J-Pouch Surgery or IPAA
What does J-pouch surgery involve?
Ileal pouch-anal anastomosis (IPAA) is the most common surgical procedure for the management of ulcerative colitis or familial adenomatous polyposis (FAP). The procedure involves removal of the entire colon and rectum, but preserves the anal canal. The small intestine (terminal ileum) is fashioned to make a pouch that looks like a “J” (J-pouch), which is connected to the anus. A temporary ileostomy is created to divert the stool from the J-pouch and allow it to heal. The ileostomy is usually reversed in 2 months.
The procedure may be performed in 2 or 3 stages depending on your overall health and nutrition at the time of surgery. When surgery is performed on an emergency basis or when medications to treat colitis (steroids) have made your tissues too friable or resulted in too much fat tissue in the mesentery (blood vessels to the colon), the procedure may be performed in 3 stages rather than 2 stages. During the first operation, the colon is removed, but the rectum is left in place and an ileostomy is created. This allows the patient to heal and come off of the medications and get stronger. During the next operation generally performed 3 months later, the rectum is removed, the small intestine is used to create the J-pouch, which is sewn or stapled to the anus and another ileostomy is created to allow the J-pouch to heal. During the last stage (2 months after the J-pouch) the ileostomy is reversed.
In patients with ulcerative colitis who are healthier and in most patients with FAP, the procedure is performed in 2 stages. During the first stage the entire colon and rectum are removed, the J-pouch is fashioned and attached to the anus, and an ileostomy is created to allow the J-pouch to heal. The 2nd stage performed 2 months later involves reversal of the ileostomy.
What can I expect after IPAA?
Although the procedure is major abdominal surgery, most colitis individuals start feeling better quickly. The sense of urgency associated with colitis is almost always resolved immediately. At first, patients will have multiple bowel movements a day, but will have the control to make it to the toilet. Over several months, as the J-pouch begins to function more like a rectum, the number of bowel movements will decrease down to 4-6 movements. The most common early complications after J-pouch surgery are related to the ileostomy, where patients can become very dehydrated due to the watery output. This may result in admission to the hospital and intravenous hydration. Constipating agents may be necessary to reduce the watery output from the ileostomy. Paralytic ileus may occur where the intestine is slow to regain function or functions in a disorganized fashion resulting in nausea, vomiting and bloating. This typically requires hospital admission with intravenous hydration and nothing by mouth until the intestine regains normal function.
Patients can develop inflammation of the pouch (pouchitis), which usually responds to antibiotic treatment. In some patients the connection point of the pouch to the anus can narrow (anal stenosis). This is treated with anal dilation in the operating room under light sedation. In a very small percentage of patients, the pouch fails to function properly and may have to be removed or revised. If the pouch is removed, a permanent ileostomy will likely be necessary. There is a small chance of developing rectal cancer after J-pouch surgery. Therefore regular follow-up with your colorectal surgeon for evaluation of your pouch is necessary.
The idea of having such a major operation may be daunting for many patients. For a thorough evaluation, treatment recommendations and to discuss the technical aspects of surgery for ulcerative colitis or FAP, call to make an appointment for a consultation with Dr. Zaghiyan in her office in Los Angeles.