The J- pouch procedure is the common name used for the operation of total proctocolectomy with ileoanal pouch anastomosis. This operation removes the entire colon and rectum, and replaces the rectum with a neorectum (a new rectum). The neorectum is a pouch made from the last portion of the small intestine (the ileum) which is connected to the anus. This connection is called an anastomosis. The J-pouch procedure has been performed in one variation or another for twenty two years. We performed our first laparoscopic colon surgery in 1994, and our first laparoscopic J-pouch procedure in 1997. If your surgeon has not offered you a laparoscopic option for your J-pouch procedure, we recommend that you obtain a second opinion with a laparoscopic colo-rectal surgeon. We would be happy to speak with you by phone to arrange consultation in our offices or with a surgeon in your geographic area. Q. Are there alternatives to the J-pouch procedure? The most common long term problem after the J-pouch procedure is recurrent inflammation in the lining of the pouch, called pouchitis. This can occur in up to 30% of patients. It occurs more often in patients with ulcerative colitis, rather than polyposis. The cause of pouchitis remains unclear. It is generally treated with oral antibiotics and/or salicylate enemas.Other long term complications include infrequent sexual dysfunction including impotence (<1%) and retrograde ejaculation (<3%) in men, and pain with intercourse (~5%) or stool leakage during intercourse (~2%) in women. The operation begins with induction of general anesthetic. Once you are asleep, the operating team positions you on the operating table with your knees apart. Your abdomen and the area around the anus are washed off and sterile drapes are applied. Now the operation begins. Next, we enlarge one of the incisions located just above the pubic bone in a side to side to direction for approximately 6 centimeters. We are able to remove the large intestine through this incision and divide it right at the point where it connects to the small intestine. We can now construct the J-pouch in the standard fashion as has been done for years in open surgery. Care is taken to construct an adequate size pouch, which can be brought down to the anus without excessive pulling on the blood supply. The J-pouch is then joined to the anus using a surgical stapling instrument. This is called the double staple technique. Q. Are the other ways to perform the J-pouch procedure?A. Many different ways have been tried to make the best possible pouch from the ileum, in terms of function as a neo-rectum. These include S-pouches, W-pouches, and several other designs. Currently the J-pouch seems to work best for the most people.
Q. Who needs a J-pouch procedure?
A. The two common indications for the J-pouch procedure are familial polyposis and ulcerative colitis. People with familial polyposis require a J-pouch procedure to prevent colorectal cancer from developing in their polyps. People with ulcerative colitis are generally "cured" of their colitis after the J-pouch procedure, as well as eliminating their risk of colorectal cancer.
A. The traditional alternative is a total proctocolectomy with permanent ileostomy. This was the only treatment available for patients with ulcerative colitis or familial polyposis for many years. It requires the patient to permanently wear a "bag" to collect waste. In general, patients report an overall higher satisfaction and quality of life in regards to work, social, and personal activities after the J-pouch procedure compared to the alternatives.
Q. If I have a J-pouch procedure, what can I expect afterwards?
A. In the long term, most patients eventually have an average of between four and six semi-solid bowel movements per day and one at night. About 90% of patients will have complete continence of stool and flatus, although a small percentage of patients will have some difficulty with soiling their clothing, and need to wear protective pads. Some patients will only experience soiling at nightime, or when passing flatus.
Q. What can I expect immediately after the operation?
A. Immediately after the operation, you will have a temporary ileostomy, where your waste comes into a "bag", to allow the J-pouch to heal. This ileostomy is closed up 6 to 12 weeks later at a second operation. At this point, most patients will have more frequent stools and more problems with soiling their clothes than they will have six months later. Many patients have ten or more bowel movements per day initially, and need to be careful to always be near a bathroom. Diet and medication can help with the adjustment.
Q. Are there any complications of the operation?
A. The J-pouch procedure is a very safe operation, with a very small risk (<1%) of death. However, complications are quite frequent including bowel obstruction (5-20%), anal stricture (5-10%), pelvic abscess (5%), and leakage from the pouch or at the anastomosis (2-10%). These last two complications can occasionally result in complex pelvic infections, fistulas, and even re-operation to remove the pouch with a permanent ileostomy (<5%). Infrequently, the surgeon will find that the ileum is too short to be connected safely to the anus, and it is impossible to create a J-pouch with good function; in those cases, a permanent ileostomy will be required.
Q. What is the difference between the open and the laparoscopic J-pouch procedures?
A. The standard procedure is done through a long midline incision which allows the surgeon and assistant to place both their hands in the abdomen and view the operation directly. In the laparoscopic J-pouch procedure, there are five small incisions approximately -inch or less through which the surgeon and assistant work using a laparoscope and long instruments. Towards the end of the laparoscopic procedure, the incision directly over the pubic bone is lengthened to approximately 4 inches to allow removal of the large intestine and formation of the pouch for the anastomosis.
Q. What are the advantages of a laparoscopic operation?
A. The advantages include decreased post-operative pain, shortened recovery time, and better cosmetic result. Studies also suggest a lower rate of adhesions after laparoscopic surgery, which may result in a lower risk for post-operative bowel obstruction
Q. How is a laparoscopic J-pouch procedure done?
A. Before your laparoscopic J-pouch operation, you'll be asked to take a cleansing bowel preparation, similar to ones you have taken prior to colonoscopy. You will be admitted to hospital on the morning of surgery directly to the preoperative suite. Generally patients are asked to take nothing by mouth on the morning of surgery, although you will receive exact instructions in your anesthesia visit.
We place five small incisions, each no bigger than 1/2 inch, for the laparoscopic camera and operating instruments. Throughout the operation we instill carbon dioxide into your abdominal cavity to give us a "working space". First we detach the large intestine from the back of the abdominal cavity, called the retroperitoneum. After freeing up (also called mobilizing) the entire large intestine except the rectum, we turn our attention to mobilizing the rectum all the way down to the anus. Care is taken not injure the nerves in the pelvis, to minimize any post-operative changes in sexual function. When the rectum is mobilized all the way to the anus, we are ready to start dividing the blood vessels to the large intestine. We are careful to divide the vessels of the right colon close to the large intestine. Saving these arteries and veins can help the J-pouch stretch down to the anus. After dividing the blood vessels, we divide the rectum within 2 cm of the anus using a stapler. We are now ready to remove the large intestine from the abdomen.
There is a different technique than the double staple technique that involves stripping off the inner lining of the rectum (the mucosa) and joining the J-pouch to the anus using sutures. This is called mucosectomy, and we will sometimes use this technique. Advocates of the mucosectomy technique feel that it removes slightly more lining of the lower rectum/upper anal canal compared to the double staple technique. Advocates of the double staple technique feel that it may improve long-term function in terms of anal sensation and continence. Neither technique is clearly superior to the other. Both have potential drawbacks and pitfalls, and both are appropriate for individual patients.
Having completed the anastomosis, we construct the ileostomy, which will divert the waste from the J-pouch and the anastomosis. This reduces the risk of pelvic infection, and allows the J-pouch to heal with minimal scarring for improved long-term function. For selected patients, we sometimes do not perform an ileostomy. The ileostomy is brought out through one of the laparoscopic incisions. At this point the operation is complete.
Most patients are in the hospital for three to five days after the laparoscopic J-pouch. Some of that time is used to learn how to take care of the ileostomy. Patients are discharged home when they are taking food and oral pain pills, and able to care for the ileostomy. Between 6 and 12 weeks later, the ileostomy is closed at a second operation. Generally a barium enema is performed prior to closing the ileostomy to be certain that there is no problem with the J-pouch.
The majority of surgeons do not perform laparoscopic J-pouch procedures, but instead perform open J-pouch procedures using longer, midline incisions. We have been successfully performing laparoscopic colo-rectal surgery since 1994 and performed our first laparoscopic J-pouch in 1997. We are convinced that there are significant benefits to our laparoscopic patients, including reduced postoperative pain, faster return to normal function, and improved cosmetic results. Recently published experience from the Cleveland Clinic and Mayo Clinic comparing their laparoscopic J-pouch patients to open surgery patients confirm that there are significant benefits to the patient with the laparoscopic approach while maintaining equivalent J-pouch function.
More pictures explaining the J-pouch procedure may find be found at www.j-pouch.org. Other more technical pictures and explanations can be found in surgical textbooks such as "Colon and Rectal Surgery" by Dr. Marvin Corman.