Pouch Advancement Surgery / Retained Rectum 6cm!!

Hi Everyone,

My wife is 1yr post-takedown J-Pouch surgery. She unfortunately has 6cm of retained rectum and has been dealing with severe inflammation. Treatment used has been daily mesalamine and hydrocortisone suppositories, started 1 month ago. Symptoms have been slightly improved, but last week's endoscopy showed no real improvement. Still on lots of painkillers and is managing "good and bad" days.

The surgeon's immediate plan is that if local treatment doesn't work, they will redo IPAA surgery with hand-sewn mucosectomy.

I asked about pouch advancement surgery. For those who you are unfamiliar with this treatment, it is used on patients that typically have 1-3cm of retained rectal cuff. When cuffitis is considered refractory, they can transanaly resect the cuff and create a hand sewn anastomosis with mucosectomy.

Question: Does anyone know typical recovery type from Pouch-Advancement surgery?

Surgeon has explained that this treatment will not work for my wife. Surgeon explained that with 6cm of retained tissue, the pouch would have to be mobilized to bring it down to the anastomosis site. She tried to explain that this couldn't be done due to the pouch being stuck to the tissue walls (normal). Can anyone help explain this further? I challenged her answer and she is actually thinking about whether or not she can use some type of new technique to mobilize the pouch. Would be first case, yippy!....sigh...

Anyway, I thought I would share our somewhat unique situation. Any thoughts would be greatly appreciated. Anyone else with pouch redo for retained rectum??

And to answer your question, hell no, this is not the original surgeon. We strongly believe that we went to the best surgeon on the West Coast for pouch surgery that is not at a Center of Excellence. He performs 10-15 pouch operations a year and had a fantastic reputation. Why we ended up with 6cm of rectum may be a question that I will never have an answer to.

We are now seeking treatment at Mayo Clinic.

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I have had cuffitis in the remaining 1-2 cetimeters of cuff for well over a year. I treat it on and off with canasa and at times hydrocortisone suppositories. I was recommended for pouch advancement surgery and decided to try every medical option available first. So far I am holding out and managing ok. I do have some days that are not as great as others and I get scoped often to check my condition (hoping to move to annual scopes this year).

I was told they could most likely detach the pouch and mobilize it all transanally, but there was a small chance they would have to do an open surgery and possible temp ostomy if they had any issues mobolizing the pouch through the anal opening. I am not sure how this would be done with 6 centimeters of remaining rectal cuff. It sounds to me like you wife may not be an option for transanal surgery.

If she is not responding to rectal medications, there are always oral choices. When I went for my SSO to another surgeon, after my original one suggested advancement surgery (my surgeon is also top notch and my issues were not surgery related), he told me I had nothing to lose by trying medications. Of course, I am not your wife and do not know how bad her symptoms are, but I can tell you I dealt with agonizing symptoms for months with little relief before finding a somewhat happier place (not perfect but much easier to manage). I also am not a fan of revisional surgery as I have read each time you have more surgery after our initial, the chances of success drop and that frightens me.

I think you are at a good center now and they should be able to advise you accordingly.
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I also have bad inflammation in the 1-2 cm of my cuff, and am scheduled for pouch advancement surgery in November.

My guess is that 6cm is too much cuff to do a transanal pouch advancement. As explained in the article below, the initially stapled anastomosis must be "within 3 cm to 4 cm of the dentate line" for the surgery to be feasible.


They simply cannot pull the pouch down that far without making an abdominal incision and basically doing a pouch redo.

I am so sorry that you are in this situation. Have you considered biologic treatments (i.e. Remicade and Humira)? If your wife is unable to respond to anything, she may just need a pouch re-do. Not the end of the world, but certainly not a piece of cake. Best of luck.
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