J-pouch surgery is a treatment option for ulcerative colitis (UC). Some people can choose whether or not to have surgery, while others require it due to UC complications.

UC is an autoimmune bowel disease that develops when the immune system mistakenly attacks the lining of the colon and rectum. This can cause inflammation and ulcers in the affected areas.

For many people with UC, the use of medications — in some cases, a combination of medications — can effectively reduce inflammation in the colon. Medications can help ease UC symptoms, which may include:

  • diarrhea
  • abdominal pain and cramping
  • blood or pus in stools
  • an urgent need to have a bowel movement

However, for some people, medication is not effective in relieving symptoms. If this is the case, J-pouch surgery is a treatment option.

According to the Crohn’s & Colitis Foundation, some people with UC live with uncomfortable symptoms to try to avoid surgery.

This article discusses what J-pouch surgery is, who is a candidate for the procedure, and when surgery is necessary.

About 23–45% of people with UC will eventually require surgery. J-pouch surgery is the most common surgical procedure for the treatment of UC.

J-pouch surgery is also called a proctocolectomy with ileal pouch-anal anastomosis. Doctors may recommend it when medication is no longer effective in managing UC symptoms.

The procedure typically involves two stages.

During the first stage, the surgeon removes both the colon and the rectum. The surgeon preserves the end part of the small intestine, also known as the ileum, to create an internal pouch. This newly formed pouch is shaped like the letter J, hence the procedure’s name. The surgeon will then create a temporary ileostomy to allow waste to exit the body into an ostomy bag.

Once the J-pouch heals, the surgeon will perform the second stage of the procedure, which involves disconnecting the ileum from the temporary ostomy. They will connect it to the J-pouch so that waste can pass through the anus.

Sometimes, J-pouch surgery may consist of three stages. Surgeons use this approach for people who:

  • have a low health status
  • take high dosages of steroids
  • require emergency surgery for bleeding or toxic megacolon — a rapid enlargement of the colon that is potentially life threatening

The goals of surgery include:

  • relieving the symptoms
  • reducing the risk of colon cancer
  • improving quality of life

A successful J-pouch procedure can eliminate the pain that UC causes. It also allows individuals to have bowel movements without relying on an ostomy bag.

Only some people with UC are candidates for J-pouch surgery. There are many factors to consider, such as:

  • the person’s overall health
  • whether medication can manage the symptoms
  • the current severity of UC
  • whether removal of the colon will be beneficial
  • whether the person has other conditions, such as obesity, diabetes, or a heart condition

People with UC may need J-pouch surgery if their medications stop working or become less effective. They may also choose to have surgery to improve their quality of life.

Some people may elect to have J-pouch surgery to reduce the risk of colorectal cancer. This is because people with UC have an increased risk of colorectal cancer. This type of cancer generally starts as a polyp, which doctors can detect during a colonoscopy. If a polyp is present, surgery to remove the colon and rectum can eliminate the risk of cancer.

Certain UC complications require emergency surgery. In these cases, it is important not to delay surgery.

Complications that require surgery include sudden, severe UC and perforation of the colon.

Sudden, severe UC is the leading cause of emergency surgery in people with UC. It is not possible to manage the symptoms of sudden, severe UC with medications or intravenous steroids.

Sudden, severe UC may cause severe rectal bleeding from deep ulcers in the colon. It can also lead to toxic megacolon.

The symptoms of toxic megacolon include:

  • pain
  • abdominal swelling
  • fever
  • rapid heart rate
  • constipation
  • swelling

A perforation, or hole, in the colon also requires immediate surgery. A hole can develop due to chronic inflammation in the walls of the colon. The contents of the colon can spill from the hole into the abdomen, leading to infection.

If a person is a suitable candidate for J-pouch surgery, they should know what to expect before and after the procedure.

Before surgery

Surgery, in general, can be emotionally and physically taxing. J-pouch surgery may involve two or three procedures that take place over several months to ensure a successful outcome.

Preparing for J-pouch surgery before the procedure can help reduce anxiety, as a person will know what to expect.

The more prepared a person is before surgery, the better they can focus on healing between the procedures.

Before the surgery, a person can speak with ostomy care personnel about using the ostomy bags that will be necessary after the first stage of the surgery. They may wish to consider ordering additional ostomy bags to ensure they have an adequate supply.

A person can also ask their doctor or surgeon to talk them through the procedure. Some individuals also benefit from additional support, such as joining a support group.

After surgery

J-pouch surgery can be life changing, and most people do very well following surgery.

The surgery is often effective in the long term. A 2022 review suggests the rate of J-pouch failure is 6%.

Complete recovery from J-pouch surgery could take up to a year. People can usually return to work and their regular activities after the pouch heals.

A person with UC may choose to delay getting the procedure for several reasons:

  • Their symptoms are mild or do not affect their quality of life.
  • Their medication is effective in managing UC.
  • They are concerned about or have an increased risk of surgical complications.

Complications of J-pouch surgery with ulcerative colitis

Having obesity can increase the risk of multiple postsurgery complications, such as hernias forming near the abdominal incision point. Other complications associated with having obesity include a higher risk of wound infections.

Another reason a person may choose to delay J-pouch surgery is the risk of damage to the sphincter muscles that surround the anal cavity. These are responsible for helping retain bowel continence.

The most common long-term complication of J-pouch surgery is pouchitis. This inflammatory condition causes increased bowel movement frequency, urgency, and pelvic discomfort.

Anyone considering J-pouch surgery can speak with a primary care doctor about the benefits and risks. The doctor can help the person decide whether the procedure is right for them.

Doctors may suggest a permanent ileostomy for people who need surgery to treat an impaired colon but cannot undergo the J-pouch procedure. A permanent ileostomy uses external or internal pouches to collect and store stool.

Another alternative to J-pouch surgery is Kock-pouch, or K-pouch, surgery, although this is not suitable for everyone with UC. In this procedure, a surgeon uses the last part of the small intestine to construct an internal reservoir. They then attach the reservoir to the inside of the abdominal wall. Waste drainage occurs several times a day via a small opening called a stoma and through a catheter.

Below are some common questions about delaying J-pouch surgery for UC.

What are the complications of J-pouch ulcerative colitis?

The most common long-term complication of J-pouch surgery is pouchitis. This inflammatory condition causes increased bowel movement frequency, urgency, and pelvic discomfort.

Other potential complications include:

  • pelvic sepsis and abscess
  • pouch presacral sinus
  • pouch fistula
  • cuffitis
  • Crohn’s disease of the pouch
  • proximal small-bowel bacterial overgrowth
  • irritable pouch syndrome

How does a person know if their J-pouch is failing?

“J-pouch failure” is the need for a pouch resection, permanent diversion, or redo pouch.

Following J-pouch surgery, a person can experience complications such as a pelvis abscess, pouch fistula, or pouchitis. In severe cases, these complications can lead to pouch failure.

Signs of pouchitis include:

  • increased stool frequency and fluidity
  • rectal bleeding
  • abdominal cramping
  • night-time fecal seepage
  • low grade fever

When is surgery necessary for ulcerative colitis?

Surgery might be necessary for a person with UC when medications are not managing their symptoms.

The decision to undergo J-pouch surgery is a deeply personal one. The entire process usually occurs in up to stages, and recovery could take up to a year.

J-pouch surgery is the most common form of treatment if medications do not deliver results, but not everyone is a suitable candidate for the procedure. There are many factors to consider, including underlying health conditions such as diabetes. A person with UC should speak with a doctor about whether J-pouch surgery is likely right for them.