Ileoanal reservoir surgery



Definition

Ileoanal reservoir surgery or ileoanal anastomosis is a two-stage restorative procedure that removes a part of the colon and uses the ileum (a section of the small intestine) to form a new reservoir for waste that can be expelled through the anus. This surgery is one of several continent surgeries that rely upon a newly created pouch to replace the resected colon and retain the patient's sphincter for natural defecation. Ileoanal reservoir surgery is also called a J-pouch, endorectal pullthrough, or pelvic pouch procedure.


Purpose

A number of diseases require removal of the entire colon or parts of the colon. Proctolectomies (removal of the entire colon) are often performed to treat colon cancer. Another surgical option is the creation of an ileoanal pouch to serve as an internal waste reservoir—an alternative to the use of an external ostomy pouch. An ileoanal reservoir procedure is performed primarily on patients with ulcerative colitis, inflammatory bowel disease (IBD), familial polyposis, or familial adenomatous polyposis (FAP), which is a relatively rare cancer that covers the colon with 100 or more polyps. FAP is caused by a gene mutation on the long arm of human chromosome 5. Ileoanal reservoir surgery is recommended only in those patients who have not previously lost their rectum or anus.


Demographics

The prevalence of familial adenomatous polyposis (FAP) in the United States is two to three cases per 100,000 persons. It develops before age 40 and accounts for about 0.5% of colorectal cancers; this figure is declining, however, as more at-risk families are undergoing detection and prophylactic colon surgery. The annual incidence of ulcerative colitis is 10.4–12 cases per 100,000 people. The prevalence rate is 35–100 cases per 100,000. People of Jewish descent have two to four times the risk of developing ulcerative colitis than people from other ethnic backgrounds. About 20% of ulcerative colitis patients require surgery of the colon.


Description

Conventional ileoanal reservoir surgery is an open procedure that is done in two stages. In the first stage, the surgeon removes the diseased colon and creates a pouch. The second stage is performed three months later, when the temporary drainage conduit is closed and the newly created reservoir allows the patient to defecate in the normal fashion. Both surgeries can also be done together, bypassing the creation of a temporary ileostomy .

Some surgeons use a laparoscopic approach to ileoanal surgery. This technique involves the insertion of scaled-down surgical instruments and a scope that allows the surgeon to see inside the abdomen through several relatively small incisions (3.5 inches [9 cm] or about compared to 6.3 inches [16 cm] or for an open procedure) in the abdominal wall. Studies indicate that there are few differences in the rates of mortality or complications between laparoscopic surgery and conventional open surgery. Because the incisions are smaller, patients typically require less pain medication with laparoscopic surgery.

Ileoanal surgery includes the following steps:

The surgeon will insert stents to bypass the surgical site and divert urinary and digestive wastes to the outside of the body, thus allowing the new connection between the ileum and the anus to heal properly.


Diagnosis/Preparation

The diagnosis of FAP is usually made after symptoms caused by polyps in the colon, such as rectal bleeding, diarrhea, and abdominal pain, have led to a physical examination , the taking of a family history, and in some cases a genetic test. Ulcerative colitis or inflammatory bowel disease patients have usually been treated with medical alternatives before they decide to have surgery. All patients who are candidates for an ileoanal procedure will have an evaluation of the upper gastrointestinal tract, an x ray of the small bowel, and a colonoscopy with a pathology review. Most patients will also be given a sigmoidoscopy and a digital rectal examination.

The surgeon will need to perform an ileostomy in about 5–10% of cases because the patient's rectal muscles are not strong enough for an anastomosis. This possibility is discussed with the patient, as well as the fact that complications in surgery may lead to an ostomy procedure. The placement of a stoma must be decided in the event that an ileostomy is necessary. The physician evaluates the patient's abdomen while the patient is sitting and then standing, in order to avoid placing the stoma inside a fatty fold of the abdomen. A stomal therapist is often called in to prepare the patient for the possibility that an appliance will be needed. In addition to the medical and surgical considerations of the procedure, the patient requires psychological preparation regarding the changes in function and appearance that accompany this surgery.

Prior to surgery, the patient must undergo a bowel preparation, which includes a clear-liquid diet for two days before the procedure. In addition to drinking nothing but clear fluids, the patient must have a cleansing enema until the bowel runs clear. The importance of a thorough bowel preparation must be explained to the patient, because leakage from the bowel during surgery can be life-threatening.


Aftercare

Open ileaoanal reservoir surgery is a lengthy procedure (as long as five hours) with a slow recovery rate (approximately six weeks) and a relatively long stay in the hospital (about 10 days). The catheters and stents that were used are removed several days after surgery. The patient will be introduced to a special diet in the hospital, and the diet will be altered if needed in response to changes in the chemistry of the colon. The patient's stools are measured, and he or she is monitored for dehydration. In addition, the patient will have the opportunity to discuss his or her concerns about care of the new reservoir and frequency of defecation with staff members before leaving the hospital.


Results

For carefully selected patients this procedure, developed over 30 years, is the preferred form of radical colon surgery when the patient's sphincter and rectum are still intact. The advantage of the ileoanal reservoir surgery is that the patient has an internal pouch for the collection of waste material and can pass this waste normally through the anus. Bowel movements may be more fluid, however, and more frequent with the new reservoir. In a small percentage of cases, the surgeon may eventually need to perform an ileostomy due to complications. In one quality of life study for patients who have undergone ileoanal reservoir surgery, researchers found only slight differences in their general health and level of daily activity compared with subjects recruited from the general population.


Morbidity/mortality

Morbidity rates with this procedure have decreased over time due to improvements in technique. The most common complication is inflammation of the pouch, which occurs in as many as 40% of patients. This complication can be treated with medication. Other complications include severe scarring around the incision, and some risk of injury to the nerves that control erection and bladder function. In one major study of 379 patients, researchers at the University of Cincinnati reported that 79 patients had pouch infections (24.3%) and another 20 patients required further surgery for obstructions of the small bowel (6.2%).

Alternatives

The major surgical alternative to an ileoanal reservoir procedure is an ileostomy. In an ileostomy, the patient's fecal matter drains into a plastic bag attached to a stoma on the outside of the patient's abdomen or into a pouch attached to the abdominal wall to be withdrawn through a plastic tube.


Resources

books

Pemberton, John H., and Sidney F. Phillips. "Ileostomy and Its Alternatives" In Sleisenger and Fordtran's Gastrointestinal and Liver Disease , 7th ed. Philadelphia: Elsevier Science, 2002.

"Tumors of the Gastrointestinal Tract: Large-Bowel Tumors." In The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.


periodicals

Allison, Stephen, and Marvin L. Corman. "Intestinal Stomas in Crohn's Disease." Surgical Clinics of North America 81, no. 1 (February 1, 2001): 185-95.

Blumberg, D., and D. E. Beck. "Surgery for Ulcerative Colitis." Gastroenterology Clinics of North America 31 (March 2002): 219-235.

Pasupathy, S., K. W. Eu, Y. H. Ho, and F. Seow-Choen. "A Comparison Between Open Versus Laparoscopic Assisted Colonic Pouches for Rectal Cancer." Techniques in Coloproctology 5 (April 2001): 19-22.

Robb, B., et al. "Quality of Life in Patients Undergoing Ileal Pouch-Anal Anastomosis at the University of Cincinnati." American Journal of Surgery 183 (April 2002): 353-360.

organizations

American Gastroenterological Association, American Digestive Health Foundation. 7910 Woodmont Aveenue, 7th Floor, Bethesda, MD 20814. (301) 654-2055. http://www.gasto.org.

American Society of Colon and Rectal Surgeons. 85 W. Algonquin Rd., Suite 550, Arlington Heights, IL 60005. http://fascrs.org,

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. http://www.niddk.nih.gov.

United Ostomy Association, Inc. (UOA). 19772 MacArthur Blvd., Suite 200, Irvine, CA 92612-2405. (800) 826-0826. http://www.uoa.org.

other

MDconsult.com. Inflammatory Bowel Disease (Crohn's Disease and Ulcerative Colitis) . http://www.MDconsult.com.


Nancy Mckenzie, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?


An ileoanal reservoir procedure is performed by a gastrointestinal surgeon specializing in reconstructive bowel or colon surgery. The operation takes place in a general hospital as an inpatient procedure.

QUESTIONS TO ASK THE DOCTOR




User Contributions:

1
Stephen Whall
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Jan 31, 2009 @ 11:11 am
I have had an ileostomy now for 2yrs, the reason being for this was Clostridium Difficile. I see that you have no mention of it, obviously written before it became life threatening.
I was not offered any of the options quoted, is this because of the infection or for other reasons I'm not party too.

Mr S.Whall
England.
2
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Apr 12, 2010 @ 6:18 pm
I had the surgery in 2001, iam very lucky i never had any inflamation of pouch. Iam baffled why you did not mention ulcerative colitis as one of the reasons to have your colon removed. About 30% of people with uc will ultimately have surgery.
3
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May 9, 2010 @ 2:14 pm
Thought this might be of interest to you. This is about J-pouch and how and why it's done. Fascinating!
4
Stacy
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Aug 1, 2010 @ 7:07 am
I have had Crohn's for almost 13 years and I've thought about having the ileoanal reservoir surgery because I have been wearing a ileostomy for almost 2 yrs and I am severely allergic to these appliances. This is the third time I've had to have a bag. I still have a rectum and anus but I would want a really good doctor to perform the surgery. I live in Alabama but I can't find a doctor I'm comfortable with yet. I might have to leave the state to get the real help I need. I think this surgery is a better option for me.
5
devin
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Oct 14, 2010 @ 11:23 pm
i am only 17 years old and had to have emergency surgery that resulted in a ostomy bag i am going to have the reconstructive surgery next year 2011 and hopefully everything goes well
6
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Oct 22, 2010 @ 9:09 am
Had the surgery 2 years ago; had my surgery in two steps...the first being the bigger op to make the pouch but stil had my bag; the second smaller one to put the ileostomy back inside and "hook up the plumbing". All surgery went extremely well and so glad i had it!
7
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Nov 29, 2010 @ 5:05 am
Due to the removal of colon, passage of stools from the stomach is quicker and hence contining stomach acid which used to be absorbed by the colon. The acidic faeces cause me great pain during its passage thru the anus. I have tried a lot of creams and sprays but some only work for a short time.
Can anyone help me pleaser as this is imparing my lifestyle?
Thanks
8
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Jan 24, 2011 @ 4:04 am
I see so many problems in common here---how can we start a self support group here???
9
Lorraine
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Jul 10, 2012 @ 2:14 pm
A family member just had the first surgery for the ileoanal anastomosis procedure. He will be having the second surgery hopefully soon. He has a bag attached to the stoma right now. He says he is inflamed. What is inflamed? What may be causing the inflamation?
10
George
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Jul 10, 2012 @ 7:19 pm
I had the second surgery 4 weeks ago. I had the ostomy for 6 weeks while recovering from the first surgery (ileostomy). My surgeon fashioned a J pouch and reversed the ostomy in the second. He has been very adamant about limiting my lifting to 5 lbs and doing as little as possible to prevent hernias while healing. I have been following these instructions pretty closely and haven't had any problems.

When I had the ostomy, I hated it. It was a problem with maintaining it for a number of days (and the appliances are expensive). I had one set fail while I was away from home for 2 days and was forced to repair it in order to get by until I got home. I found that the skin around the stoma got raw and irritated. The solution was a coating that is available from the company that supplied the ostomy appliances. This coating sealed the skin from irritants (feces) and mad the adhesive wafers stick much better and longer. It was also helpful to use the stoma paste which acts like caulking to help seal the hole. It also prevented the cut hole of the wafer from irritating the area around the stoma.

Since the reversal (and thank God, the elimination of the ostomy) I have dealt with the irritation of the anus and surrounding area. The surgeon had originally prescribed A & D Ointment, which I found worked OK but not all the time or completely. I have found it to be very beneficial to use baby wipes following elimination to make sure the area is completely clean. Using Tucks antiseptic pads helped greatly with anal the irritation. It has also been very helpful to keep the anus and surroundings lubricated with the ointment. The Desitin type ointments did not work well for me. One thin that I did find helped with the healing was Bag Balm. The high lanolin content completely healed my skin pretty quickly. Now that it has healed, I have success using the Vitamin A&D ointment that I found at Walmart. It is generic (their brand) and very inexpensive. $1.62 for a 4 oz. tube. Since it is so cheap, I use it liberally and it has helped keep me from getting irritated.

My surgeon also suggested that I take Metamucil at bedtime to help firm my stool. That has helped a lot, although I think I need to use it twice a day as my late day stools get to be loose again. I am also taking my evening dose earlier as I believe that it will help keep me from having as many movements at night

I know that I am going on. I hope that this information is helpful to someone, as I have had to learn it by trial and error. I guess we all have to. Please feel free to email me at canvasmakr@gmail.com with questions or comments.
11
julie speziale
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Jan 22, 2013 @ 10:22 pm
I had my total colectomy with ielo anal j pouch about 14 yrs ago. Until recently I had no problems. Over the past few weeks I notices a sharp twisting pain in my rt lower abdomen. My family dr. ordered CT Scan with oral and IV contrast. What showed suprised me. He said there is a shadow of another pouch on top of, or growing inside of my pouch. I go to my colorectal specialist next week for consult, and possible colonoscopy to see what can be done. This pain is relentless and I have lost several pounds throughout this horrible experience. Has anyone had any siminlar troubles, and what did you do to help this, short of more surgery? Thanks
12
Dawn
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Jan 23, 2013 @ 9:21 pm
I had the surgery 24 years ago and learned today I might have ulcerative colitis,I am still a little numb has anyone had this happen and what if it can't be controlled? Is their a fix or is reversal the only option? PS My doctor did not mention it she just noted it in the report they gave me I'm a little freeked out right now any input would be appriciated.
13
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Feb 10, 2013 @ 3:03 am
I had a total bowel removal then a j-pouch construction 7 years ago and I have had to put up with Pouchitis numerous time over the 7 years plus a wind problem particularly in the afternoon which creates a lot of discomfort if you aren't near a toilet,I can control these symptom's with Cipro but the prolonged use has unsavory side effects.I have given up all dairy product which has helped also helped to lose 10 kilos. I gave up alcohol very early in my rehab.
If anyone has a similar situation I would like to hear how they are handling things. Thank you.
14
Tracey
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Apr 3, 2013 @ 1:13 pm
I had the pelvic pouch prodedure in 2004. Knock on wood, everything has gone perfectly except I live on codiene. I find it is the only medication to stop the flow (so to speak) and I have tried many.
I take about 8 30mg pills per day which I have cut down from 12.
15
Tracy
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Jul 20, 2016 @ 1:13 pm
I had a total colectomy with ilioanal reservoir (J-Puch) about 14 years ago. Aside from the misery of 3 months with a stoma things have gone ok. I've been on T3's ever since as I cannot take codeine straight up due to an allergy. I take Metamucil - One tablespoon to 4 oz of cool water 3 - 4 times a day - plus liquid Immodium 3 -4 times a day. I cannot eat red meat (no big loss there), fruits or vegetables, and I don't generally consume alcohol (though I do sometimes give in and have a few beers on occasion). I stick to chicken/pork for my meats, eggs, cottage cheese, cheese in general as it is binding, as well as starchy foods like rice, potatoes, pasta. I also have to be very careful not to catch any flu or stomach viruses as they wreak havoc on me. I do quite well otherwise, I work out 5 days a week, and hold a full time job. I do occasionally have a "flare up" but that usually happens only when I unknowingly eat something that has an ingredient I was unaware of (caffeine is one that turns up in unexpected places). I hope this info helps someone as I've just been learning as a hit and miss on my own.
16
Brian
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Oct 5, 2017 @ 5:17 pm
I was told in 1981 that I was a good candidate for a new operation later called Park's pouch and j-pouch by my surgeon who had done a sub-total colectomy on me in May of '81 due to Toxic ulcerative colitis. When I was admitted I was not expected to live out the day, however 4 days later my surgeon - Catherine Milne at The Royal Victoria Hospital in Montreal, Canada - performed the operation and I had an ileostomy, but the necessary parts were left in as I was only 24 and an Olympic level runner. A Dr Paul Belliveau from Montreal's Royal Victoria Hospital was bringing back this new surgery created by a Dr. Parks from England and after he returned we met and it was decided I would be the first patient to undergo this operation in late '81, however complications of a fistula pushed that back to early '82 - Feb. - and by then 2 of us were in the hospital for the same procedure, so I guess we were both first. We were operated on by Dr Belliveau almost 2 days apart, so I guess that means I must be one of the earliest people to have had this procedure done, 35 almost 36 years ago now, so much of the early stats were from me, I had to be available for the next 20 years nobody else in Canada was doing this then and I am told it stayed at The Royal Vic with Dr. Belliveau until he moved 20 years exactly after doing the procedure. Both surgeons have retired and the only Dr I see today has never done this, so I have to admit even though 35 years have gone by I wish the guy who made it was still available, after all no one had ever had this done in Canada or The US at that point. I believe Belliveau taught it to a surgeon or 2 in Boston, other than that I am not aware anybody else has done it here in Canada. Because I did have an ileostomy for a year while I waited for Belliveau to return from England, I know what it's like and the option was clear to go with the Park's Pouch, no contest, however having to stay the 20 years was problematic and when hospitalized in Ottawa just a 2 hour drive from here when I said I had the pouch it was foreign to everybody there except 1 nurse, so I have to admit, it was a better option, but not terribly comforting to know a hospital down the road didn't know of its existence just a few years ago. So if anybody is interested in what it's like to have had this for almost 36 years, by all means I'd like to exchange info with others like all of you..Here's to 35 years more than was intended.

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