J-Pouch Surgery: What to Expect

This procedure allows for stool to exit the body through the anus

The ileal pouch-anal anastomosis (IPAA) procedure, commonly known as J-pouch surgery, is a complex treatment for severe disease or injury affecting the large intestine (colon). J-pouch surgery is designed to remove the damaged tissue of the colon and allow the patient to continue to have “normal” bowel movements, meaning stool leaves the body through the anus.

During the J-pouch procedure—or more often multiple procedures—the colon is surgically removed and the small intestine is reconstructed to allow for stool to exit the body through the anus in a controlled fashion.

Also Known As

J-pouch surgery has multiple names depending on the stage of surgery and the country in which it will be performed. In addition to the ileal pouch-anal anastomosis, J-pouch surgery is sometimes called:

  • Ileo-anal pouch
  • Ileo-anal reservoir (IAR)
  • Internal pouch
  • Restorative proctocolectomy
  • Ileal-anal pull-through
  • Kock pouch
  • Ileostomy takedown

When Is J-Pouch Surgery Performed?

In cases where the colon is extensively diseased and/or damaged, it must be removed because a person's life is being ruined by frequent diarrhea.

For instance, it's not uncommon to hear of people with severe inflammatory bowel disease having 25 or more bowel movements a day. These can leave you unable to leave the house for fear of having an accident. This uncontrolled diarrhea is often accompanied by pain and sometimes blood in the stool.

When removal of the colon is necessary, you have two options for treatment: J-pouch surgery or an ileostomy.

J-Pouch vs. Ileostomy

An ileostomy is a surgical bypass of the large intestine. During this procedure, the end of the small intestine is separated from the beginning of the large intestine. This creates a new path for stool.

With an ileostomy, stool travels from the small intestine through an incision in the body and into an appliance that is outside of the body. This appliance adheres to the skin and has a removable bag where stool can collect and then be discarded.

Many people choose J-pouch surgery because they do not want to have an ileostomy long-term, saying that the device is uncomfortable or unsightly. Some complain that there is an odor or that the ileostomy interferes with sexual intimacy, irritates the skin, or is generally annoying.

Who Is a Candidate for J-Pouch Surgery?

A colon-rectal surgeon will be the final decision-maker on whether or not a patient is a candidate for the J-pouch procedure. That decision will be based on many factors, including the following:

  • The overall health of the patient
  • Type of problem in the large intestine
  • The severity of the problem
  • Whether or not the problem can be fixed by removal of the colon
  • Whether or not the risks of the procedure outweigh the potential benefits

The condition of the colon will not be the only factor in whether the patient is a candidate for surgery. A patient who has severe ulcerative colitis that does not respond to medication, which is the most common reason for the procedure, may not be a candidate for surgery because they have a heart condition that could make anesthesia too risky, or their diabetes is too poorly controlled.

In general, to be a candidate for the J-pouch procedure, the patient must have severe colon disease or damage. Trauma would be a reason for damage that is treated surgically, such as a gunshot wound to the abdomen that causes significant injury to the large intestine. Medically, ulcerative colitis is the most common reason for the procedure, colon cancer is also a common reason for the colon to be removed.

Familial adenomatous polyposis, a condition that almost always leads to colon cancer, is also a common reason for J-pouch surgery. This condition typically results in patients having colon polyps by the time they reach their mid-thirties and developing colon cancer in the decade or two that follow. The J-pouch procedure is ideally performed prior to the diagnosis of cancer, rather than as a treatment for cancer.

Treating known Crohn’s disease — which differs from colitis in that the ulcerative lesions can appear in areas other than the colon — with J-pouch surgery is controversial. This is because it is possible to remove the colon and create the J-pouch only to find that the J-pouch develops new ulcerative lesions, potentially leaving the patient worse off than when they started treatment.

Risks

In addition to the standard risks of surgery, including a reaction to anesthesia and well-known complications such as pneumonia or blood clots, there are additional risks that are specific to the ileostomy and J-pouch procedures. These risks include:

  • Bleeding or leaking: Both internal and external incision lines have the potential to leak or bleed after surgery.
  • Ileus: This is a complication where the muscular movements of the intestine (peristalsis) stop after anesthesia. In most cases, this resolves in the days following surgery.
  • Obstruction: This is where narrowing caused by surgery or another problem prevents the movement of food and stool through the digestive tract.

What to Expect

The J-pouch is a small pouch formed from the end of the small intestine into a J shape where stool can wait until it is time for a bowel movement. The rectum is removed during the procedure, but in many ways, the J-pouch is a surgically created rectum. The muscular J-pouch can not only store stool until it is time for a bowel movement, but you will have some or total control over the timing of the bowel movement.

During Surgery

The J-pouch procedure is typically planned to be performed in two steps, meaning two separate surgeries will be performed often two to three months apart. In the first procedure, the colon is removed. The small intestine is separated from the large intestine, and an ileostomy is formed so stool can exit the body. The J-pouch is created at this point, but it will not receive any stool initially.

For several months after the first surgery, the newly formed J-pouch is allowed to heal and strengthen. Once the J-pouch is healed, an additional procedure is performed to allow stool to travel through the small intestine. It passes into the J-pouch where it's temporarily stored. Stool then exits the body through the rectum as it did prior to the initial surgery.

This two-surgery process is the most common method for a J-pouch procedure, but it can also be completed in one surgery. In those instances, an ileostomy is not performed. The colon and rectum are removed; the J-pouch is formed and connected to the rectal stump (the small remaining portion of the rectum just inside the anus) in the same procedure.

In some cases, surgeons perform surgery in three phases, but this is less common. 

All steps of the procedure are performed under general anesthesia and typically result in a 3- to 7-day hospital stay, depending on the number of stages performed and the overall health of the patient.

These procedures are complex and difficult to truly understand without visual aids. For that reason, The Crohn’s and Colitis Foundation has created a video to clearly explain the J-pouch procedure.

After Surgery

After J-pouch surgery has been completed, it can be many months before you reach your “new normal” for bowel movements. This may seem very different from what's considered normal for people without a J-pouch.

Things to expect:

  • Bowel movements should be controlled (you should not have accidents).
  • Bowel movements should occur at least once every three days.
  • Stool should be formed but not hard and not painful.
  • Stool is typically the consistency of porridge or mashed potatoes.

After the recovery is complete, the average patient experiences five or six controlled bowel movements per day.

For someone who was experiencing bloody diarrhea dozens of times a day, this can seem like a wonderful improvement, but for someone who had regular bowel movements and had the procedure to prevent cancer, the changes in the bowels may be alarming, and it may be difficult to adjust.

J-Pouch Surgery Recovery

Part of the recovery process will involve learning which foods and fluids can potentially aggravate your J-pouch and cause poorly controlled bowel movements. You may also need to continue using some medications to decrease diarrhea and increase bowel movement control. 

Once post-J-pouch surgery dietary and medication needs are understood and the site is healed, people are usually satisfied with the results. Between 10% and 20% of people are dissatisfied with their outcomes. In these cases, you may elect to have an ileostomy or another procedure after having the J-pouch procedure.

J-Pouch Surgery Complications

There are many potential problems after having a J-pouch procedure, luckily many of them are easily treated or prevented. The staff at your surgeon’s office and the enterostomal therapy nurse (nurses who specialize in the care of ostomy and other wounds) can be of significant assistance when recovering. Do not hesitate to discuss any issues with these medical professionals as they have likely seen the problem before.

Keep in mind that these issues typically improve after surgery, as the patient learns the way their body functions after surgery and recovers fully:

  • Decreased nutrition: Frequent diarrhea can lead to fewer vitamins, minerals, and calories being absorbed by the body. Over time, patients who were malnourished before surgery often become better nourished once diarrhea subsides.
  • Stricture: Areas of surgical incisions, including the small intestine, J-pouch, and anus can experience a narrowing due to scarring. This narrowing can result in small bowel obstruction, difficulty with food or stool moving through the digestive tract and difficulty with bowel movements.
  • Skin erosion: One function of the colon is to absorb excess acid from the intestinal tract. Without the colon to perform this function, some patients experience burning at the site of their stoma or around the anus that is commonly referred to as “butt burn”. This can be prevented with a barrier ointment on the skin.
  • Pouchitis: An inflammation of the pouch, this condition can be painful and is typically treated with two medications: Flagyl and Cipro.
  • Incontinence: While the purpose of the J-pouch is to help the patient be in control of when they move their bowels, some patients experience incontinence during their recovery. Few experience incontinence that lingers past the recovery phase.
  • Diarrhea: Technically speaking, diarrhea is six or more loose stools per day, and for some, that level of loose stools is better than their previous level of control. For others, this is worse than previous, but during the initial few weeks of recovery, diarrhea is common and expected. It is typically improved with medication such as Lomotil or Imodium along with dietary changes. Dense and starchy foods, such as potatoes and pasta, can help firm the stool. Report ongoing diarrhea to your surgeon.
  • Dehydration: Frequent bowel movements can lead to dehydration, so diarrhea should be addressed and fluid intake increased if dehydration is present. Dehydration can be best judged at home by the color of urine. Dark urine indicates an increased need for fluid, while clear and nearly colorless urine indicates adequate hydration. Report dehydration to your surgeon.
  • Low sodium: Sodium can be lost via diarrhea, and should be replaced with electrolyte-containing fluids such as Gatorade or Pedialyte. Low sodium is typically diagnosed with lab testing, so be sure your surgeon is aware if you are found to have low sodium.
  • Pelvic abscess: This is a pocket of infection that develops in or near the J-pouch site and requires medical and potentially surgical treatment.
  • Sexual dysfunction: Erectile dysfunction is a known risk of the procedure for men. For women, infertility due to scarring around the ovaries is a known potential complication, as is painful intercourse.
  • Crohn’s after J-pouch: The difference between Crohn’s and colitis is that Crohn’s disease can happen anywhere in the digestive tract while colitis is limited to the large intestine. If Crohn’s lesions only appear in the colon prior to surgery, it could logically be diagnosed as colitis, only to find that the lesions are later found in other locations after surgery. This could lead to a J-pouch that has ulcerative lesions.
  • Small meals: Some people with J-pouches find they can only tolerate multiple small meals rather than three large meals per day.
  • “Normal Problems”: Standard problems faced by most individuals, such as flatulence, tend to be worse with a J-pouch. Food that would normally cause gas may cause more gas or gas that is stinkier than it would have been prior to surgery. This is a typical outcome of the procedure, and may not resolve after the recovery is complete.
  • Need for ostomy: In serious cases where incontinence becomes an ongoing issue, the J-pouch isn’t healthy or non-functioning, or the patient is unsatisfied, an ileostomy is the treatment of choice.
  • Pregnancy: The pressure of the fetus in the pelvis, where the J-pouch rests, can cause difficulty with bowel movements and continence. Both the colon-rectal surgeon and the obstetrician will play a role in helping the pregnant mother to have the best possible control during the first trimester when this problem is the most significant, and determining the best type of delivery.

A Word From Verywell

J-pouch surgery is a complex and challenging one, that is only done for patients who are either extremely ill or hoping to avoid a strong family history of colon cancer.

The decision to have J-pouch surgery is not to be taken lightly and should only be done after locating a surgeon who performs these procedures on a routine basis and after having an in-depth discussion about the risks and potential rewards of surgery.

Frequently Asked Questions

  • Can a J-pouch surgery fail?

    Yes, according to one study, about 4% of J-pouch surgeries will fail. The majority happen within three years of surgery. The rate may be higher for different conditions. For example, about 11% of patients with Crohn’s disease experienced failure according to other research studies.

  • How long does J-pouch surgery take?

    The surgeries needed for a J-pouch procedure may take between six and 10 hours each. This varies depending on your body size, severity of your condition, overall health, and if you've had previous surgeries.

  • Can you get pregnant with a J-pouch?

    Yes, but there is a significant risk of infertility. About 40% of women have trouble conceiving after J-pouch surgery. This may be due to surgery causing blockages in the fallopian tubes.

8 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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  2. Crohn's & Colitis Foundation. J-Pouch Surgery.

  3. American Cancer Society. What Is an Ileostomy?.

  4. Mozafar M, Shateri K, Tabatabaey A, Lotfollahzadeh S, Atqiaee K. Familial adenomatous polyposis: ileo-anal pouch versus ileo-rectal anastomosis. Gastroenterol Hepatol Bed Bench. 2014;7(4):206-10.

  5. Freeha K, Bo S. Complications Related to J-Pouch Surgery. Gastroenterol Hepatol (N Y). 2018;14(10):571-576.

  6. Helavirta I, Lehto K, Huhtala H, Hyöty M, Collin P, Aitola P. Pouch failures following restorative proctocolectomy in ulcerative colitis. Int J Colorectal Dis. 2020;35(11):2027-2033. doi:10.1007%2Fs00384-020-03680-1

  7. UNC School of Medicine. J-Pouch Procedure.

  8. Ng KS, Gonsalves SJ, Sagar PM. Ileal-anal pouches: A review of its history, indications, and complications. WJG. 2019;25(31):4320-4342. doi:10.3748%2Fwjg.v25.i31.4320

By Jennifer Whitlock, RN, MSN, FN
Jennifer Whitlock, RN, MSN, FNP-C, is a board-certified family nurse practitioner. She has experience in primary care and hospital medicine.