J-Pouch Surgery l United Ostomy Associations of America

J-Pouch Surgery

A J-Pouch (also known as Ileal Pouch Anal Anastomosis (IPAA)) is an internal pouch (J, S, or W-shaped) that is fashioned out of the small intestine upon a proctocolectomy, allowing the patient to defecate via the anus and avoid a permanent ostomy.

J-Pouch/IPAA surgery is rarely done in Crohn’s disease patients, as disease can present in the j-pouch itself. However, IPAA may be an option should the patient not want an ostomy. Crohn’s disease patients may also need to be optimized on medication (usually biologics) if J-pouch/IPAA surgery is done. It is always best for patients with Crohn’s disease to discuss the best routes offering the best prognosis with their gastroenterologist and surgeon.

J-Pouch surgery is commonly done in cases of refractory ulcerative colitis where there is no disease in the small intestine.

J-Pouch surgery may be done in cases of colorectal cancer, dysplasia, severe pancolitis, toxic megacolon and/or a bowel perforation which may lead to an ostomy temporarily.

See Figure 7 above to better understand J-pouch anatomy and the stages of surgery.

3 Stages of J-Pouch Surgery

J-Pouch surgery is usually done in 3 stages with a period of approximately 12 weeks between surgeries, depending on how sick the patient is entering surgery. (Actual number of stages may vary based on the surgeon’s recommendations and the patient’s health)

Stage 1:

Remove the colon and most of the rectum, leaving behind only approximately 1cm of a rectal cuff. The patient is given an end ileostomy to allow the bowel to heal and the body to recover.

Stage 2:

Create the J-pouch out of the small intestine. The patient is usually given a loop ileostomy and the J-pouch is allowed to heal.

Stage 3:

Connect the J-pouch to the rectal cuff, creating an ileoanal anastomosis. This connection allows the patient to defecate normally through the bottom.

In most cases, J-pouch surgery
alleviates ulcerative colitis significantly.

However, J-pouch surgery is NOT a cure for ulcerative colitis. Sometimes patients develop complications:

Dehydration
This can occur along with diarrhea and intestinal blockages.
Anastomotic leak
Leaks can sometimes happen at the site where the J-pouch and rectal cuff are stitched. This can result in sepsis and can require immediate surgery to correct.
Pouchitis
This is inflammation of the J-pouch that can result in frequent, bloody bowel movements. This can be similar to IBD symptoms prior to proctocolectomy. Pouchitis usually requires antibiotics and/or resumption of additional IBD therapies to treat.

Cuffitis
This is inflammation of the rectal stump or cuff that can result in accidents and increased bloody, bowel movements. This can be similar to proctitis symptoms prior to proctocolectomy. Cuffitis usually requires suppositories or enemas to treat. If very severe, the patient may need follow-up surgery to remove the mucosal lining of the rectal cuff (rectal mucosectomy) or to advance the J-pouch forward.
Development of strictures & fistulae
This can be a post-surgical complication or related to the underlying IBD. Usually, such severe complications result in a re-evaluation of the disease and the diagnosis may sometimes be changed to indeterminate colitis or Crohn’s disease. Gastroenterologists and colorectal surgeons usually collaborate on such cases to assess how to best treat (surgery, IBD medications, both, etc.). In many situations, in order for the bowel to heal from severe complications, the J-pouch is disconnected and a temporary loop ileostomy is given (sometimes reversible, often not reversible).

Keep in mind that...

the patient has the right to decide to move forward with the J-pouch or keep the ostomy upon removal of the colon. Also, not all temporary ostomies are able to be taken down and not all J-pouches are able to be connected. It would be best to discuss your particular situation with your surgeon prior to moving forward.

Written by Tina Aswani Omprakash. Medically reviewed and validated by Jordan Axelrad, MD, MPH. These webpages are funded by a grant from The Leona M. and Harry B. Helmsley Charitable Trust.

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