chosen 30 years ago if I had a choice, but from where I
am today it seems the right choice.
Larry Finch
La...@Prolifics.com
Larry...@aol.com
