The ileal pouch anal procedure or J-pouch procedure is a surgery performed for the cure of ulcerative colitis and familial adenomatous polyposis (FAP). The formal term for the surgery is restorative proctocolectomy with ileoanal J-pouch and temporary diverting loop ileostomy. This operation removes the diseased colon and rectum and makes a new reservoir, or pouch from the small intestine (ileum). This ileal pouch is then surgically attached to the anal canal. This procedure was devised to cure the disease and also to avoid a permanent ileostomy. It is performed in two stages.
The procedure was first developed by Sir Alan Parks from England in the 1970s. There have been further modifications and advancements in the United States by other colon and rectal surgeons. The procedure is a complex operation and should be done by an experienced colon and rectal surgeon specifically trained to do the operation. When the ileal J-pouch is performed in the appropriate patient, results should be excellent with no physical limitations or restrictions. Mild or moderate dietary restrictions may be needed in order to avoid excessive diarrhea.
Most surveys done after ileal J-pouch surgery revealed greater than 90% of patients are happy with the procedure. However, 5 to 10% will have difficulty, some of which will end up requiring removal of the ileal pouch.
This is an extensive operation with multiple steps. The entire colon and rectum is removed. A 2-centimeter segment of rectum above the anal canal is spared. This is called the transition zone and improves control of bowel movements and sensation. Occasionally, this area may need to be removed (mucosectomy) in patients with FAP and only occasionally with ulcerative colitis. This usually does not cause a significant problem when this is done. The small intestine is usually not able to reach the anus; however, by certain surgical maneuvers, enough length is usually obtained. Two 15-centimeter segments of ileum are spliced together making a pouch which functions as a storage organ and then is attached to the anal canal segment. This is called a J-pouch which is the most common type of pouch construction. A temporary loop ileostomy is made for safety reasons in order for the pouch to heal properly. The ileostomy is then taken down with a relatively minor operation three months later providing a barium pouch x-ray study is normal. The anal sphincter muscles remain intact.
The main surgery has three main steps:
The operation takes approximately three to six hours depending on the size of the patient and other technical factors. After surgery, a nasogastric tube is generally in place for two to three days. This is needed to remove excess fluid and air from the stomach and intestinal tract to prevent vomiting and abdominal distention. Another drainage tube exits from the left lower quadrant of the abdomen to drain the area around the ileal pouch. Another drainage tube exits the anus and is used to drain the pouch itself. A urinary catheter in the bladder will be in place measuring urine output. Usually, all of these tubes will be removed on the fourth to sixth postoperative day. Pain control is usually managed by the patient through the IV or an epidural catheter in the back alleviating abdominal pain.
With an outstanding laparoscopic team and dedicated nurses, Shawnee Mission Medical Center has been aggressive in bringing laparoscopic procedures to the hospital. Graham has been performing various colon surgeries for years, and has smoothly transitioned to the laparoscopic approach.