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Ileal pouch surgery allows patients with certain colon disorders or certain types of cancers to avoid living long term with an ileostomy. This procedure removes the colon, rectum and anal canal lining and uses the end of the small bowel (ileum) to create a new rectum. There is a 2-stage surgery or a 3-stage surgery. 

Those who have the 3-stage surgery have been very ill with ulcerative colitis, on high doses of prednisone, and have had major weight loss that affected your body’s ability to heal. 

3 Stage Surgery

  • Stage 1: Remove the colon and create an end ileostomy. Once you feel better, are off prednisone, gain weight, are active and your nutrition has improved (protein levels, anemia and kidney status is in a normal or close to normal range) you are ready for the next stage. This stage could take 3 months to one year. 

  • Stage 2: Remove rectum and construct an internal ileal pouch from the small bowel (ileum). The ileal pouch is connected to the anus. A loop ileostomy will replace the first ileostomy. It will take you about 3 months to recover in this stage. If you have problems, it could take you much longer. 

  • Stage 3: When the ileal pouch is healed, the ileostomy is taken down or reversed (closed). This surgery is often 3 months after stage 2.

If your medicines are not working for you, you have cells that are changing to precancer or cancer, you have a narrowing in the bowel, or issues with your bone health or vascular health you may have the 2-stage surgery. It is also considered if you have not had a recent hospital stay, are in good health, and you do not need high doses of prednisone. 

2 Stage Surgery

  • Stage 1: Remove the colon and rectum, construct the ileal pouch and create loop ileostomy.

  • Stage 2: Ileostomy is taken down or reversed (this surgery is often 3 months after stage 1).

Getting Ready for Surgery

The month before the surgery, you will need a pre-op history and physical exam. The provider will talk with you about your health and the questions you have. We will mark your abdomen for the location of the ileostomy. We may order blood tests, EKG and x-rays for you. We will help you learn how to prepare for surgery, tell you where to go for the surgery and give you instructions for medicines, skin prep, bowel prep and recovery. 

Complications 

  • Infection

  • Bleeding that requires transfusion

  • Internal infection cause by an opening between the ileal pouch and the anal canal tissue

  • Ileus-Food and water moves too slowly through the intestine or stops causing cramping pain, bloating 

  • Blood clots and blood clot to lung

  • Trouble passing urine or trouble emptying the bladder. 

  • Not able to have an erection or semen may travel backwards into the bladder 

  • Pelvic nerve damage causing pain, abnormal sensation and weakness in pelvis or leg. 

  • The pouch may not function as it should causing too many or too few stools, pain, or bleeding

  • Narrowing where the ileal pouch connects to the anal tissue

  • Dehydration and kidney injury. 

  • Ileostomy complications 

Ostomy

A loop ileostomy is made from a portion of your small bowel. You may notice a small red rubber tube or a white rod or bridge under the stoma (the opening of the ileostomy). This bridge supports the stoma and helps it heal. We will remove the bridge before you go home or at your first clinic visit. 

A new stoma is red and swollen. The swelling will decrease in the first 4-6 weeks. You may have some bleeding around the stoma when you clean around it. This is normal. It should stop on its own. The stoma should not hurt if you bump it, but it could bleed. Over time, the sutures around the base of the stoma will dissolve and fall out. 

The end ileostomy has one opening and the stool will flow out of it. There is no plug to stop the flow of stool. 

The loop ileostomy has 2 openings. Stool comes out through one opening into the pouch system. The other opening will travel down to the ileal pouch. The stool from the pouch will vary in texture from a thin liquid to applesauce or pudding thickness. It can irritate the skin. The best way to protect your skin is to have an intact skin barrier and empty the pouch when it is one third to one half full or about 5-7 times a day. 

You may have stool come out from the anus. This is normal. The second opening in the loop ileostomy can carry some of the stool from inside the ileostomy pouch down through the lower intestine and into the pouch and you may feel like you need to have a bowel movement. If you feel like this, sit on the toilet and see if stool comes out. 

You may not have stool passing from the anus, but you will pass mucous. You will need to empty this mucous to prevent leaks. Once the mucus starts to pass then you will need to sit on the toilet to empty it. Sit on the toilet as you feel the urge to empty the pouch and gently bear down. This feeling or urge may feel like pinching or low pelvic cramping. You may want to wear a pad to protect your clothes. 

After surgery, your bedside nurse and an ostomy nurse will work with you. They will check your stoma and measure it to decide the size ostomy pouch you will need. You will learn how to care for it at home. In the hospital, the nurse will change the ostomy wafer every 2-3 days. We do it more often in the hospital, so you will learn how to change and care for the stoma. You should be active in this process when you are ready. Family members should be present for teaching if they will be helping you at home. At home, a home care nurse will also help you with the ileostomy. They will teach you how to change it if your insurance will cover this. 

Please read the ostomy handout and watch the videos about your ostomy before the surgery.

Before you are discharged from the hospital you will need to know how to take care of your stoma and change the ostomy alone. You should get enough ostomy supplies to last until your first clinic visits.

Talk to the health care team about any question or concerns you have. We want to provide you with the teaching, resources and support that you need to have success at home. 

Stoma Complications 

  • The size of the stoma should decrease but it may decrease and be at skin level or below which can make it hard to pouch.

  • The sutures holding the stoma and skin together may break apart causing a hole. If the hole is all the way around the stoma, the stoma can fall below the skin level causing bleeding around the stoma.

Skin 

The best way to protect your skin around the ostomy is to empty the bag when it is 1/3 - ½ full. Remove the ostomy using the adhesive remover. Wash the adhesive off the skin using warm water. Apply the skin prep. Change the ostomy if you feel burning or stool is leaking under the wafer. Changing it will help keep our skin from getting irritated. 

The incisions should heal in 10-14 days. You can wash the wound with the cleanser we give you or with soap and water. Do not sit in the bathtub, hot tub, or swim until the incision is healed. Do not use lotions, powder or ointments. 

Your incision will be slightly puffy, pink and may feel numb at first. This is normal. A small amount of clear liquid may leak from the incision. If it leaks clear or pus-like drainage call the clinic. 

Check daily for signs of infection: 

  • Increasing redness or warmth at the incision site.

  • Pus-like drainage 

  • Excess swelling or bleeding

  • Temperature above 100.4 F taken by mouth for 2 readings taken 4 hours apart

Rectal Skin Care 

It is common to have some rectal skin irritation. You can prevent irritation by using baby wipes instead of toilet paper and by using skin ointment or Vaseline. Make sure the rectal area isn’t moist or wet. Dry the area well. You don’t want to trap moisture under the creams. 

Diet

The diet food and fluids is vital to regulating your stools so you are not having multiple stools and are not at risk of stool leaks or getting dehydration. 

You will follow a low fiber diet until your first visit after the surgery. We will give you a list of foods for this diet at your pre-op visit. Your diet will shift from a low fiber diet to a high fiber diet to help thicken the stool. 

Once you have the ileostomy reversed, a high fiber diet will help you have stools that look like oatmeal or pudding. The number of stools you are having will decrease over time as the diet moves to high fiber. You likely need to sit twice on the toilet to completely empty the stool. The pouch is small, and it doesn't hold much stool (maybe 1/2 cup) so the pouch will empty and then more stool will move into the pouch and you will need to empty again. This may take only minutes.

You may pass gas at the end and then you know you have completely emptied for a short time. You will need to take a daily multivitamin with iron.

You will have 15-20 bowel movements per day after the ileostomy takedown. Two weeks after surgery you should be having 8-12 bowel movements per day. You may be getting up at night 2-3 times. Try to eat 3 meals a day. Eat a serving size of the food choices. Try not to eat between meals. This will help regulate the bowel movements. Stop eating between 6:30pm -7:00pm. Late night snacks increase bowel movements at night. There are foods that you will have to avoid because they may cause a blockage in the intestine. A short list of these foods is popcorn, nuts, chunky peanut butter, corn, sausages with casings, diet and non-diet sodas. We will give you more information about the diet and foods that can cause problems. 

Prevent Dehydration

  • Get flu vaccines.

  • If you get a GI bug and have diarrhea or vomiting you may need IV fluids. 

Dehydration can affect how our heart and muscles work and can injure your kidneys. These are serious problems. 

Anal Pouch Suture Line Stricture 

This is a narrowing caused by scar tissue where the ileal pouch and the anal canal tissue connect. Stool can back up in the pouch. We can treat the stricture by dilating or stretching the scar tissue. We do this as an outpatient procedure with IV sedation. 

Symptoms of Stricture

  • Increased small bowel movements and or leaks.

  • Feeling like you don’t completely empty out your pouch when you have a bowel movement.

  • Spitting stool and feeling like you have not completely emptied the pouch. 

  • Straining to empty.

Pouchitis 

This is when the pouch gets inflamed. People that have had ulcerative colitis may have this problem. Your diet can cause your increased bowel movements and not pouchitis. To help prevent pouchitis you will need to take a probiotic daily. If you still get pouchitis while taking a probiotic then we may prescribe you an antibiotic.

Symptoms of Pouchitis

  • Frequency > more than 12 liquid stools a day

  • Urgency

  • Feels like "colitis" back again, feel pressure

  • Leaks (common at night)

  • Bleeding

  • Temperature (rare)

Please watch bowel and bladder changes and call us if you notice changes so we can treat them before they cause more serious problems. We should see you once a year even if you are not having any problems. Some of the problems that can develop can be long term and may lead to another ileostomy placed or more surgery.