An Overview of Ileoanal Reservoir (Pouch) Surgery

Linda B. Hurd, RN, MSN

• The ileoanal reservoir procedure is a surgical treatment option for chronic ulcerative colitis, colon cancer and familial polyposis patients who need to have their large intestine (colon) removed. An ileoanal reservoir (or pouch) is an internal pouch formed of small intestine. This pouch provides a storage place for stool in the absence of the large intestine. Anal sphincter muscles assist in holding in the stool. Several times a day, stool is passed through the anus.

• Ileoanal reservoir surgery is a widely accepted surgical treatment for ulcerative colitis or familial polyposis because it eliminates the disease, gives the patient control of bowel movements and does not require a permanent ileostomy. Each patient considering this surgery is carefully evaluated to determine if this procedure is appropriate for them. This procedure is performed in one, two or three stages, but is most often done in two stages, usually 2-3 months apart.

Stage I:

• The first surgery removes the entire large bowel and the lining of the rectum, but leaves the rectal muscle intact. A reservoir or "pouch" is made out of small intestine and then is connected to the anus. Next, a temporary ileostomy is made. An ileostomy is a surgically created opening between the small bowel and the skin of the abdomen through which stool and gas are passed. This temporary ileostomy diverts the stool; protecting the reservoir (pouch)while it heals. (See figures 1, 2 and 3)

What to expect after the first surgery:

• In the initial weeks after surgery, waste material coming through the ileostomy is liquid but then begins to thicken. A good diet with increased fluid intake is needed to keep well hydrated and nourished. Patients wear an ileostomy appliance over the ileostomy that collects the waste as it passes through the ostomy (or opening) on the abdomen. Learning to care for the ileostomy is a little tricky but with practice becomes very manageable. Patients also may occasionally pass small amounts of mucus or blood through the rectum.

• Approximately four to six weeks after the first surgery, an x-ray study of the pouch is performed. If the study shows that the pouch is healed, then the second surgery can be scheduled.

Stage II:

• The second surgery (usually done 2-3 months after the first) "takes down" or removes the ileostomy and reconnects the bowel. The pouch now becomes functional so that waste passes into the pouch, where it is stored. When an "urge" is felt, the stool can be passed through the anus, out of the body.

• In most cases, the second surgery can be done at the ileostomy site without re-opening the first incision. The skin at the former ileostomy site is usually left to close on its own. (See figure 4)

What to expect after the second surgery:

• Once a patient starts passing stool through the anus, stools are frequent and liquid. There may be accompanying urgency and leakage of stool. All of these aspects improve over time as the anal sphincter muscles strengthen and the pouch adapts to its new function. Stools become thicker as the small intestine absorbs more water. In addition, medications to decrease bowel activity and bulk-forming agents to thicken the stool may be prescribed.

• Patients can help during this adaptation process by avoiding foods that may cause gas, diarrhea and anal irritation. Careful skin care around the anus will protect the skin from the irritation of frequent stools. Continuing anal sphincter muscles exercises (Kegel Exercises) during this time is also beneficial.

• After six months, most people can expect about five to six semi-formed bowel movements during the day and one at night. The pouch takes up to one year to fully adapt. In most patients, functioning of the pouch continues to improve over time.

General Considerations:

• When considering and undergoing this surgery, all patients and their loved ones have concerns and questions. Sometimes they feel isolated and frightened. It is helpful for all involved to receive general information about this surgery and understand what to expect during the course of these procedures. In addition, patients and family members may be interested in contacting an ileoanal support group, which provides a place to learn more about this surgery and to meet others with similar concerns and experiences. Be sure to talk with your gastroenterologist, surgeon or ET nurse about these issues and keep in close contact with them during the surgeries and throughout the rehabilitation process. Patient satisfaction with this surgery is high and with both ulcerative colitis and familial polyposis patients, their disease is cured!

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