Why J-Pouches Aren't Done for Crohn's Disease

Ileoanal pouch anal anastomosis (IPAA)—or, as it's more commonly known, J-pouch surgery—has become the preferred type of surgery for many people who have ulcerative colitis and who require surgery. This type of surgery may also be done for familial adenomatous polyposis (FAP) or certain cases of colorectal cancer.

However, for people diagnosed with the other form of inflammatory bowel disease (IBD), Crohn's disease, a J-pouch is usually not considered a viable option.

What's a J-Pouch?

In J-pouch surgery, the colon is removed along with part or all of the rectum. The last section of the small intestine is used to make a pouch—usually in the shape of a "J," but "S" and "W" shapes are also sometimes done.

The pouch is then connected to the anus (or rectum, if there is some left), which makes elimination of stool more "normal." The surgery is often done in two steps, but may also be performed in one or three steps.

J-pouch surgery is typically done for people with ulcerative colitis either when medical therapy fails and symptoms become unmanageable, or when there are pre-cancerous changes in the colon (large intestine). (People with ulcerative colitis are at greater risk of developing colon cancer.)

Why This Surgery Isn't Typically Done for Crohn's Disease

With ulcerative colitis, the disease and associated inflammation is located in the large intestine. Removing the large intestine, while not a cure for IBD, does take away the organ that is most affected by the disease.

With Crohn's disease, any part of the digestive tract could be affected by inflammation, however, and even if the large intestine is removed, Crohn's disease could still recur. In fact, the most common locations for inflammation in people who have Crohn's disease are the ileum and the large intestine.

The ileum is the last section of the small intestine, and it is the part used to make the pouch in IPAA surgery. The classic rationale is, if the Crohn's disease does affect the pouch, the pouch might "fail" and ultimately need to be removed. There are also patients who have have been diagnosed with ulcerative colitis, had J-pouch surgery, and then have later had the diagnosis changed to Crohn's disease (although this is not common).

Studies about J-pouches in people with Crohn's disease have yielded mixed results. Some show that as many as half of patients with Crohn's disease and a J-pouch experienced pouch failure and needed to have more surgery to remove it and create a permanent ileostomy. Yet other studies show that certain carefully selected patients with specific types of Crohn's disease may be able to tolerate J-pouch surgery.

With the advent of biologic therapies for IBD (such as Remicade, Humira, Cimzia, Stelara, and Entyvio), however, people with Crohn's disease have more treatment options than ever before.

So, IPAA Is Never Done in Cases of Crohn's Disease?

As with most things concerning IBD, there are exceptions. Currently, there is a debate among key opinion leaders regarding whether certain patients with Crohn's disease can receive a J-pouch and do well with it.

There are some cases of people diagnosed with Crohn's colitis or indeterminate colitis who have undergone J-pouch surgery. However, there is a higher risk of complications and subsequent pouch failure in this group of patients.

There have been no randomized studies on the J-pouch in Crohn's disease patients that could provide enough quality evidence to end the debate one way or the other.

As with many other controversial topics in IBD, there is no strategy that has been proven to be superior. Any decision about creating a J-pouch for patients with Crohn's disease should only be made by specialty teams at tertiary care centers that are highly experienced and specialized in treating IBD.