What You Should Know About UC Surgery
A step-by-step guide to what goes on before, during, and after UC surgery.
So you and your doctor are talking about the big “S” word in ulcerative colitis (UC): Surgery. Maybe your medications aren’t working after trying different kinds, your symptoms are just too intense, or your doctor has found pre-cancerous or dysplastic colonic mucosal changes. Another possibility: You have a dangerous complication like toxic megacolon, which isn’t common but when it happens, has a high risk for perforation, sepsis, and (don’t panic) death. Your large intestine needs to be removed, for good. What procedure might you have, and what will the experience be like? We went to the experts for answers.
There Are Two Surgery Types
The standard UC surgery is a proctocolectomy. There are two versions: proctocolectomy with ileal pouch-anal anastomosis (also IPAA or J-pouch surgery) and proctocolectomy with end ileostomy. In the J-pouch procedure, your colon and rectum are removed; in the end ileostomy, your colon, rectum, and anus are taken out. The J-pouch is most common, says Rudolph Bedford, M.D., a gastroenterologist at Providence Saint John’s Health Center in Santa Monica, CA. “This is really the surgery for ulcerative colitis,” he says. End ileostomies remain an option, says David M. Poppers, M.D., Ph.D., a gastroenterologist at NYU Langone Health in New York City, but aren’t as common.
Each Version Has Pros and Cons
A J-pouch procedure results in gastrointestinal continuity—you can use your anus to poo thanks to the internal pouch. In contrast, an end ileostomy results in a stoma, an opening in the abdomen that lets feces pass into an external ostomy bag. While both have benefits (no ostomy with a J-pouch, no potential pouchitis with an end ileostomy), they also have drawbacks—but both are safe, effective procedures. Some people are a better candidate for one or the other, so discuss options with your doctor, says Ashkan Farhadi, M.D., a gastroenterologist at MemorialCare Orange Coast Medical Center in Fountain Valley, CA.
You’ll Need to Prep for Surgery
Preparing for either proctocolectomy procedure is like most surgeries: You usually take a laxative to clean out your bowels the day prior so your large intestine is ready for the procedure, says Dr. Bedford. Before surgery, be sure to ask your doctor any questions you have about the procedure itself, as well as recovery time for your specific situation, so you’re armed with info. Once you’re in the hospital for the actual procedures, you’ll have general anesthesia before both.
Surgery Option #1: J-Pouch
A proctocolectomy with IPAA is done in stages, which can be broken into three parts but are often done in two if your health is good, says Dr. Farhadi. For each stage, you’re typically on the operating table for about two to three hours. Your doctor might perform either procedure using a camera and few small surgical incisions, called a laparoscopy. A minimally invasive technique, this type of surgery can mean a shorter hospital stay (exactly how long you stay will be based on your individual needs).
J-Pouch Surgery: Stage 1
During the first part of the procedure, the colon and rectum are removed, and a pouch is formed out of the end of your small intestine in the form, most commonly, of a letter J, and joined to the top of the anal canal. You keep your anus and anal sphincter, which allows you to control your bowels, ostomy-free. But first, a temporary opening (an “ileostomy”) is created, allowing waste to pass through the abdominal wall into an ostomy bag, while the pouch heals. In this stage/form of the procedure, the ostomy is only temporary, Dr. Bedford emphasizes, for about eight to 12 weeks.
J-Pouch Surgery: Stage 2
During the second, and often last, stage of a J-pouch procedure, the ileostomy is closed, and the two ends of the bowel are reattached. Waste can then pass through the small intestine, collect in the pouch, and exit the anus as usual, according to the Crohn’s & Colitis Foundation. While theoretically completing this stage restores your body functions right away, you won’t be completely “back to normal” for a little while, as you’ll see next.
J-Pouch Recovery Takes Time
Post-op, your body needs time to fully heal, which could be several months or up to a year, depending on your rate of recovery. During that time, you still may experience up to 12 bowel movements a day. They might be soft or liquid and come with urgency. Don't worry, things will get better. If you’re having watery stool, eating applesauce, bananas, rice, or peanut butter might help, according to the Mayo Clinic. And stay hydrated! As time passes, your J-pouch should get bigger and your anal sphincter muscles stronger, which will reduce pooping. Still, “individuals should expect at least five bowel movements a day,” Dr. Farhadi says.
J-Pouch Can Have Complications
What’s called pouchitis, an infection of the pouch, is the most common complication after J-pouch surgery, happening in about one-quarter to nearly one-half of those with a J-pouch. Symptoms include diarrhea, abdominal and joint pain, fever, and dehydration. It can be treated with antibiotics, Dr. Poppers says. If you’re experiencing any of these symptoms post-surgery (even years later), alert your doctor immediately. Other surgical complications include ileostomy blockage, dehydration, diarrhea, and possible scar tissue that might impact women’s fertility. Men might have changed sexual function post-op, so be sure to discuss when to safely have sex again with your doctor.
Surgery Option #2: Proctocolectomy With End Ileostomy
Now, let’s talk about proctocolectomy with end ileostomy. This surgery is similar to a J-pouch in that one end of your ilium is attached to your abdomen, where your surgeon then creates a small hole called a stoma, which allows stool out of the small bowel, right into an ostomy bag. After the procedure, you’ll constantly wear the ostomy bag to catch stool, and need to empty it multiple times a day. An ileostomy can typically be reversed, Dr. Poppers says, and converted to an internal pouch. “I think that’s an important point,” he says.
This Option Also Has Potential Complications
While an end ileostomy procedure does come with potential complications like infection from surgery or at the stoma site, blockage, or issues with the stoma itself, it avoids pouchitis, Dr. Poppers points out. That doesn’t mean you should rush to have a more permanent ileostomy, but it could be a consideration if an ostomy is not an issue for you, and your needs trend toward this procedure type.
Surgery Can Truly Help
While surgery is always a major step and not without risks and complications, UC is “principally surgically curable” when the large intestine is removed because it’s limited to the colon and rectum, according to a study in Viszeralmedizin. While chronic pouchitis is one of the main factors limiting surgical success in curing UC, there’s still a long-term pouch success rate of >90%, 10 and 20 years later, researchers found. “For most patients, when they get the surgery, there is actually a sense of relief,” says Dr. Bedford. “No more bloody stools. And typically no more abdominal pain and steroids.”
- UC Surgery: Crohn’s & Colitis Foundation. (2021.) “Surgery for Ulcerative Colitis.” crohnscolitisfoundation.org/what-is-ulcerative-colitis/surgery
- All About Stomas: Bladder and Bowel Community. (2021.) “What Is A Stoma?” bladderandbowel.org/bowel/stoma/what-is-a-stoma/
- About the J-pouch Procedure: Penn Medicine. (2018.) “Total Proctocolectomy with J-pouch Reconstruction for Ulcerative Colitis.” pennmedicine.org/for-health-care-professionals/for-physicians/physician-education-and-resources/clinical-briefings/2018/february/total-proctocolectomy-with-jpouch-reconstruction-for-ulcerative-colitis
- About Proctocolectomy With Ileostomy: MedlinePlus. (2021.) “Total proctocolectomy with ileostomy.” medlineplus.gov/ency/article/007381.htmv
- How Common Is Pouchitis?: Gastroenterology & Hepatology. (2018.) “Complications Related to J-Pouch Surgery.” ncbi.nlm.nih.gov/pmc/articles/PMC6384396/
- Pouchitis Overview: Mayo Clinic. (2020.) “Pouchitis.” mayoclinic.org/diseases-conditions/pouchitis/symptoms-causes/syc-20361991
- What to Eat After Surgery: Mayo Clinic. (2019.) “Ileoanal anastomosis (J-pouch) surgery.” mayoclinic.org/tests-procedures/j-pouch-surgery/about/pac-20385069
- Surgical Outcomes: Viszeralmedizin. (2015.) “Surgical Principles in the Treatment of Ulcerative Colitis.” ncbi.nlm.nih.gov/pmc/articles/PMC4608637