Ileal Pouch-Anal Anastomosis

The ileal pouch-anal anastomosis (IPAA) procedure is done after the colon and lining of the rectum are surgically removed (colectomy) due to disease. It is most often performed for patients with inflammatory bowel disease (ulcerative colitis or familial polyposis coli). It has helped patients with severe forms of these diseases for many years. For certain patients, this surgery cures the disease. When possible, it is preferred over other procedures that result in an outside belly (abdominal) opening for removing waste (ileostomy).

Other names for this procedure include ileoanal pouch, pelvic pouch procedure, and ileoanal reservoir procedure. A J-pouch is the most common way to create the reservoir for stool. It is created using a portion of the small intestine (ileum) in a "J" shape and is connected to the anus (end of the rectum). After this is done, waste can move from the small intestine, through the new J-pouch, and out through the anus.

LET YOUR CAREGIVER KNOW ABOUT:

  • Allergies to food or medicine.

  • Medicines taken, including vitamins, herbs, eyedrops, over-the-counter medicines, and creams.

  • Use of steroids (by mouth or creams).

  • Previous problems with anesthetics or numbing medicines.

  • History of bleeding problems or blood clots.

  • Previous surgery.

  • Other health problems, including diabetes and kidney problems.

  • Possibility of pregnancy, if this applies.

RISKS AND COMPLICATIONS

You will be monitored closely for complications at each stage of the surgery. Many complications are temporary and can be treated. Complications may include:

  • Skin irritation, swelling, bleeding, or infection around the anus or temporary opening (stoma) in the abdomen.

  • Obstruction or blockage of the ileostomy.

  • Dehydration and sodium or potassium imbalance.

  • Bleeding.

  • Leakage at the J-pouch to anus connection.

  • Difficulty controlling bowel frequency.

  • Problems or reactions to anesthesia and breathing tube insertion.

  • Damage to the bowel, surrounding tissue, or other organs.

  • Need for a repeat procedure.

Long-term follow-up with your caregiver is essential to managing complications.

BEFORE THE PROCEDURE

It is important to follow your caregiver's instructions prior to your procedure to avoid complications.

  • Your caregivers will review the procedure, the anesthesia being used, and what to expect after the procedure with you.

  • You will be asked to stop taking certain medicines for several days prior to your procedure, such as blood thinners (including aspirin).

  • You may be asked to take certain medicines or stool softeners.

  • You may be instructed to perform Kegel exercises for several weeks leading up to the procedure. This is to strengthen the muscles of the anus.

  • You will need to avoid eating solid foods for up to 2 days prior to the procedure. You will be allowed only liquids. The night before the surgery, you may be advised to not eat or drink anything until after the surgery. This is to avoid complications from the anesthesia.

  • You will be asked to take an antibacterial shower the night before and the morning of the procedure.

  • The areas for cuts (incisions) will be marked on your abdomen.

  • Blood tests, urine tests, heart monitoring, and X-rays will be performed.

  • Intravenous (IV) fluids and medicines (antibiotics) that kill germs will be given.

PROCEDURE

The J-pouch is usually created immediately after the colon and lining of the rectum are removed. The rectal muscles and nerves are left intact. The pouch is created from the small intestine in a "J" shape and is connected to the anus (end of the rectum). To allow the new pouch time to heal, waste may be temporarily redirected from the end of the small intestine (above the new pouch) out toward the abdomen through an opening (stoma). This is a temporary pathway for diverting waste (ileostomy). The hospital stay is generally 5 to 10 days.

After 8 to 12 weeks, a procedure is performed to reverse the ileostomy and close the stoma. The hospital stay is generally 3 to 7 days. After this, waste can move from the small intestine, through the new J-pouch, and out through the anus. This last stage of the J-pouch surgery takes about 1 hour to complete.

If the J-pouch is created and no ileostomy is needed, that is a 1 stage procedure. If the J-pouch is made with an ileostomy at the first operation, followed by reversal of the ileostomy weeks later, that is a 2 stage procedure.

Occasionally, a 3 stage procedure may be done.

  • In the first stage, the colon is removed and an ileostomy is created. This is the first surgery.

  • In the second stage, the upper rectum and lining are removed. A J-pouch is created from the small intestine and attached to the anus. Until the J-pouch is ready for use, a temporary pathway above the J-pouch is constructed using the same stoma that was created for the ileostomy in the first stage. This is the second surgery.

  • After 8 to 12 weeks, in the third stage, the ileostomy is reversed. This is the third surgery.

AFTER THE PROCEDURE

Initial Surgery

  • The waste material will be collected in an external bag connected to the temporary stoma. Your caregiver will help you adjust to the new bag and teach you how to use this temporary external pouch.

  • You will be monitored closely for pain and other symptoms and will be given plenty of fluids.

  • You will be instructed on a proper diet.

Final Surgery

  • The waste through the anus will be watery at first.

  • You will be monitored closely for pain and frequency of bowel movements.

  • You will be given fluids.

  • There may be tubes coming from the wound(s) for drainage.

  • You may be given medicines to thicken the stools or reduce bowel activity.

  • A specific diet will be recommended until your intestines adjust to the new pouch.

  • Your caregiver may teach you how to perform Kegel exercises to strengthen the anus.

  • Once your condition is stable, you will be discharged home.

  • You will be asked to follow-up with your caregiver for testing and examination for several months.

It is common to have many bowel movements a day following these procedures. This will taper off to 4 to 6 bowel movements per day over time.

FOR MORE INFORMATION:

The J-Pouch Group: www.j-pouch.org.

United Ostomy Associations of America (UOAA): www.ostomy.org.