A J-Pouch is created in operations that remove the colon and rectum. Typically, this is for ulcerative colitis and hereditary conditions that increase the risk of colorectal cancer such as Familial Adenomatous Polyposis (FAP) and Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome.
Increasingly this procedure is being performed laparoscopically, with improved cosmesis, earlier return of bowel function and discharge from hospital [1].
Timing of pouch surgery
For ulcerative colitis, Pouch surgery is best performed when the disease is well controlled. For hereditary cancer syndromes, Pouch surgery the decision on when to perform Pouch surgery will depend on a number of factors, including the youngest age of a family member to have colorectal cancer. The risk of infertility and sexual dysfunction following pelvic surgery needs to be discussed with your colorectal surgeon, and an appropriate timing of you pouch surgery to factor in you plans for having a family.
Sperm harvesting and IVF
Sperm harvesting may be recommended prior to pouch surgery because of the risk of impotence and infertility. In women infertility can result, and this usually responds well to invitro fertilisation, as the infertility is usually due to mechanical blockage within the fallopian tubes.
Pouchitis
Pouchitis is inflammation of the pouch, with acute pouchitis occurring in 15%. This usually responds to a course of antibiotics. Antibiotic resistant refractory pouchitis is more difficult to manage, and fortunately less common occurring in only 5% of cases. Other causes for pouchitis may include smoking, poorly controlled disease, or unrecognised Crohn’s disease.
Medical management of pouchitis
Pouchitis usually responds to oral antibiotics (ciprofloxicin or flagyl). Resistant cases require a visit to your colorectal surgeon where a biopsy will be needed. Bacterial overgrowth often responds to Probiotics such as VSL#3®, with the usual dose 6g/day. This contains the health bacteria that normally line the gut and protects against overgrowth by unhealthy bacteria [2-4].
Resistant cases of chronic pouchitis will require the involvement of you gastroenterologist, with consideration of immune modulating agents including steroids such as prednisone, azathoprine, and occasionally infliximab®
Surgery for pouchitis
Occasionally further surgery is required for medically resistant chronic pouchitis. Usually revision surgery is possible, although re-do pouch surgery is sometimes required. On rare occasions, removal of the pouch with formation of a permanent ileosotmy is required.
Reference
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Ahmed AU, Keus F, Heikens JT, et al. Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial adenomatous polyposis. Cochrane Database Syst Rev. 2009:CD006267.
