Ileo-anal pouch

In medicine, the ileal pouch–anal anastomosis (IPAA), also known as restorative proctocolectomy (RPC), ileal-anal reservoir (IAR), an ileo-anal pouch, ileal-anal pullthrough, or sometimes referred to as a J-pouch, S-pouch, W-pouch, or a pelvic pouch, is an anastomosis of a reservoir pouch made from ileum (small intestine) to the anus, bypassing the former site of the colon in cases where the colon has been removed. The pouch retains and restores functionality of the anus, with stools passed under voluntary control of the patient, preventing fecal incontinence and serving as an alternative to a total protoctocolectomy with ileostomy. During a total proctocolectomy, a surgeon removes a person's diseased colon, rectum, and anus.[1] For the ileostomy, the end of the small intestine is brought to the surface of the body through an opening in the abdominal wall for waste to be removed. People with ileostomies wear an external bag, also known as an ostomy system or stoma appliance, to collect waste which can be emptied and changed as needed.

With an ileo-anal pouch, the pouch component is a surgically constructed internal intestinal reservoir; usually situated near where the rectum would normally be. It is formed by folding loops of small intestine (the ileum) back on themselves and stitching or stapling them together. The internal walls are then removed thus forming a reservoir. The reservoir is then stitched or stapled into anal area where the bottom of the rectum was.

Pouch surgery is elective, meaning it is entirely optional, and should be done on the basis of choice by people who doctors deem suitable for a pouch after medical evaluations. Pouch surgery is considered reconstructive with the benefit being for quality of life and not disease removal, similar in theory to a breast reconstruction after a mastectomy removes diseased breast tissue. Before a pouch is created, a person's diseased colon and rectum are removed. Standard medical screening exams for pouch candidates include but are not limited to biopsies, radiology imaging, sphincter function tests, fertility consultations for people of childbearing age with the wish to get pregnant, and psychological support due to intensity of the pouch operations.[2] A similar ileal pouch without the anal anastomosis is a Kock pouch.

Reasons for pouch construction

Ileo-anal pouches are constructed for people who have had their large intestine surgically removed due to disease, injury, or infection. Diseases and conditions of the large intestine which may require surgical removal include:

There is debate about whether patients with Crohn's disease and indeterminate colitis are suitable candidates for an ileo-anal pouch due to the risk of the disease occurring in the pouch. Crohn's disease can manifest in many different parts of the digestive tract, so the removal of the colon and creation of a pouch, while alleviating symptoms that occurred in the large intestine, does not eliminate Crohns disease.[4][5]

Additional contradictions that may prevent a person from being able to undergo pouch surgery include but are not limited to weak sphincter muscles, advanced age (elderly) due to the higher risk of fecal incontinence, pelvic radiation therapy, and women with a history of obstetric complications.[6]

With regards to ulcerative colitis (UC), the disease is a systemic autoimmune condition. The main risk UC presents is typically inflammation that causes ulcers in the lining of the colon and rectum. This common expression happens in the mucosal layer of the intestine that is only present in the colon and rectum (not the small intestine), which is why the disease was named 'ulcerative colitis'. Therefore, Ulcerative colitis is considered 'cured' of the problematic disease activity in the colon and rectum only, after both the large intestine and rectum are removed. Reasons to remove this mucusal layer include severe discomfort that reduces quality of life, bowel perforation from inflammation, and development of tumors that are cancerous from long-term inflammation. Even after a person has their colon and rectum removed, ulcerative colitis still lives on inside that person's body because it is a systemic autoimmune condition. It can still manifest in other ways including primary sclerosing cholangitis (PSC) in the liver, the eye condition uveitis, and certain forms of arthritis throughout the body.

Pouch surgery does not cure a patient of ulcerative colitis, removal of the diseased mucusal layer in the colon rectum cures the disease in the colon and rectum only, if the entire colon and full rectum are removed. For example, if a rectal remnant remains, UC diease can be retained in the small remnant. Active disease feels similar to ulcerative proctosis when the full natural rectum was in place. It is also medically treated the same way ulcerative proctosis was before any surgery.

An intestinal pouch is elective reconstructive surgery that helps suitable patients avoid having an ileostomy.[7] People who need to have their colon and rectum removed are usually presented with several options including total proctocolectomy with end ileostomy ("Barbie" or "Ken" butt), colectomy with rectum left in place, pelvic pouch (ileo-anal pouch / IPAA), or continent ileostomy such as a Koch pouch (for example if someone has weak spchinter muscles) or a diseased anus. The end decision should always be the patient's choice, based on if their health permits the option to have a good outcome. A pouch should never be offered as the only treatment option due to the fact it is reconstructive and not curative. If a person has indeterminate colitis, they should also be informed before a pouch is recommended and created that their pathology is unknown due to the even higher risk indeterminate folks face.

While UC and FAP patients and are sometimes controversially considered cured of problematic symptoms after pouch creation due to the removal of disease activity in the colon and rectum, there are still many complications that can arise. While life with a pouch is typically viewed as a significant improvement compared to life with an ileostomy, patients living with a pouch may still face daily pains and discomforts including the inability to sleep through the night, a changed diet, severe or frequent gas pain, nutrient deficiencies, and the inability to digest certain foods.

The most common complication of pouch surgery is an umbrella term called pouchitis that encompasses many causes of inflammation of the pouch. While ulcerative colitis pouch patients may experience a dysbiosis sparked type of inflammation more than people who get a pouch because of cancer or FAP, pouchitis can be caused by a number of factors in any pouch.[8] Pouchitis is grouped into four main categories of origin: inflammatory, mechanical, surgical, or functional. Pouchitis can be a driver of pouch dysfunction for some.[9]

History

The surgical procedure for forming an ileal pouch-anal anastomosis (IPAA) was pioneered by Sir Alan Parks at the London Hospital, today called the Royal London Hospital, in 1976. The surgery was originally envisioned as a quality of life enhancing procedure for people who needed to have their colon and rectum removed. People who opted to have the procedure would be able to avoid an ileostomy by restoring intestinal continuity. Shortly after performing the world's first few pouch procedures, Sir Alan along with Professor John Nicholls joined St Mark's Hospital also in London where they continued to develop the intestinal pouch procedure. The pair first published details of the procedure in the British Medical Journal in 1978 with the article "Proctocolectomy without ileostomy for ulcerative colitis".[10]

Sir Alan Parks' ileo pouch-anal anastomosis (IPAA), was a surgical advancement from the ileoanal anastomosis procedure developed in the 1940s. With an ileum-anal anastomosis, the entire colon and rectum were removed. Next a surgical join (anastomosis) was used to connect the end of small intestine (ileum) to the anus. It was described by the German surgeon Nissen in 1934 and American surgeons Ravich and Sabiston in 1947.[11]

In 1980, surgeons in Japan published the first study on the J-shaped pouch. Dr. Utunomiya is created with its creation.[12] After Sir Alan's untimely death in 1982, his colleague, Professor John Nicholls premiered the W-pouch which was an augmentation of the J-pouch made to expand the pouch's capacity and reduce the person's frequency of bowel movements.[13]

As intestinal pouch surgery became more common, the J-pouch eventually became the dominate shape due the fact it was easier to construct. The original Sir Alan S-pouches had a bit of intestine at the bottom of the design that often made them difficult to evacuate. Some patients later underwent advancement surgery to remove the extra tip of small intestine and lower the pouch directly onto the anus to remedy evacuation difficulties [14] The W-pouch was entirely hand-sewn and required a very experienced and skilled surgeon plus more time in the operating room.[15][16] A J-pouch wasn't as technical and therefore, more surgeons could perform the procedure.

In the United States, Australian born colorectal surgeon Dr. Victor Warren Fazio was a driving force behind the procedure's adaptation into American colorectal surgery offerings. He established the Cleveland Clinic's prestigious pouch practice in 1983 when the clinic performed its first pouch surgery. In 2002 the Cleveland Clinic opened the world's first pouch center with its "Ileal Pouch Center".

About the same time as the Cleveland Clinic began offering the restorative proctocolectomy procedure (RPC), surgeons at the Mayo Clinic in Minnesota also started offering it to suitable patients including Dr. Roger R. Dozois who published several early studies on the pouch operation in the United States.[17][18]

Surgical procedure

In this elective and reconstructive surgical procedure a pouch, or intestinal reservoir, made from ileum (small intestine) is attached to the anus after the colon (large intestine) and rectum have been removed.

  • A J-pouch is two 15 to 20 cm sections of the small intestine[19] formed into a J-shaped pouch in order to replace the function of the rectum and store stool until it can be eliminated. J-pouches can either be hand sewn or stapled. Most J-pouches today are constructed using linear staplers.[16]
  • An S-pouch is a hand sewn formation consisting of three 15 cm limbs of terminal ileum to construct the S shaped pouch with a with a 2 cm exit conduit at the bottom. The S-pouch was the first pouch formation originally premiered by Sir Alan Parks in 1976 in London. It was later found that the 2 cm conduit caused some people evacuation difficulties. The S-pouch was advanced to remove the conduit and improve ease of evacuation.[16]
  • The W-pouch is a hand sewn pouch formation constructed using four loops of 12 cm length terminal ileum. The W-pouch was created by Professor John Nicholls in the early 1980s at St Mark's Hospital in London as an augmentation of the S and J pouches with the aim to reduce frequency of movements. Unlike the S-pouch, it does not have an exit conduit at the bottom. It is essentially a combination of two Js to create the larger capacity W. The W-pouch is anastomosed directly to the anus the same as the J-pouch.[16]

1, 2, and 3-step operative pouch procedures

The entire procedure can be performed in one operation, but is usually split into two or three procedures based on the person's overall health at the time of surgery.

Two-step pouch surgery

If a colectomy is planned, and not done as an emergency due to servere injury or illness and the person is in good health, some surgeons will recommend a two-step procedure. When done as a two-step, the first operation (step one) involves a proctocolectomy (removal of the large intestine and rectum), and fashioning of the pouch. The patient is given a temporary defunctioning ileostomy (also known as a "loop ileostomy"). After a healing period determined by the surgeon based on the individual patient, the second step is performed, in which the ileostomy is reversed. This step is referred to as ileostomy reversal or takedown. The reason for the temporary ileostomy is to allow the newly constructed pouch to fully heal without waste passing through it, thus avoiding leaks that can lead to infection.[20]

Three-step pouch surgery

When a colectomy is performed as an emergency (which can arise from toxic megacolon and other complications including infection), or when the patient is extremely ill, the colectomy and pouch construction are performed in separate stages, resulting in a three-part surgery.[21]

Outside of serious illness, some surgeons also prefer to perform a subtotal colectomy (removing all the colon except the rectum) first, since removal of the rectum can lead to complications with the anal sphincters. After the subtotal colectomy, the second operation consists of pouch creation with installation of a double or loop ileostomy to protect the pouch while it heals. Waste continues to exit through an opening in the abdominal wall. Then usually three to six months later when surgeons feel the pouch has healed, the loop stoma is reversed and the pouch becomes fully operational restoring intestinal continuity.[22]

Fertility concerns and preservation using the three-step pouch procedure

The pouch can also be formed as part of a three step procedure for people of childbearing age who have not completed their family planning. When there is a wish for pregnancy, the process can be paused after subtotal colectomy until family planning is complete if doctors feel remaining disease in the rectum, if any, can be safely managed until removal during pouch creation.

A fall in female fertility was reported in a Danish study by Olsen et al. in 1999 showing a drop after pouch surgery to less than 50% of the normal population.[23] There are well researched risks to fertility for both men and women. Highly specialized pouch centers globally typically offer fertility counseling as part of their patient selection and informed consent process.[24]

A rare risk to male fertility is nerve damage that impairs or prevents ejaculation. Risks to fertility for women include removal of the rectum reducing fertility by at least 50%, a dysfunctional pouch sparking a hostile environment in the pelvis preventing embro implementation in the uterus and scar tissue formation over fullopian tubes blocking ovulation, although, scar tissue formation appears to be less likely with laprascopic than open surgery.[25]

Anal anastomosis

Just as debate continues on which formation of pouch functions best, there is also an ongoing discussion about the pouch's type of anal anastomosis - or method used to attach the pouch to the anal canal. Both methods have risks and benefits.

  • Hand Sewn: Surgeons typically use this type of anal anastomosis to remove all of the rectal mucosal layer, although very small islands may still remain. A hand sewn anal anastomosis may be necessary when ulcerative colitis, FAP, or cancer patients retain disease in the anal canal to remove all remaining disease. When a hand sewn anastomosis is preformed, it is typically placed at level called the dentate or pectinate line which is the transitional line between anal canal skin and colorectal mucusal layer. It is technically more demanding for a surgeon to perform a hand sewn anal anastomosis than a stapled anal anastomosis.[26]
  • Stapled: A stapled anal anastomosis is done using a tool that seals the pouch to the anal canal. Unlike with a hand sewn anastomosis that usually does not leave any mucusal layer, a staple pouch will retain 1–2 cm of rectal mucusal layer because the staple needs something to 'grab' to anastomose the pouch. This retained 1–2 cm of rectum is referred to as the 'cuff'. The cuff can retain disease and cause minor or more serious complications for some pouches. The ideal location for the staple is considered it be 1 cm above the anorectal junction.[27] Numerous studies have been published over the years showing that excessive length of the cuff can be a contributor to pouch failure due to retained disease and/or pouch dysfunction. Stapled anal anstomosis' are considered easier to preform than hand sewn which typically take more time and skill.[28][29]

Specialized pouch centers

Many national gastroenterology associations including the British Society of Gastroenterology (BSG)[30] and the European Crohns and Colitis Organisation (ECCO)[31] recommend that pouches should ideally be created at facilities that have specialized pouch centers when possible due to the high level of technical skill required for multidiscipinary management of a pouch. Numerous studies also show that there is a direct relation between the success of a pouch and the experience a surgeon has with previous pouch creations.[32][33]

In addition to specialized doctors for colorectal surgery, gastroenterology, pathology, radiology, gynecology and urology, fertility, psychology, nutrition, and rehabilitation including physiotherapy, facilities with pouch centers often also have a specialized pouch nurse or pouch nursing team. The pouch nurse is usually an extension of the IBD nursing team or stoma nurse team. Pouch nurses provide healthcare, advice, and support specific to the concerns of pouch patients before and after surgery.[34][35]

Complications and disorders

While most people who undergo elective reconstructive pouch surgery have either no issues or occasional minor discomfort, some pouches experience more serious complications that need medical management with a variety of therapies including medication and/or additional surgery. [36][37][38]

Inflammatory disorders
  • examples: pouchitis, cuffitis, Crohn's diease of the pouch, Celiac disease, IgG, IgG4

Pouchitis is a general term that refers to a wide spectrum of diseases and conditions that cause inflammation of the pouch. It is a common complication after IPAA/RPC. People report many symptoms including abdominal pain or cramps, increased bowel frequency, urgency of movements, strong evacuation urges, daytime incontinence, noctural seepage, and/or rectal bleeding. Studies show pouchitis occurs more often in people who got their pouch because of ulcerative colitis rather than familial adenomatous polyposis (FAP) which suggests that the pathogenic (microbial) background of UC may contribute to the development of pouchitis in some pouches.[8]

Diagnosis of pouchitis: Pouchitis is diagnosed based on the presence of symptoms together with endoscopic and histological evidence of pouch inflammation. For example biopsies may be taken during a pouchoscopy (a camera exam like a colonoscopy but for the pouch) to rule out infection from Clostridium difficile infection (C Diff) or Cytomegalovirus (CMV). Treatment of infections usually begins with antibiotics and may also include multi-strain probiotics.

After exams and tests, pouchitis is divided into two categories based on findings: idiopathic or secondary. In indiopathic pouchitis the cause of inflammation is still unclear. With secondary pouchitis there is an association with a specific causative or pathogenetic factor. Secondary pouchitis can be classified into subgroups. It is possible to have one or more causes of pouch inflammation at the same time.[39][40]

Antibiotic therapy for pouchitis: Standard treatment of pouchitis when first reported (acute pouchitis) without any other obvious cause identified such as infection or anal join leak (fistula) is oral antibiotics for two weeks, typically ciprofloxin 500 mg every 12 hours. Alternatives to ciprofoxacin for initial therapy include metronidazole 500 mg (twice daily) or tinidazole 500 mg (twice daily).[40]

For pouches with acute idiopathic pouchitis, response to antibiotic therapy is typically examined clinically by asking the patient if they have experienced an improvement with their symptoms plus looking endoscopically using a pouchoscopy after completing antibiotic therapy. While endoscopic mucosal healing may lag behind symptomatic improvement, mucosal healing is a treatment target for patients with pouchitis.[41]

Probiotics for pouchitis: If pouchitis responded to antibiotic therapy, some people may be prescribed probiotics, depending on invidual circumstances, to help maintain remission and heal the pouch's mucus layer. The most clinically researched multi-strain probiotic for pouchitis is the De Simone Formulation (formulation name) invented my medical doctor Professor Claudio De Simone.[42][43][44]

The probiotic formulation was clinically researched for inflammatory bowel diseases including pouchitis under the brand name VSL#3 until 2016 when the makers of VSL#3 changed their formulation.[45] The original De Simone Formulation is no longer in the probiotic named VSL#3, however, it continues to be sold under a variety of brand names globally including Visbiome and Vivomixx.[46]

In August 2019 the American Gastroenterology Association (AGA) issued a correction for its official pouchitis guidance stating that the probiotic formulation in VSL#3 had changed.[47] Other bodies and journals such European Crohn's and Colitis Origanisation (ECCO)[48] have also issued clarifications. As has the Cochrane Library with a clarification regarding the formulations for probiotics using the De Simone Formulation and the new VSL#3.[49] Research since 2016 is published under the formulation's name "De Simone Formulation" or an individual regional brand names. The new post-2016 formulation of VSL#3 is also a multi-strain probiotic that some use for the treatment of various gastrointestinal disorders. Research on the new formulation starts from 2016.

Cuffitis: Cuffitis is inflammation of the retained rectal 'cuff' usually in a stapled pouch-anal anastomosis or the spot where the intestinal pouch was attached to the anus to restore anal evacuation. Symptoms are typically similar to ulcerative proctosis for ulcerative colitis pouches including burning in the anal canal, a change in bowel movements, and sometimes rectal bleeding.[50]

Cuffitis diagnosis: Most expert pouch centers plus national gastroenterology society guidelines worldwide recommend a cuff be no longer than 2 cm with the aim to staple the pouch about 1 cm above the anorectal junction, leaving about 1 cm of rectum or mucus layer behind for the staple to attach the pouch to the anus.[51][50][52] This retained 1 to 2 cm of rectum can therefore, sometimes retain ulcerative colitis in UC pouches. In contrast, hand sewn pouch-anal anastomosis' typically do not retain any mucus layer but sometimes a cuff is also used and it might cause discomfort for some hand sewn pouches. Cuffitis is clinically diagnosed by symptoms plus endoscopically (pouchoscopy).

Treatment of cuffitis: First-line therapy for accute cuffitis due to retained rectal mucusal layer is usually similar to the treatment for ulcerative proctosis that ulcerative colitis patients would have likely used before pouch surgery. Mesalazine suppositories or enemas are sometimes prescribed first (brand names include Asacol, Canasa, and Pentasa). If those do not provide enough relief then treatment might be escalated to corticosteroid suppositories or enemas such as Budesonide. Biological therapy may be prescribed if all other medical therapies fail to manage cuffitis and the person either isn't suitable for or does not want to undergo a revision operation to remove the retained cuff and hand sew the pouch on the level of the dentate line (spot where anal skin changes to rectal mucus layer).[50][53][54][55]

Crohn's diease of the pouch: Unfortunately, some people undergoing IPAA/RPC may be later diagnosed with underlying Crohn's disease because the disease likely had not fully expressed itself at the time of surgery. Crohn's diease of the pouch is associated with high failure rates. Pouches may experience fistula leaks that cause pelvic sepsis and other complications.[56]

Celiac disease: Celiac disease is an autoimmune condition that causes inflammation in the small intestine after gluten is eaten. It can cause pouchitis symptoms and discomfort. Some pouches that are celiac initially get misdiagnosed with Crohn's of the pouch. Celiac disease is typically diganosed by biopsy of the pouch.[57][58]

Other inflammatory conditions including IgG and IgG4: Immunoglobulin related diseases can also cause problems for a pouch. The two most common that are biopsied for are IgG and IgG4. IgG molecules can initiate inflammatory reactions, both good and bad. When the autoimmune reaction is inappropriate, a pouch might have problems with IgG. IgG4 is a subclass of IgG. IgG4 disease is a chronic immune-mediated fibroinflammatory disorder that can manifest with painless enlargement of organs or tumor-like masses.[59][60][61][62]

Pouch infections

Biopsies of the pouch should confirm if an infection is the root cause of pouch inflammation. If an infection from Clostridium difficile infection (C Diff) or Cytomegalovirus (CMV) is found, initial therapy is usually antiboitics.[63]

  • examples: anastomotic leaks, fistulas, sinus, pelvic sepsis

The pouch surgery itself can be the reason for some complications.[38]

Anastomotic leaks: Anastomotic leaks occur on the lines where the pouch was sutured or stapled. They usually occur close to the time of surgery but can appear months or years later. When an astomotic leak occurs, it can form a fistula or tract of fluid.

Fistulas: Most fistulas will connect from an astomotic leak leak to another area of the body such as a pouch-vagina fistula, perianal fistula, or presacral fistula with pelvic collection. In some circumstances fistulas develop years after pouch creation due to the development of Crohn's disease. Fistula's caused by Crohn's disease are often treated with biological therapy while a fistula from an anastomotic leak requires different therapies as biologics rarely help close a leak in a surgical suture or staple line of the pouch.[64][65]

Pelvic collection/sinus: A pelvic collection or collection of fluid anywhere from a leak is called a sinus. When an astomotic leak isn't treated promptly or doesn't heal it can cause pelvic sepsis.

Pelvic Sepsis: Pelvic sepsis also called peri pouch sepsis is a main cause of pouch failure and it creates conditions that make major revisionary surgery difficult.

Mechanical disorders
  • examples: large or small pouch, U-bends, twists, prolapse, stricture, weak spinchters[66]

Large or Small Pouch: Standard guidelines for J-pouch construction is to use two loops of 15–20 cm ileum. If the pouch is too small, the pouch will have a small volume. This will increase the frequency of moments and could also be a cause of pouch failure.[38]

U-bend: This happens when the surgeon fires the linear stapler and it malfunctions. Usually the flaw is not noticed until after surgery is complete during first pouchoscopy. The pouch is called a "u" bend because instead of stapling the two full sections of ileum together into a "j", the stapler doesn't create the 'j' but instead retains the shape of a 'u'.

Strictures or stenosis Narrowing of the anal canal under the pouch can cause evacuation difficulties. Anal stricture can be a cause of pouch failure if not managed properly. Anal stricture is a common complication of pouch surgery. It is treated with dilitation or stretching under anesthesia. Some people are also prescribed home dilitation routine using a Hegar dilator to manage chronic stenosis that keeps returning after dilitation.[67]

Functional disorders
  • examples: irritable pouch syndrome, pelvic floor dysfunction, evaculation difficulties, coexisting psychiatric diagnosis[66]

Pelvic floor dysfunction and evaculation difficulties Pelvic floor dysfunction is a common complication of pelvic surgery. The Mayo Clinic believes it is an under reported complication of IPAA/RPC surgery with up to 75% of pouch patients experiencing non-relaxing pelvic floor dysfunction. Biofeedback therapy is the main treatment for pelvic floor dysfunction.[68]

Dysplasia or neoplasia
  • examples: adenomas, cancers

Cancer is a rare event after a pouch is created. However, retained rectal mucusa can develop dysplasia over time especially if cuffitis is an ongoing complication. Cancer can also develop in the pouch when there has been long-term pouchitis (inflammation of the pouch for any reason). People who got their pouch as a result of bowel cancer may also experience cancer of the pouch.[69]

Systemic or metabolic disorders
  • examples: malnutrition, anemia, vitamin B12 and vitamin D deficiency, low potassium [70]

Removal of the entire large intestine (colon) and amounts of the terminal ileum at the end of the small intestine leads to fluid and nutritional absorbotion issues for all pouches. The colon absorbs water and salts. Dehydration can occur if a person does not get enough fluids. When the pouch is constructed small amounts of ileum are lost to the stomas and any stoma revisions. The pouch itself is also made from ileum. If a pouch is defunctioned (fails) the person also loses this extra amount of ileum when the pouch is disconnected from the digestive tract. The importance of ileum is that it absorbs key vitamins and minerals including B12 and magnesium.

Revision, redo, salvage surgery for failed pouch

When a pouch fails, suitable patients can choose to undergo surgery to repair or completely redo a pouch (if enough terminal ileum remains to produce a second pouch).[71][72] People can also choose to convert their failed ileo pouch-anal anastomosis to a continent ileostomy such as a Koch pouch in some circumstances. Revisional surgeries are considered highly specialized.[73] They require a skilled surgeon with complex revisional experience for the best chance at a good result. Many expert pouch surgeons advocate for early referrals to specialists for best outcomes.[74] If a repair or redo can not be undertaken because of factors like severe disease, or a repeat surgery fails, or a patient wishes to have their pouch removed with undergoing additional surgery, a pouch excision operation can be performed to remove the pouch. Removal of a pouch comes with complication risks.[75]

Quality of life after surgery

Pouch surgery was originally designed and premiered to improve quality of life for people who needed to have their colon and rectum removed. It is generally viewed as providing benefits over living with an ileostomy from a total proctocolectomy.

Bowel motions

After the colon is removed a person does not have the ability to form solid stool. Because waste will always be liquid, people experience several movements per day when their pouch's capacity is full. The number of movements per day may be similar to when someone was in an ulcerative colitis flare. The aim of pouch surgery is 4-8 movements per day, although, some people experience many more. People with a small volume pouch will likely experience more movements.[76]

Diet

Many people with a pouch eat their normal diet after surgery while others have to alter their diet due to discomfort when digesting certain foods. People with a pouch can follow any diet they choose while monitoring their overall nutritional status due to the loss of bowel causing absorption issues. People diagnosed with vitamin or mineral deficiences may be prescribed injections or tablets. Others may be referred to a nutritionist to design meals that provide additional amounts of needed vitamins and minerals. Studies show that some foods may also contribute to pouch inflammation.[77]

Support for pouch patients

Having an intestinal pouch is considered a rare condition. Some national organizations and specialist charities usually associated with inflammatory bowel disease (IBD) or ostomies provide some information to people considering or who have undergone pouch surgery. Some of the larger national organizations globally include:

See also

References
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Notes
  • McGuire, B B; Brannigan, A E; O'Connell, P R (15 June 2007). "Ileal pouch–anal anastomosis". British Journal of Surgery. 94 (7): 812–823. doi:10.1002/bjs.5866. PMID 17571291. S2CID 8337023.
  • Bach, Simon P; Mortensen, Neil J. M (February 2006). "Revolution and evolution: 30 years of ileoanal pouch surgery". Inflammatory Bowel Diseases. 12 (2): 131–145. doi:10.1097/01.MIB.0000197547.80558.59. PMID 16432378. S2CID 20465425.
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