Ileoanal Anastomosis (J-pouch surgery)

Ileoanal anastomosis, also known as ileal pouch-anal anastomosis, is a surgical method to treat ulcerative colitis.

Normally, the food you eat gets partially digested in your stomach and passes into your small intestine where it is broken down, and nutrients are absorbed. The undigested part of the food passes from the ileum (last part of the small intestine) to the large intestine or colon. Here, the water is absorbed, and the remaining solid waste (stool) is stored in the last section of the large intestine and the rectum before getting eliminated through the anus (back passage).

When the inner lining of the colon gets inflamed and forms ulcers, it results in a chronic condition called ulcerative colitis. Pus formation or bleeding may occur from such ulcers, and the capability of the large intestine to absorb water from the digested food and hold stools decreases.

The condition is treated initially with medicines, but if you still experience troublesome symptoms from ulcerative colitis, surgery is advised. 

Ileoanal anastomosis involves the removal of the large intestine and rectum. In this procedure, the ileum is folded to make a pouch to hold the stools until they are expelled from the body. The pouch is connected to the opening of the anus. The surgeon will then form an ileostomy (a temporary opening on the abdominal wall to which the ileum is attached). The opening will have a bag in which stools are collected. This will allow the ileal pouch to heal. Once the ileal pouch is healed in about three months, a second surgery is performed to reverse the ileostomy.

Ileoanal anastomosis surgery is recommended in the following conditions:

• Ulcerative colitis
• Familial adenomatous polyposis (a condition in which thousands of polyps [abnormal growths] may develop in the intestine)

Some symptoms of ulcerative colitis include:

• Diarrhoea
• Increased frequency of passing bowels
• Mucus and blood in stools
• Cramp-like pain in the abdomen
• Weight loss
• Fatigue
• Lack of energy
• Anaemia

Symptoms of familial adenomatous polyposis are:

• Constipation for a long duration
• Blood in stools
• Weight loss
• Abdominal cramps
• Diarrhoea
• Decrease in the amount of bowel movement
• Vomiting
• Fatigue
• Fullness, bloating, and pain due to gas

The surgery is contraindicated in people with abnormal functioning of the anal sphincter (the muscle at the anus that controls the passage of stools by allowing the anus to open or close) or if the procedure can cause damage to the anal sphincter. It is also not recommended if a person has a cancer at the end of the rectum and need removal of both the rectum and anus.

A laparoscopic procedure is not advised under the following conditions:

• If you need a colectomy
• Are pregnant
• Are obese
• Have had a previous abdominal surgery

The relative contraindications (surgery can be performed but with caution) include Crohn’s disease and primary sclerosing cholangitis (a chronic liver disease in which bile formation is reduced).

The following preparations are needed before the surgery:

• Your doctor will take your complete medical history and perform a physical examination. 
• You will have to undergo a few tests, including electrocardiogram (ECG), blood tests and methicillin-resistant Staphylococcus aureus (MRSA, a harmful bacteria that is resistant to antibiotics) test.
• Tell your doctor about all the medicines that you take, including herbs, supplements, and non-prescription medication. He/she will ask you to discontinue blood thinners like aspirin and ibuprofen two weeks before the surgery to prevent clotting of blood.
• If you are a regular smoker, your healthcare provider will ask you to stop smoking.
• You will be asked to fast from midnight prior to the surgery.
• You will need a special bowel preparation medicine to empty your bowels before the surgery.
• You will have to sign an approval form to grant your permission for the procedure.
• A nurse will explain to you ways to care for your stoma before your surgery.
• Arrange for a friend, family member, or responsible adult to drive you home following the procedure.

Once you reach the hospital, the hospital staff will provide you with a hospital gown. You will lie on your back with your legs raised at a higher level than your heart. Your blood pressure, oxygen levels, and heart rate will be checked and an intravenous (IV) line will be inserted in your arm to provide you with medicines and fluids during the surgery. Support stockings and a special injection may be required to reduce the risk of blood clots in legs.

A catheter (tube) will also be attached to your bladder to drain urine. The surgery will be performed under general anaesthesia (medicine given to make you fall asleep). You will breathe with the help of an oxygen mask.

Ileoanal anastomosis can be performed by an open or laparoscopic method. 

Open procedure is done in the following way:

• The surgeon will make an incision (cut) at the midline in your lower abdomen.
• He/she will check your abdomen for any unusual findings and your small intestine for Crohn’s disease. If anything unusual is detected, surgery will not be performed. 
• Next, the surgeon will cut off your colon and rectum and remove them from your abdomen. 
• He/she will shape your ileum into a J- or S-shaped pouch and placed back into your abdomen.
• After its construction, the surgeon will check the pouch for bleeding and leaks and staple it in position.
• He/she would make a temporary ileostomy near the pouch and then place a tube in the operated region to drain any accumulated fluid.
• Finally, the surgeon will close the cut with dissolvable stitches, staples or tissue glue.

A laparoscopic technique involves four to five small incisions instead of a single big one. The surgeon will pass a laparoscope (a tube that has a camera attached to it) through one of the cuts to take images of the inside of your abdomen. The other openings will be used to pass various tools for performing the surgery. 

The time taken by this surgery may vary; however, it usually lasts for about two to four hours. Once your surgery is complete, the medical staff will shift you to the recovery ward, where your vital signs will be monitored. You will require a hospital stay of about three to seven days. During your stay, you can expect the following:

• You will be given medication to control pain.
• The hospital staff will encourage you to get out of the bed and walk around soon after the surgery.
• The IV line will be removed when you can drink well on your own. The catheter and drain tube will be removed at the time of discharge.

Once you reach home, you will need to take the following care:

• Incision care: Do not apply any lotion or ointment on the incision site.  You will be allowed to shower after two days, but tub baths, swimming, and hot tubs should be avoided until the follow-up. Steri-strips and tissue glue fall off on their own and should not be forcibly removed. 
• Pain management: Take medicines for pain as prescribed by the doctor. Slowly lower their dose as pain reduces in a few days. 
• Activities: Do not lift any heavy objects for at least six weeks. Perform activities like walking and climbing stairs when comfortable but do not over-exert yourself.
• Work: You may resume work in about two to three months when you feel healthy enough to perform your tasks. 
• Diet: You do not need any special diet, but you may need to avoid spicy food and food rich in fibre when you have an ileostomy. You may also need to consume more fluids.
• Counselling: You may talk to special counsellors if you feel like you need additional support.
• Driving: You can resume driving in about two to four weeks.
• Ileostomy care: The skin around the stoma needs to be clean. The stoma bag should be changed twice or thrice in a week and emptied four to six times daily.

When to see the doctor?

Visit or call your doctor when you notice symptoms like:

• Fever
• Swelling, redness, or drainage at the site of the surgery
• Increased pain
• If the incision opens
• Nausea and vomiting
• Excessive sweating
• Inability to urinate 
• Chills
• Swelling in the legs

The surgery carries the following risks:

• Bleeding in the abdomen
• Leaking of the anastomosis
• Portal vein thrombosis
• Obstruction in the small intestine
• Infertility
• Malignancy
• Infection, opening up of the wound, bleeding at the incision site
• Pelvic infection
• Formation of fistula (abnormal pathways formed due to infections)
• Risks due to general anaesthesia, including headache, sore throat, and nausea.

Your follow-up will be scheduled one to two weeks after the discharge to review the outcomes of the surgery and discuss further treatment if required.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.