Pan Procto-colectomy and Pouch

What is Pan-proctocolectomy and Pouch Surgery?

Pan-proctocolectomy and pouch is a complex surgical procedure in which the entire colon (large intestine) and rectum are removed and an internal pouch is created using the end of your small intestine, known as the ileum, to collect stools which is connected to the anus. The creation of this pouch is also known as ileal pouch anal-anastomosis (IPAA) or J-pouch as the pouch is commonly shaped like a letter “J.” The J-pouch procedure avoids the need for creation of a permanent opening in the abdomen called a stoma for passing of stools. Pan-proctocolectomy and pouch reconstruction is most often performed in either 2 or 3 phases depending upon the severity of the condition and the physical health of the patient.

Indications for Pan-proctocolectomy and Pouch Surgery

Pan-proctocolectomy and pouch surgery is indicated for symptoms of inflammatory bowel disease (IBD) that is not responsive to other treatment methods such as medications or if the severe inflammation has damaged your entire large intestine and rectum requiring reattachment of your digestive system. Some of the conditions necessitating pan-proctocolectomy and pouch procedure include:

• Ulcerative colitis
• Crohn’s disease
• Lynch syndrome, commonly known as hereditary nonpolyposis colorectal cancer (HNPCC)
• Synchronous colorectal cancers 
• Pre-cancerous or dysplastic colonic mucosal changes

Preparation for Pan-proctocolectomy and Pouch Surgery

Pre-procedure preparation for pan-proctocolectomy and pouch surgery will involve the following steps:

• A thorough examination by your doctor is performed to check for any medical issues that need to be addressed prior to surgery.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could threaten the safety of the procedure.
• You will be asked if you have allergies to medications, anaesthesia, or latex.
• You should inform your doctor of any medications, vitamins, or supplements that you are taking.
• You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for 1 to 2 weeks prior to surgery.
• You should refrain from alcohol or tobacco at least 24 hours prior to surgery.
• You should not consume any solids or liquids at least 8 hours prior to surgery.
• You will be placed on a special diet prior to surgery and laxatives may be used to clean out your bowel.
• You may be instructed to shower with an antibacterial soap the night prior to surgery to help lower your risk of infection after surgery.
• Arrange for someone to drive you home as you will not be able to drive yourself after surgery.
• A written consent will be obtained from you after the surgical procedure has been explained in detail.

Procedure for Pan-proctocolectomy and Pouch Surgery

Pan-proctocolectomy and pouch surgery can be performed in up to 3 phases; however, the procedure is usually performed in 2 phases either through open surgery or laparoscopic (keyhole) surgery under general anaesthesia. Your surgeon will decide the type of surgery you receive based on your circumstances. In general, the surgery involves the following steps:

• In the first phase of the surgery, your surgeon makes a surgical cut in your abdomen and removes the large intestine and rectum and preserves the anus and anal sphincter muscles. Then your surgeon makes a small J-shaped pouch using the last 12 inches or 30 cm of your small intestine and the pouch is attached to the anus.
• A non-permanent ileostomy is usually created to provide sufficient time for your newly created pouch to heal. To create an ileostomy, a loop of your small intestine is pulled through an opening in your abdomen, called a stoma, to enable waste matter to exit your body into a temporarily attached ostomy bag.
• During this period, you are required to wear an ostomy bag around the clock and need to empty the bag many times a day.
• You will have your second phase of surgery 8 to 12 weeks later, once the pouch has completely healed.
• The second surgery reverses the non-permanent ileostomy and reattaches the small intestine into the healed pouch. Your internal pouch now collects all waste matter and enables it to pass through the anus in the form of a bowel movement.
• Some surgeons may opt to perform just one-phase surgery, in which the pouch is constructed and attached to the anus without creation of a temporary ileostomy. However, this is performed less commonly than the two-phase procedure due to increased risk of infection.
• A three-phase procedure may be suggested for individuals who are on high doses of immunosuppressive medications, in poor physical health, or in some who are required to undergo an emergency surgical procedure to repair bleeding or toxic megacolon.
• In a three-phase surgery, the first procedure removes the colon and makes an ileostomy. In the second procedure, your surgeon removes the rectum and the end of the small intestine is used to make a pouch and connect to the anus. The third procedure is performed 8 to 12 weeks after the second procedure to reverse the ileostomy and reconnect the small intestine to the pouch.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after pan-proctocolectomy and pouch surgery will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anaesthetic reactions to the medications and anaesthesia used. Your nurse will also monitor your blood oxygen level and other vital signs as you recover.
• You may experience pain, inflammation, and discomfort in the operated area. Pain and anti-inflammatory medications are provided as needed.
• Medications may also be prescribed as needed for symptoms associated with anaesthesia, such as vomiting and nausea.
• Walking and moving around in bed is strongly encouraged as it lowers the risk of blood clots and pneumonia. It also helps to stimulate your bowels and assist with passing gas.
• Antibiotics are prescribed to address the risk of surgery-related infection.
• Your diet is slowly advanced post surgery. You will start with nutrition through IV drips, then to clear liquids, and finally progress to having normal solid foods, as tolerated.
• After surgery, you may pass stools 10 to 15 times a day with notable urgency. However, this should subside as you heal to 6 to 8 bowel movements a day of paste-like consistency.
• It is important to keep the surgical site clean and dry. Instructions on surgical site care, stoma care, urine and stool collection bag/pouch, and bathing will be provided.
• Refrain from smoking for a specific period of time as it can negatively affect the healing process.
• Refrain from strenuous activities and lifting anything heavier than 10 pounds for the first couple of months. Gradual increase in activities over a period of time is recommended.
• Eating a healthy low fat, high fibre diet is strongly recommended to promote healing and a faster recovery as well as drinking 8 to 10 glasses of water daily to prevent constipation. Laxatives or stool softeners may also be recommended as needed.
• Most patients are discharged after 3 to 7 days of hospital stay depending on the type of surgery. You will need to take off work at least a couple of weeks to a month to rest and promote healing. You may take a couple of months or more until you begin to feel back to normal.
• Walking is a good exercise and is strongly recommended to improve your endurance.
• Refrain from driving until you are fully fit and receive your doctor’s consent. Most patients can resume driving around 3 to 4 weeks following surgery.
• You will be able to resume your normal activities within a couple of weeks but may have certain activity restrictions.
• A periodic follow-up appointment will be scheduled to monitor your progress.

Risks and Complications of Pan-proctocolecotmy and Pouch Surgery

Pan-proctocolectomy and pouch surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as:

• Infection
• Bleeding
• Malnutrition
• Dehydration
• Vitamin and mineral deficiencies
• Post-procedure pain
• Pouch fistulas
• Hernias
• Leakage from the pouch
• Pouchitis
• Small bowel obstruction
• Damage to adjacent nerves, vessels, and organs