Ileal Pouch

Ileal Pouch

This operation is known by a number of different names: restorative proctocolectomy (RPC) or ileal pouch-anal anastomosis (IPAA). It used predominantly in the treatment of patients with ulcerative colitis (UC) or familial adenomatous polyposis (FAP) when surgical removal of the whole of the colon and rectum is required and the patient wishes to avoid a permanent ileostomy. The operation is commonly performed in a number of stages, with 2 and 3-stage procedures being the most common.

One-stage

The whole of the colon and rectum are removed and the ileal pouch created from the last part of the small bowel. This is then joined to the top of the anal canal without the need for an ileostomy. It is rare for patients to have this done.

Two-stage

There are two variants to the two-stage operation:

In the first, the colon is removed and an end ileostomy is fashioned. This is most commonly performed for a severe flare of colitis. At the second operation, the rectum is removed and the ileal pouch created and joined to the top of the anal canal without the need for an ileostomy.

In the second variation, the whole of the colon and rectum are removed and the ileal pouch created and joined to the top of the anal canal in a single operation. A loop ileostomy is then created upstream of the pouch. At the second operation, typically 3 months later, the ileostomy is closed.

Three-stage

In the first operation the colon is removed and an end ileostomy is fashioned. This is most commonly performed for a severe flare of colitis. At the second operation, the rectum is removed and the ileal pouch created and joined to the top of the anal canal together with a loop ileostomy upstream of this. At the third operation, the ileostomy is closed.

Outcomes

Following ileal pouch surgery the majority of patients report a good quality of life and are able to return to normal activities with little to no restrictions. I know of international athletes, ultra-marathon runners and professional sportsmen who have ileal pouches.

Bowel function with an ileal pouch is not the same as someone who has a normal functioning colon and rectum. Most patients with an ileal pouch will open their bowel between 5 and 7 times per day, and may occasionally need to get up at night. Some patients will experience urgency – the need to rush to the toilet. Up to half of patients having a pouch for ulcerative colitis will experience pouchitis (inflammation within the pouch) at some point, and this can feel like a flare of colitis. It frequently settles with a course of antibiotics.

Whilst most patients are able to enjoy a stoma-free life and achieve a good quality of life, as with any major operation, there is a risk of complications and no two pouches will function the same way. As a result, some patients may find that their pouch “fails” and they may need to return to having an ileostomy or having the pouch removed.

Alternatives

Rejoining the small bowel to the top of the rectum (an ileorectal anastomosis) may be an option in patients where there is no longer any evidence of inflammation within the rectum following surgery to remove the colon. It negates some of the risks associated with surgery in the pelvis and can achieve similar functional results to the ileal pouch. If, at a later stage, the rectum becomes inflamed and needs to be removed, an ileal pouch procedure can be undertaken if desired.

If a patient is completely happy with life with an ileostomy and does not want to accept the risks associated with an ileal pouch, then the rectum and anus can be removed (a completion proctectomy). It is not possible to undergo an ileal pouch procedure at a later stage after this operation, so it is important to ensure you are happy with your decision.

Further information

The Ileoanal Pouch an iBook by Richard Lovegrove, Fran Woodhouse and Neil Mortensen. Download

The Red Lion support group. Link

The Kangaroo Club support group. Link

Crohn’s and Colitis UK. Link

The Ileostomy Association. Link