POUCH

Pouch procedures

If your specialist has explained to you that your colon (large intestine) or rectum need to be removed in order to clear the cancer, your body will no longer be able to pass solid waste naturally. Surgeons can create an alternative method for your body to store and pass solid waste, using part of your own small intestine. The combination of strenuous research, ingenious minds and stapling techniques have led to a number of different methods for constructing pouches. By the ileum being folded in different ways, surgeons have developed a series of pouch procedures, including the J-pouch, K-pouch, and S-pouch.

J-pouch

Also known as the ileal or pelvic pouch. This is a new procedure that does not require the patient to have a permanent stoma (an alternative opening to the bowel on the abdominal wall). After the colon and rectum are removed, the surgeon will create a ‘J-shaped’ reservoir from part of the small intestine (also known as the ileum). It is constructed by folding loops of the ileum back on themselves, stitching or stapling, then removing the internal walls. The reservoir, or pouch, is then connected to the anal canal, allowing the patient’s stool to pass through the bowel via the typical route. This eliminates the need for a permanent stoma and external bag.

As well as a cancer treatment, pouch construction is also used for patients with:
• Ulcerative colitis and Crohn’s disease
• Toxic megacolon
• Familial adenomatous polyposis

The J-pouch procedure can be performed as one longer operation, but your surgical team may opt to split it into two or three separate operations. If this is the case, the first operation will involve removing the large intestine and rectum, and constructing the pouch. An temporary ileostomy procedure may be performed to divert solid waste away from the newly formed reservoir, to allow for healing without the risk of infection.

Patients can expect to regain voluntary control of passing stool, as well as the relief of leaving behind the constant need to locate the nearest bathroom.

K-pouch

Also known as the continent ileostomy, or the Kock pouch. This procedure is generally chosen for patients who are unfit for a J-pouch surgery, either because the position of the cancer requires the anus and anal sphincter to be removed, or because the patient has developed severe incontinence following a previous surgery. The K-pouch procedure differs from a conventional ileostomy because there is no requirement for an external bag to be worn to collect the output of the small intestine. Using this technique, the patient is left with a stoma (an alternative opening to the bowel on the abdominal wall), but no colostomy bag.

The K-pouch procedure involves the surgical team creating an internal pouch using part of the patient’s own small intestine. A special valve is also fashioned from a section of the small bowel, which will ensure that liquid waste and gas cannot escape from the pouch. Using the valve, the constructed pouch is joined to an opening in the abdominal wall. Solid waste will collect in the internal pouch, and will remain in the body until the patient feels the urge to empty it. When this happens, which may be four or five times a day, the patient must insert a thin tube (a catheter) about five inches into the stoma, to allow the waste to drain out of the body.

Patients who require this procedure will have the advantage of remaining continent, without the hindrance of requiring an external bag. Many find that this is an important factor in patients’ quality of life.

S-pouch

The S-pouch procedure is similar in nature to the J-pouch procedure, only the reservoir is created using a more extended, different fold pattern. S-pouches tend to be hand-sewn rather than stapled. The S-pouch is a longer construction than the J-pouch, meaning it is chosen in instances where there is excessive tension or a larger space between the small intestine and the anal passage. The S-pouch procedure is not chosen as often as the J-pouch procedure due to the need for hand-sewing. This is because a stapling technique is associated with better outcomes.

After your pouch procedure

Bowel motions

Once the procedure is completed, you may frequently and urgently need to pass liquid stools. It is typical for a patient to have 8-12 bowel movements a day immediately after the surgery is complete, but this will decrease with time. With the J and S-pouches, you can expect to have more frequent bowel movements than you are used to, due to the fact that the constructed pouch has a lesser volume than your colon did. You can also expect more your stools to be looser (more watery) than you are used to, as the ileum cannot absorb as much water as the colon.

Diet with a Stoma

You may find that you can become dehydrated more easily than you did before your surgery. This is due to the inferior ability of the ileum to absorb water, meaning that your body loses more water through the stool than it did previously. Another possible complication is salt deficiency.

You may choose to add more carbohydrates to your daily intake, to solidify the output of the pouch. This also reduces the risk of dehydration. Some patients find that eating ‘little and often’, to make adjusting to life with a pouch easier.

Once the function of your pouch has settled down, you will most likely be able to reintroduce a balanced and varied diet. Your specialist will encourage you to eat meals that are high in proteins and carbohydrates, and low in fiber, immediately after surgery. Some foods have been known to irritate pouches, but your specialist will discuss all this with you.

Complications

Ileo-anal pouches can sometimes become inflamed. This complication is known as pouchitis.
Symptoms include:
• Diarrhoea
• Bloody diarrhoea
• Difficulty or urgency in passing stools
• Pain
You should inform your specialist team if you suspect you may have pouchitis, as it can be easily treated with a 7-10 course of combination antibiotics.