J-Pouch Surgery: Procedure, Risks & Benefits

J-pouch surgery is a procedure that is performed after a patient has had a proctocolectomy. This is an operation to remove the colon (large intestine) and rectum, the organs that store and eliminate solid wastes. The colon and rectum are removed in certain disease conditions including:

• Chronic (long-term) ulcerative colitis inflammation of the mucosal lining of the rectum and colon (tiny ulcers and small abscesses in the colon and rectum that flare up and cause bloody stools and diarrhea).
• Hereditary forms of colorectal cancer or multifocal colon and rectal cancer.
• Familial adenomatous polyposis (an unusually large number of polyps in the colon).

If you have had these organs removed, you may have an ileal pouch-anal anastomosis (IPAA) procedure to provide a new way to store and pass intestinal contents per anus. In an IPAA, the ileum (the lowest part of the small intestine) is formed into a pouch to store solid wastes. This pouch is connected to the anal canal, allowing you to store and pass stool through the body’s usual route.

J-Pouch Surgery

There are three types of ileal pouches: J-pouch, S-pouch and the W-pouch. The J-pouch is the type that is used most often because it requires the shortest length of intestine, is the easiest to construct, and provides the best function.

In order to have an ileal pouch procedure, your intestinal muscles, sphincter, nerves and anus must still be able to function normally. This will allow the person to maintain control of bowel movements once a pouch is constructed.

Your doctor will look at various factors to determine if you are a good candidate for J-pouch surgery. These may include:

• Conditions other than ulcerative colitis, such as Crohn’s disease, indeterminate colitis, IBD-unclassified: The J-pouch is not always the preferred treatment for these conditions.
• Obesity: Obese patients tend to have a longer surgery time, increased difficulty of constructing a J pouch, an increased risk of infection, a longer recovery time in the hospital and more complications after surgery. If you are significantly overweight, your doctor might recommend that you try to lose weight before the surgery.
• Lack of anal sphincter function: The lack of muscle control is often found in older patients and in women who were injured during childbirth.
• Pelvic radiation before pouch surgery: This condition may relate to higher rates of pouch failure and pouchitis. In addition, pelvic radiation after J-pouch surgery can also cause problems such as pouchitis, diarrhea and night-time voiding. Pouchitis is an irritation and inflammation of the pouch.

Completed J-pouch procedure using two loops from the small intestine.

How is a J-pouch surgery performed?

J-pouch surgery usually occurs in one, two or three stages. The number of stages depends on the condition and the health of the patient.

A J-pouch (also called an ileal pouch or pelvic pouch) is made by using two loops of small intestine, each measuring about 6 inches long. The pouch is connected to the top of the anal canal in an area called the anal transition zone to eventually allow for elimination of stool. After the pouch is constructed, it can hold about 2/3 of a pint of fluid.

The surgeon also creates a temporary hole in the abdomen called an ileostomy. This hole allows waste to pass into an external (outside the body) bag called an ostomy bag while the J-pouch heals.

Once the J-pouch heals, the surgeon closes the ileostomy and reattaches the two ends of the bowel. This connection enables the body to accumulate waste in the pouch and eliminate it through the anus.

What are the benefits of J-pouch surgery?

Successful J-pouch surgery eliminates the pain and suffering caused by diseases such as colitis and familial adenomatous polyposis. It also allows people who have had the surgery to pass stools normally and not have to rely on an ostomy. This can have an enormous psychological benefit.

What are the side effects of J-pouch surgery?

The most common side effect of J-pouch surgery is pouchitis, an inflammation (swelling) of the pouch that occurs when the pouch becomes irritated and inflamed. About half of patients who undergo IPAA surgery for ulcerative colitis will have pouchitis at least once in their lifetime. Pouchitis is usually treated with a 7 to 14-day course of antibiotics. The doctor may also recommend probiotics (“good” bacteria that normally live in the digestive tract) such as Lactobacillus, Bifidobacterium and Thermophilus, and medicine to control diarrhea.

Other complications of J-pouch surgery include:

• Increased bowel frequency (having to go to the bathroom more often).
• Anastomotic leak (resulting in infection or fistula in the pelvis after surgery).
• Abdominal cramping or bloating.
• In women, infertility (inability to bear children), due to scarring around the ovaries and Fallopian tubes after surgery.
• In men, impotence (inability to have an erection) because of nerve damage from the surgery.
• Pelvic sepsis (infection).
• Pouch bleeding.
• Small bowel obstructions (blockage in the small intestine).
• Cuffitis (infection of the part of the rectum left called the cuff; colitis in the cuff).

What is the prognosis (outlook) for people who have J-pouch surgery?

Most people who have J-pouch surgery can return to work and their normal activities after the new pouch heals. It may take up to a year for bowel function to ‘normalize’ to a new normal of an average of five to six bowel movements a day. Until that time, the patient will often have a greater number of bowel movements every day (up to 12). This increased frequency usually decreases as the pouch stretches to hold more fluid and surrounding muscles get stronger.