J-pouch surgery is a surgical treatment for ulcerative colitis. Doctors may recommend J-pouch surgery when medications and other treatment methods are not effective. A surgeon first removes the colon and rectum before creating a pouch shaped like the letter “J” out of the end of the small intestine. The J-pouch works as an alternative method of allowing bowel movements.
Doctors may also refer to a J-pouch as a proctocolectomy with ileal pouch anal-anastomosis (IPAA).
This article explores what a person can expect during and after J-pouch surgery. It will also consider the advantages and drawbacks of this technique compared to other ostomy procedures, explaining any potential complications and the recovery time for people undergoing this procedure.
J-pouch surgery can occur in one to three stages, depending on the health of the individual:
In the first surgery, a surgeon will remove the colon and rectum. The anus and anal sphincter muscles will remain in place.
The surgeon will form a J-shaped pouch from the ileum, a section of the small intestine, and connect it to the top of the anal canal.
They may create a temporary ileostomy, which opens the abdomen to allow part of the small intestine outside the abdominal wall. This creates an opening for waste to leave the body into an external pouch, called an ostomy bag.
People need to wear the ostomy bag for the duration of healing. They will also need to empty it throughout the day.
Once the J-pouch heals, individuals will have their second surgery, which may be 8–12 weeks after the first.
During the second stage, a surgeon will remove the temporary ileostomy and reattach the small intestine. The J-pouch will now be able to help the body remove waste through the anus during bowel movements.
In some cases, a surgeon may carry out stages 1 and 2 in one surgery without creating a temporary ileostomy. However, this is less common because of an increased risk of infection.
People may have a three-stage process if they:
- have additional health issues
- are taking high doses of steroids
- require emergency surgery for bleeding or toxic megacolon
In the first surgery, a surgeon will remove the colon and form an ileostomy. In the second surgery, a surgeon will remove the rectum, form the ileum into a J-pouch, and connect the pouch to the anus.
In the third surgery, 8–12 weeks after the second surgery, a surgeon will remove the ileostomy and attach the small intestine to the J-pouch.
People will experience some pain from J-pouch surgery, as it is a major operation. The pain will vary according to an individual’s pain response and how the body responds to pain medication.
Before a J-pouch operation, people may be able to talk with an anesthesiologist about postoperative pain management options. They can also discuss what will happen during the operation.
After the operation, people will need to stay in the hospital for recovery, where nurses will monitor and help control any pain they experience.
Individuals may choose to receive epidurals for pain relief, or patient-controlled analgesia (PCA). PCA is a computerized pump, which nurses will attach to an intravenous (IV) line. This allows people to control their own pain relief medication using a button attached to the device.
The United Ostomy Associations of America say that people may expect the following time frames for J-pouch surgery:
For Stage 1 surgery, people may be in the hospital 5–7 days before the operation. This allows for preoperative checks, such as blood and urine tests. Individuals will also learn about the surgery and what to expect.
About 1–2 days before the procedure, doctors may put people on an all-liquid diet and provide fluids through an IV line.
The duration of the operation can vary between each person but may take between 2–4 hours.
Stages 2 and 3
For Stage 2 or 3 surgery, people may be in hospital 2–3 days before the operation. The surgery may take around an hour.
Pros of J-pouch surgery include:
- People can continue to have bowel movements through the anus.
- Apart from possible abdominal scarring, a J-pouch is not visible to others.
- People may find it easier to choose clothing that fits and feels comfortable rather than fitting it around a stoma over the long term.
- J-pouch surgery involves less maintenance, as a person will not need to change a stoma bag after the healing is complete.
- Up to 50% of people with stomas may experience long-term issues, such as:
- bowel obstruction
- bag leakage
- skin irritation
Disadvantages of J-pouch surgery include:
- J-pouch surgery requires more surgery than a stoma.
- J-pouch surgery involves major surgery, which can cause complications.
- There is a risk of developing pouchitis, an inflammation of the pouch.
- Males may experience sexual dysfunction due to nerve damage.
- Females may have scar tissue around the ovaries and fallopian tubes, which could affect fertility.
People may experience the following after having J-pouch surgery:
- Increased bowel movements: A person may experience up to 12–15 bowel movements each day, which decreases once they leave the hospital to around 4–6 a day.
- Rectal drainage: Mucus may seep out through the anus, but this is a temporary side effect until the ileostomy closes.
- Irritation of the skin around the anus: People can manage this with skin care and by avoiding certain foods, such as spicy foods, tea, and coffee, which may increase irritation.
- Some seepage or incontinence: A person may notice seepage or incontinence, particularly at nighttime, which will usually resolve over time.
- Irregular menstrual cycle: If people menstruate, they may have an irregular menstrual cycle for up to a year following the operation.
People will need emergency medical attention if they experience any of the following complications following J-pouch surgery:
Pouchitis is an inflammation of the J-pouch. Up to 50% of people may develop this complication in the 2 years following surgery. Symptoms include:
Doctors can treat pouchitis with antibiotics.
Anastomotic leak or stricture
An anastomotic leak can occur if the contents of the intestine leak through the site of the anastomosis, where the small intestine joins the rectum. It could also acquire an infection and be fatal. A person may require additional surgery and hospital stays.
Anastomotic stricture develops when the anastomotic site becomes narrowed, which may require additional surgery to repair.
Small bowel obstruction
Adhesions, which are bands of scar-like tissue, can join organs and tissues together, which may lead to small bowel obstruction. Symptoms include:
- abdominal pain or cramps
- unable to make bowel movements or pass gas
In some cases, resting the bowels through IV fluids and avoiding eating for a few days may treat small bowel obstruction. In other cases, people may require surgery.
The risk of an ileal pouch failing is around 10% for people with ulcerative colitis. If a pouch fails, people may need to revert to using a stoma.
Reasons for J-pouch failure can include:
- a change in diagnosis from ulcerative colitis to Crohn’s disease
- pelvic sepsis
People need to follow postsurgical care instructions from a healthcare professional. This may include:
- protecting the skin around the anus with proper skin care to prevent irritation
- drinking plenty of fluids to prevent dehydration and the risk of obstruction
- eating a low fiber diet for around 4 weeks and then gradually increasing fiber
- only resuming sexual activity when safe
- eating foods high in potassium to help with diarrhea, such as bananas, sweet potato, and oranges
- eating moderate amounts regularly and chewing food thoroughly
J-pouch surgery is a treatment method for ulcerative colitis. Doctors can carry out the procedure over the course of one to three operations.
First, a surgeon removes the colon and rectum. They then create a J-shaped pouch with the end of the small intestine. The J-pouch replaces the colon and rectum to allow waste to pass out through the anus.
People can discuss the benefits and risks of J-pouch surgery and what to expect during and after the procedure with their healthcare provider.