I did not have toxic megacolon nor was I very sick at the time of step 1, or at least I did not feel any more sick than being in my usual flare. My last scope preceded step 1 by about 9 months and it showed dysplasia and inflammation of the entire colon. During that time I booked 2 appointments with my surgeon and the surgery date was delayed because he wanted me to lose weight. I weighed a solid 162 pounds and my appetite was good prior to surgery. My surgeon wanted me to lose 10 pounds, so I dropped from 172 to 162 which was hard taking 60 mg of Prednisone. During that time I began to deteriorate although the extent was not known until the colon came out.
It was not an emergency surgery - it was a planned surgery and the J Pouch was also planned. I did not feel much worse than I had in the prior 9 months. However, when the colon came out my surgeon said it was dissolving in his hands. He said the surgery could not have waited and it would have been an emergency due to toxic megacolon had it waited any longer. However since it was planned, I got lucky so to speak. My surgeon was Dr. Gelernt of Mount Sinai in NYC who at that time was considered the best J Pouch surgeon in the USA. He had done thousands of pouches by 1992, had done the first K Pouch in the USA and had studied with the famed Dr. Nils Kock in Sweden. I was simply lucky in my timing of a planned surgery and in having the best surgeon at that time.
If it had been an emergency I would have been a 3 step. Because I was planned they used the time to do the J Pouch since my ileum was healthy and my weight was solid. At that time, the surgery of step 1 of a 2 step took a long time to do both the colectomy and J Pouch formation. 2 surgeons were used (Dr. Steven Gorfine assisted Dr. Gelernt) and the entire procedure lasts many hours, so it has to be planned in advance. You cannot build a J Pouch "on the fly." They did not do the surgery laparoscopically at that time. I did lose 27 pounds after surgery from various post-surgical complications.
Many people delay surgery for various reasons, usually indecision, and the result is they deteriorate and go from 2 step candidates to 3 step or emergency surgery candidates. If emergency surgery is needed and you cannot be rushed to a Cleveland Clinic or other top notch facility in GI care, I believe the ultimate chances for a good result go down. My own deterioration was not something I actually felt or perceived in terms of feeling much worse, and it occurred during a period of months.