Overview of J-Pouch Surgery
A j-pouch, or ileal pouch reconstruction, is a complex type of surgery used for people who have ulcerative colitis, particular types of colon cancer, or familial polyposis. Developed in the 1970s, this surgery eliminates the need for an external pouch to collect waste because a pouch that functions as a rectum is made from the end of the small intestine in the body. The procedure can be performed in one, two, or three steps, but is most often done in two.
The first step in j-pouch surgery is the removal of the colon or large intestine. The anal sphincter muscles are left in place and a small section of the rectum may also be left, which varies based on a number of factors. The lining of the part of the rectum that is left may be removed, which is called a mucosectomy. The surgeon will then create the actual pouch out of the last part of the small intestine, which is called the ileum. This pouch can be constructed in a few different ways to create a j-pouch, an s-pouch, or a w-pouch, but the most commonly done shape in recent years in the United States is the “j.” The open end of the pouch is then connected to the anus (or to the rectal stump if there is one).
Finally, the surgeon creates an ileostomy, which will be temporary while the j-pouch heals. An ileostomy is a procedure in which a part of the small intestine is brought through the skin of the abdomen. This external piece of the small intestine is called a stoma, which is Greek for “mouth.” Waste exits the body through the stoma and is collected in an ileostomy appliance that is worn on the abdomen. The ileostomy diverts stool from passing through the j-pouch so that the pouch is given time to heal.
After the patient has had time to heal (usually two or three months but it can also be much longer in certain circumstances), the second step of the procedure will be performed. During this step, which is also called a takedown, the ileostomy is reversed and the j-pouch is connected. The stoma site is closed up, making the digestive tract into one long tube again. The patient will no longer need the external ileostomy bag, and waste will be passed out through the j-pouch and the anus.
One Step and Three Step Procedures
Occasionally, a surgeon and patient will decide to complete the entire procedure in one step. The surgeon will perform the colectomy, create the j-pouch and connect it all in one operation. The one step eliminates the need for a second or third surgery or a temporary ileostomy. In recent years the practice of doing this surgery all in one step has come into question because there may be a greater risk of pouch-related complications.
If a patient is very ill, the surgeon may elect to use three steps to complete the procedure. In the first step, the colectomy is done, and the temporary ileostomy is created. In the second step, the j-pouch is constructed, and the third step is the takedown. The wait between each of these surgeries is two to three months, depending on the health of the patient. The intervals may be longer for patients who were quite ill at the time of the colectomy. While three surgeries is a major investment, there is some evidence emerging that three surgeries may be associated with a lower risk of complications in the long run.
The vast majority of j-pouches are successful and people who have the surgery experience improved quality of life. People who have this surgery still require regular check-ups with a gastroenterologist and/or a colorectal surgeon to ensure the health of the pouch and to follow-up on any potential pouch-related issues or development of extra-intestinal complications.
- Ileal Pouches. Cleveland Clinic. Oct 8, 2019.
- Hicks CW, Hodin RA, Bordeianou L. Possible overuse of 3-stage procedures for active ulcerative colitis. JAMA Surg. 2013;148(7):658-64. doi:10.1001/2013.jamasurg.325
- Ileal Pouches Procedure Details. Cleveland Clinic. Oct 8, 2019.
- Weston-petrides GK, Lovegrove RE, Tilney HS, et al. Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg. 2008;143(4):406-12. doi:10.1001/archsurg.143.4.406
- Mège D, Figueiredo MN, Manceau G, Maggiori L, Bouhnik Y, Panis Y. Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients. J Crohns Colitis. 2016;10(8):898-904. doi:10.1093/ecco-jcc/jjw040
- Bikhchandani J, Polites SF, Wagie AE, Habermann EB, Cima RR. National trends of 3- versus 2-stage restorative proctocolectomy for chronic ulcerative colitis. Dis Colon Rectum. 2015;58:199-204. doi:10.1097/DCR.0000000000000282
- Mège D, Figueiredo MN, Manceau G, Maggiori L, Bouhnik Y, Panis Y. Three-stage Laparoscopic Ileal Pouch-anal Anastomosis Is the Best Approach for High-risk Patients with Inflammatory Bowel Disease: An Analysis of 185 Consecutive Patients. J Crohns Colitis. 2016;10:898-904. doi:10.1093/ecco-jcc/jjw040
- The American Society of Colon and Rectal Surgeons. Ulcerative Colitis. https://www.fascrs.org. 2018.