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J-Pouch: What is it?

J-Pouch: What is it?

J-Pouches are J-shaped reservoir pouches constructed of the leftover small intestine after colon and rectum removal due to ulcerative colitis or hereditary conditions like FAP (familial adenomatous polyposis). In this procedure, a surgeon folds the small intestine upon itself, giving it the shape of a J, and attaches it to the rectal canal, using the third and final part of the small intestine (ileum). Technical names for these procedures are ‘total proctocolectomy’ (removal of colon, rectum, and anus) and ‘ileoanal anastomosis’ (the actual creation of the J-pouch).

“Total proctocolectomy with or without ileal J-pouch anal anastomosis is the preferred surgical procedure in children who are in need for removal of the colon. These pathological entities consist of familial adenomatous polyposis (FAP), inflammatory bowel disease (IBD), and especially ulcerative colitis (UC). The first two of these pathologies usually manifest in late childhood and early adolescence. Total proctocolectomy must be performed in order to prevent malignant transformation, which could lead to significant incontinence problems. Incontinence is the leading cause of a negative impact on the quality of life in this group of children.”1

Methods of Ileoanal Anastomosis

“The ileoanal anastomosis or IPA A may be performed using either hand-sewn anastomosis with endorectal mucosectomy or stapled techniques with extrarectal dissection. (…) Endorectal mucosectomy presumably gets rid of the majority of diseased rectal columnar epithelium and theoretically decreases the risk of residual mucosal inflammation, dysplasia or cancer. However, complete mucosectomy can be difficult and residual islets of rectal columnar epithelium could be retained which may be at risk for malignancy. In addition, mucosectomy does not completely eradicate the risk for pouch neoplasia.

In stapled anastomosis, extrarectal dissection for proctectomy is performed and distal 1-2 cm of anorectal mucosa in ATZ (Anal Transition Zone) is preserved. Single- or double -stapled technique is used to create the anastomosis, which is placed higher than hand-sewn anastomosis. The preservation of ATZ improves anal sensation, including the ability to discriminate flatus and feces, and leads to recovery of motor function of anal sphincter. Mucosectomy with hand-sewn anastomosis is thought to be technically difficult and time-consuming, and most adult colorectal surgeons prefer stapled IPA A due to ease of surgery and better functional outcomes. [..]

Commonly constructed ileal pouch are J-pouch, S-pouch, and Kock pouch (K-pouch). Among them, the J-pouch surgery is most commonly performed, which resembles the letter figure of ‘J’’. The J-pouch body has two limbs, afferent and efferent limbs (15-18 cm long each) with one ‘U’ turn. On endoscopy, a normal, healthy J-pouch shows a classic owl’s eye appearance, with one eye representing the pouch inlet and the other revealing the dome of the ‘J’.  […] Not all patients are technically fit for the construction of a J-pouch. For example, patients with a short mesentery or deep narrow pelvis may have difficult to let the pouch body to reach the rectal stump. In that case, the construction of an S-pouch is an alternative.”2

Colonic J-Pouch

“The technique of creating a colonic J pouch is similar to that of an ileal J pouch, though the colonic J pouch should be much smaller. Healthy diverticular-disease-free descending the colon is used for the pouch. The pouch should be assessed for adequate tension-free reach to the level of the distal rectal or anal resection margin. A 6-8 cm distance from the stapled proximal resection margin is measured and will form the efferent limb of the pouch. This limb is folded back onto the colon so that the anti-mesenteric borders are approximated.”3

How does The J-Pouch Work?

The pouch serves as storage for waste matter from the intestines, which are responsible for absorbing nutrients and water. They also serve as a waste disposal system. This system allows the patient pass bowel movements through the usual anal route. In other words, it works as a stool pouch, avoiding a permanent ostomy procedure.

Who Can Be a Candidate For a J-Pouch?

  • Chronic ulcerative colitis patients. “Ulcerative colitis (UC) is a chronic disease affecting the large intestine, with an increasing incidence worldwide. Nearly 1 million individuals each in the United States and Europe are affected by this condition and many more globally. Over the past decade, since the publication of the last guideline from the American College of Gastroenterology (ACG) on this topic, the management of the disease has grown increasingly complex with the availability of additional therapeutic classes. In addition, algorithms for initiating, optimizing, and monitoring response to existing therapies have undergone considerable evolution.
    UC is a chronic immune-mediated inflammatory condition of the large intestine that is frequently associated with inflammation of the rectum but often extends proximally to involve additional areas of the colon. The absence of rectal involvement has been noted in fewer than 5% of adult patients with UC at diagnosis but may be seen in up to one-third of pediatric-onset colitis. The initial presentation of the new UC is characterized by symptoms of an inflamed rectum, namely, bleeding, urgency, and tenesmus (a sense of pressure). The condition may present at any time and at all ages, but there is a predominant age distribution of onset that peaks between ages 15 and 30 years. The pattern of disease activity is most often described as relapsing and remitting, with symptoms of active disease alternating with periods of clinical quiescence, which is called remission. Some patients with UC have persistent disease activity despite diagnosis and medical therapy, and a small number of patients present with the rapid-onset progressive type of colitis known as fulminant disease.
    UC causes significant morbidity and a described low incidence of mortality. Patients with active disease are more likely to have comorbid psychological conditions of anxiety and depression and are more likely to have impaired social interactions or career progression. Long-standing UC is also associated with a defined risk of dysplasia and colorectal cancer, which is believed to be related to long-standing unchecked inflammation.
    Management of UC must involve a prompt and accurate diagnosis, assessment of the patient’s risk of poor outcomes, and initiation of effective, safe, and tolerable medical therapies. The optimal goal of management is a sustained and durable period of steroid-free remission, accompanied by appropriate psychosocial support, normal health-related quality of life (QoL), prevention of morbidity including hospitalization and surgery, and prevention of cancer. An emerging goal in UC management is that of mucosal healing. To achieve these goals, understanding of the most effective diagnostic, treatment, and preventive strategies is necessary. As with any medical decision making, involvement of the patients’ preferences forms an important component of care.”4
  • Familial Adenomatous Polyposis (FAP) patients, because FAP is an inherited disorder characterized by cancer of the large intestine (colon) and rectum. “Familial adenomatous polyposis (FAP) is characterized by the development of multiple colorectal polyps, which are premalignant lesions with a strong tendency to progress into carcinomas. Gardner syndrome, characterized by colorectal polyps as well as extracolonic manifestations such as dental abnormalities, osteomas, epidermoid cysts and desmoid tumors, was initially considered a separate entity, but has now been recognized as a variant of FAP. AP is caused by mutations in the adenomatosis polyposis coli (APC) gene on chromosome. […]

Colorectal adenomas usually develop into endoscopically detectable lesions at 10-20 years of age and increase in number and size over time. Untreated FAP patients develop colorectal cancer at a median age of about 40 years. FAP patients should be screened with endoscopy with 1-2-year intervals from 10-15 years of age up to 40 years of age and prophylactic colectomy is performed when adenomas are detected. Extraintestinal manifestations, in particular, epidermoid cysts, dental abnormalities, osteomas, and CHRPE often precede the development of adenomas and may serve as clinical markers of FAP.”5

  • Those for whom medical therapy has failed to control their symptoms.

“When a leak from the tip of the J pouch is detected endoscopically or radiographically, management depends upon the condition of the patient, nature, and degree of the defect, and the presence of any associated abscesses. Options include endoscopic drainage, fibrin glue injection, or salvage surgery with pouch repair of the leak site with sutures or via a stapler, or ultimately pouch resection and redo IPAA. Abscesses may also drain spontaneously into the IPAA, which may subsequently lead to the formation of a stricture or fistula. Early recognition and prompt treatment of patients with pelvic abscesses is likely to result in preservation of the pouch with functional results similar to those for patients who did not have sepsis (75–90% preservation), whereas delayed treatment leads to formation of a scarred, noncompliant pouch and is associated with a high likelihood for pouch excision. Hemodynamic instability and peritonitis of patients with pelvic sepsis mandate an exploratory laparotomy with peritoneal washout and the creation of an ostomy if the pouch was not defunctioned at IPAA. Patients who require laparotomy have a high rate of pouch excision (>40%) and a low rate of ileostomy closure.”6

What Are the Benefits Of a J-Pouch?

  • A J-Pouch avoids a permanent ostomy, which would require the use of stoma pouches. Since you will not require ostomy supplies, J-Pouch is a cost-saving alternative. It provides psychological and emotional relief. It allows you to control bowel movements since your J-pouch will hold the stool content until you are ready to evacuate.

“The J Pouch balances storage and expulsion best when 5 to 6 cm in length, and sigmoid and descending colon J pouches function equally well. There are some reports of increased need for enemas with a pouch, especially pouches longer than 5 cm. Overall, the J pouch seems to provide better function than straight anastomosis; however, the construction of a J pouch is not always technically feasible.

Other pouch options exist. The transverse coloplasty pouch has shown functional equivalence to the J pouch in some randomized studies.”7

After a J-Pouch surgery, your body will require an adaptation period. You can expect more frequent bowel movements and/or some type of sexual dysfunction. In men, it can result from nerve damage; in women, it is a consequence of scar tissue around the ovaries and fallopian tubes. If these side effects appear, discuss them with your physician to obtain medical advice and treatment.

References:

(1) Ateş, U., Ergün, E., Göllü, G., Küçük, G., & Yağmurlu, A. (2017). Laparoscopic proctocolectomy with ileal j-pouch anal anastomosis in children. Turk J Gastroenterol, 28, 384-7. Available online at http://www.turkjgastroenterol.org/sayilar/301/buyuk/384.pdf

(2) Shen, B. (2008). Crohn’s disease of the ileal pouch: reality, diagnosis, and management. Inflammatory bowel diseases, 15(2), 284-294. Available online at https://academic.oup.com/ibdjournal/article-abstract/15/2/284/4643542

(3) Longo, W. E., Reddy, V., & Audisio, R. A. (Eds.). (2015). Modern Management of Cancer of the Rectum. Springer London. Available online at https://books.google.co.ve/books?id=VIieBQAAQBAJ&pg=PP1&dq=Modern+Management+of+Cancer+of+the+Rectum+Walter+E.+Longo,+Vikram+Reddy,+Riccardo+A.+Audisio&hl=es-419&sa=X&ved=0ahUKEwjG67Om7KDiAhVGvlkKHcnBChMQ6AEIJzAA#v=onepage&q&f=false

(4) Rubin, D. T., Ananthakrishnan, A. N., Siegel, C. A., Sauer, B. G., & Long, M. D. (2019). ACG Clinical Guideline: Ulcerative Colitis in Adults. American Journal of Gastroenterology, 114(3), 384-413. Available online at https://journals.lww.com/ajg/Fulltext/2019/03000/ACG_Clinical_Guideline__Ulcerative_Colitis_in.10.aspx

(5) Fletcher, C. D., Unni, K. K., & Mertens, F. (Eds.). (2002). Pathology and genetics of tumours of soft tissue and bone (Vol. 4). Iarc. Available online at https://books.google.com/books?hl=es&lr=&id=dg9am0g4EP8C&oi=fnd&pg=PA3&dq=Pathology+and+Genetics+of+Tumours+of+Soft+Tissue+and+Bone+nilbert+coffin&ots=zuuhLImpr0&sig=IKft7FtBfFBiRxslXft-1Mf8zE0

(6) Pappou, E. P., & Kiran, R. P. (2016). The failed J pouch. Clinics in colon and rectal surgery, 29(02), 123-129. Available online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4882179/

(7) Baxter, N. N. (2014). Treatment of Colorectal Cancer, Surgical Oncolocy Clinics of North Merica. Clinics Review Articles. Available online at https://books.google.co.ve/books?id=s8raAgAAQBAJ&printsec=frontcover&dq=isbn:0323264158&hl=es&sa=X&ved=0ahUKEwiynJKG7qDiAhXQx1kKHSNCAxQQ6AEIJjAA#v=onepage&q&f=false

María Laura Márquez
13 October, 2018

Written by

María Laura Márquez, general doctor graduated from The University of Oriente in 2018, Venezuela. My interests in the world of medicine and science, are focused on surgery and its breakthroughs. Nowadays I practice my profession...read more:

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