J-pouch surgery may be a treatment option for people with ulcerative colitis (UC) when medications are not effective in managing the symptoms.
UC is a type of inflammatory bowel disease involving inflammation that originates in the rectum and extends upward into the colon.
Although medications can treat the symptoms of UC, they cannot cure the disease. Instead, a gastroenterologist may recommend surgery to remove the diseased colon and prevent the spread of inflammation. The most common type of surgery for UC is a proctocolectomy with ileal pouch-anal anastomosis, also known as J-pouch surgery.
In this article, experts discuss when J-pouch surgery may be appropriate for UC treatment and what important points to consider when weighing the risks and benefits of surgery.
J-pouch surgery is a specialist procedure, meaning that a gastrointestinal surgeon who specializes in colon and rectal surgeries will perform it. During the procedure, the surgeon removes the colon and rectum. They then attach the small intestine to the anus, creating an internal pouch shaped like the letter J. This allows for regular bowel movements.
“However, the small intestine is less efficient at absorbing fluid than the colon,” Dr. Ashwin Ananthakrishnan told Medical News Today. Dr. Ananthakrishnan is a gastroenterologist at Massachusetts General Hospital.
Reattaching the small intestine to the anus forms a small pouch. As Dr. Ananthakrishnan explained, this acts as an internal reservoir to help allow for improved fluid reabsorption, an important step in the digestive process.
Dr. Muneera Kapadia told MNT that surgeons typically perform J-pouch surgery in two to three stages, during which time, they might use an ostomy bag. Dr. Kapadia is a gastrointestinal surgeon at the University of North Carolina.
However, as completed J-pouch surgery allows individuals to have normal bowel function, a long-term or permanent ostomy is not necessary.
There are various instances when a person with UC and their healthcare team may consider J-pouch surgery.
“Most commonly, it is for refractory disease where existing medications are not working,” Dr. Ananthakrishnan explained. “Or, in some cases, if the patient is too ill to allow time for the medications to work.”
However, Dr. Maia Kayal, a gastroenterologist at Mount Sinai Hospital in New York, suggested that doctors can consider J-pouch surgery at an earlier stage in some cases of UC.
“It is often incorrectly described as a ‘last resort’ treatment or considered only when medications for UC have ‘failed,’ and it is important to realize that this is not necessarily the case,” she said. “Surgical and medical treatments for UC should be discussed early with patients and the benefits and risks of each considered.”
Dr. Kapadia said that, in general, people who are active and have good anal function are candidates for J-pouch surgery. People who are very sick or weak and those experiencing incontinence may not be eligible for this procedure.
Doctors may also decide to use J-pouch surgery if they find cancerous or precancerous lesions, known as dysplasia, in the colon.
In most people, J-pouch surgery is a curative treatment option that can relieve many of the symptoms associated with inflammation in the colon. These include:
- urgent bowel movements
- bloody stool
- abdominal cramps and pain
- sleep disruption
- weight loss
“It allows for a more predictable return to relatively normal quality of life for such patients and even gets them off medications that could potentially be associated with side effects without any benefit,” said Dr. Ananthakrishnan.
It can also help prevent the spread of cancer when doctors use it to remove cancerous or precancerous lesions.
There are important postsurgical considerations to be aware of, though. “Having the right expectations following surgery is important,” Dr. Kapadia emphasized.
“The J-pouch itself is smaller than a colon,” explained Dr. Laura Raffals, a gastroenterologist at the Mayo Clinic in Minnesota. “So while patients are able to go to the bathroom normally, they often have more frequent bowel movements than people with a healthy colon would experience.”
The experts indicated that most people could expect to have between five and 10 bowel movements a day after J-pouch surgery, although some individuals may have more.
“However, because these bowel movements are controlled and not associated with significant fecal urgency, patients find their quality of life is much improved compared with their quality of life with a sick colon,” added Dr. Raffals.
Some people may also experience bladder or sexual dysfunction after surgery. In some cases, people may also have a reduction in fertility after J-pouch surgery. This may be due to scar tissue that develops in the pelvis that can block the fallopian tubes. When considering J-pouch surgery, people should discuss their reproductive plans with their healthcare team.
One of the most common complications after J-pouch surgery is inflammation in the pouch, known as pouchitis. Nearly
- increased stool frequency or urgency
- pelvic discomfort
- abdominal cramping
It is often possible to treat pouchitis relatively easily with antibiotics. However, chronic pouchitis may occur in up to 30% of cases.
“While this is uncommon, we see this in some of our patients,” said Dr. Raffals. “Fortunately, our treatment options have improved tremendously, and we can often provide good medical therapy for these chronic inflammatory conditions involving the pouch.”
In some cases, what appears to be chronic pouchitis may actually be Crohn’s disease of the pouch, so it is important to follow up with a gastroenterologist if symptoms of pouchitis persist despite treatment.
J-pouch surgery is technically a cure for UC. However, there are important steps that people can take to care for their intestinal health, which may even help prevent pouchitis.
“In general, it is advisable for patients to follow a healthy diet and avoid foods high in refined sugar,” said Dr. Raffals. “Patients may benefit from eating foods that will help thicken their stool output, such as starchy foods and other foods high in soluble fiber.”
Dr. Kayal noted that pouchitis might, in part, result from changes in the populations of bacteria of the gut, known as the microbiome. Some
While some experts may suggest probiotics to help maintain a healthy gut microbiome, Dr. Kayal noted that the research supporting their use after J-pouch surgery has been inconsistent, and their use remains controversial.
“However, a study from 2019 found that fruit consumption was associated with modification of the gut microbiome and lower rates of pouchitis,” she added.
In addition to dietary changes and medication, Dr. Kapadia emphasized that regular, long-term follow-up with a gastroenterologist is important for pouch surveillance.
In some cases, doctors may prescribe medications or supplements to support healthy bowel movements. Antidiarrheal medications, such as loperamide (Imodium), can help reduce the frequency of bowel movements, while fiber supplements can help thicken stool.
“J-pouch surgery can dramatically improve a patient’s quality of life, especially when medications are not working to treat ulcerative colitis,” Dr. Kapadia concluded.
However, while many people with UC can benefit from J-pouch surgery, Dr. Raffals added that it is important to understand that life with a J-pouch is not the same as life with a healthy colon.
If someone is considering J-pouch surgery, they should talk with an experienced gastroenterologist or surgeon to help weigh the benefits and risks to determine whether it is the right option for them.