How are the different types of pouch surgeries performed?
A J-pouch is made by using two loops of small intestine, each measuring about 8 inches long (20 cm each). The pouch is connected to the top of the anus to allow for elimination of waste matter. After the pouch is constructed, it holds the stool, which is not solid, until the patient is ready to use the bathroom. This is called the ability to defer defecation. Most people who have a J-pouch move their bowels approximately 7 times a day, some once at night, and most don’t have problems with accidents.
The J-pouch is the type that is used most often because it requires a shorter length of intestine than other pouches, is the easiest of the pouches to make, and is highly effective. J-pouch procedures are the preferred method for treating cases of chronic ulcerative colitis in which symptoms are hard to control with medications, or for patients who develop polyps or cancer. J-pouches are also used in cases of familial adenomatous polyposis, and sometimes for colon and rectal cancers.
It usually takes two or three operations to make the J-pouch, and almost all patients will have a temporary ileostomy bag for 3 to 9 months while the new J-pouch heals. Patients who cannot or should not have a J-pouch may need a permanent ileostomy.
The S-pouch is made in a similar way as the J-pouch, except it has a 1-inch (2-cm) “out-spout” of small intestine below the pouch that is attached to the anal canal (using the same technique as the J-pouch). An S-pouch is usually made if the surgeon finds that the J-pouch cannot reach the top of the anus. An S-pouch may be used to help a new (redo) pouch reach if the previous pouch has complications and doesn’t work properly.
Three loops of small intestine, each about 6 inches in length (about 15 cm each), are used to make the S-pouch. The pouch is able to hold from one-half to one pint of fluid. As with the J-pouch, it usually takes two or three operations to make the S-pouch, and almost all patients will have a temporary ileostomy bag for 3 to 9 months while the new S-pouch heals. Patients who cannot or should not have an S-pouch may need a permanent ileostomy.
Some patients who have an S-pouch have trouble completely emptying the pouch. These patients have to clear the pouch with intubation (inserting a tube into the pouch through the anus). It should be noted that this procedure is not done often currently.
K-Pouch (also known as a Kock Pouch or Continent Ileostomy)
Most patients who cannot have a J- or S-pouch will have a permanent ileostomy bag. However, the Kock pouch, or K-pouch, is an alternative to a regular (end) ileostomy. The K-pouch is used in cases of ulcerative colitis when the large intestine and rectum need to be removed because of disease and the anal sphincter muscles are weak, or because a J- or S-pouch cannot or should not be made.
About 16 inches (40 cm) of the last portion of the small intestine are used to build an internal reservoir, which is then attached to the inside of the abdominal wall. A small opening called a stoma leads out and is used several times a day to drain waste matter through a catheter (tube) inserted into the K-pouch.
Three loops of the small intestine, each about 12 inches long (about 30 cm), are stitched or stapled together to form the pouch. Another length of intestine, approximately 4 inches (about 10 cm), is used to make a valve or “nipple” between the stoma and the pouch. The nipple acts as a flap valve to keep waste and gas inside the pouch until the patient drains it with a tube. When stool and gas build up inside the pouch, the flap is pushed shut to prevent leakage.
The main advantages of the K-Pouch over a regular ileostomy are that:
- The patient does not require a bag.
- The stoma is covered with a gauze pad, Band-Aid, or “mini-bag.”
- The patient chooses when to empty his or her bowels.
The main disadvantages of the K-pouch are that:
- The procedure is rarely performed.
- The re-operation (revision) rate is around 50%.
- If the K-pouch needs to be removed, the patient loses more small intestine relative to the other kinds of pouches.