Get Up Close and Personal With Your J-Pouch
Here is everything you should know about a J-pouch from procedure to maintenance.
Maybe you’ve tried many different medications for your ulcerative colitis (UC) and you’re still experiencing significant inflammation. Or maybe you’re just exhausted with medication and its myriad of side effects. And maybe, your gastroenterologist (GI) visits center around one urgent question: What happens next?
The answer might be something called a proctocolectomy with ileal pouch-anal anastomosis, also known as an IPAA or J-pouch surgery (we’ll call it J-pouch for short). While not as popular as it was about 20 years ago, experts say about one-third of the estimated 1 million people with UC in the U.S. will have one of the two types of UC surgeries—J-pouch (the most common) or proctocolectomy with end ileostomy.
In the J-pouch procedure, the organs involved in UC inflammation—your colon and rectum—are removed. As a result, this chronic condition is no longer chronic, says Benjamin Hyatt, M.D., a gastroenterologist at Middlesex Digestive Health & Endoscopy Center in Acton, MA. Potential postoperative complications and other possible issues aside, this surgery can cure UC.
One 2015 study reported long-term pouch success rate at 90% and higher, up to 20 years after the procedure. “When [a J-pouch surgery] goes well, it’s great. It’s curative,” says Andrew Boxer, M.D., a gastroenterologist at Jersey City Medical Center - RWJBarnabas Health Medical Group, in Jersey City, NJ. “You don’t worry about doctor’s visits, you don’t worry about medicine, you’re not worried about blood draws.”
However, J-pouch surgery is no walk in the park—it’s major surgery, after all—but it can also give you a new lease on life after years of UC symptoms. Let’s take a deep dive into J-pouches, from what it is to what you can expect after.
What Is a J-Pouch?
In essence, a J-pouch is like a pseudo-colon and artificial rectum, a creative way of making a new place to store and empty feces. Made from two 6-inch loops of the small intestine to form a pouch in the shape of a J (hence the name), it’s an internal reservoir where stool collects before being expelled out of the body through the anus—the typical way we all poo.
How Is the J-Pouch Surgery Performed?
There are two, sometimes three, stages to the procedure, says Dr. Hyatt. Typically in the first stage, your surgeon will permanently remove your colon and rectum in an end ileostomy, form the J-pouch, attach it to the anal canal, and create a temporary ileostomy to allow the pouch to heal. (An ileostomy is the process of creating an external hole in the abdomen, called a stoma, that allows stool to flow out of the body into an ostomy bag, which you then empty once it fills.)
This stage is often performed with a minimally invasive technique called a laparoscopy, and you might be in the operating room for two to three hours.
Fast forward eight to 12 weeks later, and you’ll be back in the operating room for another two to three hours to have the second, and typically last, stage of the J-pouch procedure. At this point, your surgeon will remove your temporary ileostomy and reconnect the small intestine, allowing stool to flow through, into the J-pouch. Surgeons work to preserve the GI tract’s musculature in the procedure, so people with UC and a J-pouch should still have an anal sphincter, allowing them control of their bowel movements.
“After [a J-pouch] surgery, patients can use the bathroom and not be expected to have incontinence,” Dr. Boxer explains.
What Happens After a J-Pouch?
So you’ve had the surgery and have a new J-pouch. What should you expect next?
To go the bathroom. A lot.
The reasons? The colon helps remove fluid from fecal content, which solidifies stool, and it holds stool, too. With that and the rectum gone, stool leaves your body faster because of changed consistency; plus there is less storage space available. After all, “you’re changing your physiology and your anatomy” with this surgery, Dr. Boxer points out. Things are going to be a little different inside your body for months—possibly up to a year after surgery.
“Patients will have more bowel movements a day,” Dr. Hyatt explains. “It’s not unusual for someone after a pouch to have 8 to 10 bowel movements a day.” Those bowel movements can lessen over time as the J-pouch fully heals and holds more stool, and can also be managed with fiber supplements or anti-diarrhea therapies (always talk to your doctor before starting any new treatment regime, especially after surgery).
One of the best things about J-pouch surgery is the fact that your UC is effectively cured—you potentially won’t need any long-term maintenance of UC or the pouch itself. You’ll likely see your GI specialist within the first year of surgery. And while some specialists might want to see you for a surveillance check-up, maybe every year, others might not need to see you again unless you have a specific issue. This might differ for your individual case, however, so be sure to ask your specialist what’s best for you for any follow-up visits.
What Are the Possible Complications of a J-Pouch?
The most common complication of J-pouch surgery is pouchitis, says David M. Poppers, M.D., a gastroenterologist at NYU Langone Health in New York City. Occurring in some 50% of patients, it happens when the pouch becomes infected, or inflamed, and can lead to symptoms similar to UC itself: crampy abdominal pain, diarrhea, fever, dehydration. It can be treated with antibiotics, Dr. Poppers says, and because it can happen right after surgery or years later, tell your doctor right away if you experience any of these (or other concerning) symptoms.
Chronic pouchitis is a major reason for reduction in surgical success in J-pouch procedures, so treatment is key. A probiotic called VSL#3 might help in this area, Dr. Poppers says, with research showing good results in helping chronic pouchitis cases. But as always, talk to your doctor before starting any additional treatment.
Other complications of the surgery include blockage, dehydration, and diarrhea.
“Anytime you have a surgical procedure in the abdomen and pelvis, there is the possibility of adhesions and bowel obstruction in the future,” Dr. Poppers points out.
UC Surgery: Crohn’s & Colitis Foundation. (2021.) “Surgery for Ulcerative Colitis.” https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis/surgery
UC Surgery Statistics: World Journal of Gastroenterology. (2019.) “Ileal-anal pouches: A review of its history, indications, and complications.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6710180/
Surgical Outcomes: Viszeralmedizin. (2015.) “Surgical Principles in the Treatment of Ulcerative Colitis.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4608637/
How Common Is Pouchitis: Gastroenterology & Hepatology. (2018.) “Complications Related to J-Pouch Surgery.” ncbi.nlm.nih.gov/pmc/articles/PMC6384396/
Probiotic and Pouchitis: Gut. (2004.) “Once daily high dose probiotic therapy (VSL#3) for maintaining remission in recurrent or refractory pouchitis.” gut.bmj.com/content/53/1/108.citation-tools