Hi all,

I am having three stage IPAA, and I already had the first stage done with Dr Alexander Greenstein at Mt Sinai in NYC. I am going to have the next stages soon, I need to decide on a surgeon/surgery technique for my j-pouch construction.

Dr Alexander Greenstein  is the son of Dr Adrian Greenstein, who was a legend in j-pouch surgery. He was trained by his father, went to Cornell, and does a large number of j-pouch surgeries at Mt Sinai, as they have an IBD research center there. He is proficient in laparoscopic surgery for j-pouch construction. 

Dr Remzi is an expert on pouch reconstructive surgery, and if you search his name on this website, you will see that he is a legend here on the forums among people with problematic pouches. His assistant says he does fifty-fifty pouch reconstruction and fresh j-pouches. He does the first and last step surgeries laparoscopically. However, he does the second step, the construction of the pouch, as an open surgery.

BTW, as a side note, he prefers three stage IPAA over two stage IPAA for all patients (not just weak patients), and recommends a six month wait between the first and the second stages (google mesenteric tension to understand why), and a three month wait between the second and the last stages. Dr Greenstein, on the other hand, recommends a five month and a two month wait respectively. The waiting time between surgeries is not a deciding factor for me, as I am quite happy with my ileostomy, to the point that I even considered not getting a j-pouch at all.  Anyways, the surgery technique is the deciding factor for me.

Now, I have to make a decision between the two surgeons/surgery techniques. Dr Remzi/open surgery vs Dr Greenstein/laparoscopic surgery.

I am not concerned about the scar, because Remzi makes a small scar under the bikini line for women. I am more concerned about all the horror stories I read here on untreatable pain due to adhesions, and obstructions due to the adhesions, both problems that can surface many years after the surgery. Open surgery leaves more adhesions than laparoscopic surgery. I am not sure whether I should go with Dr Remzi, although he is called “Remzi the great” on the forums, due to my fear of adhesions.

Dr Remzi told me that Dr Greenstein is a very good surgeon, therefore he does not need to offer me to the surgery himself. Therefore, I think, since Dr Remzi also thinks Dr Greenstein is going to do a good job, and Dr Greenstein would do the j-pouch construction laparoscopically, why bother with open surgery, even if it would be “Remzi the great” doing it. What do you think?

Original Post

Most of us have had one or the other technique for our pouch surgery, but can’t directly compare them. I will confirm that my recovery from a different laparoscopic surgery was *much* easier than my open (pouch) surgery recovery. If I had the choice you have (i.e. laparoscopic surgery with a highly skilled, well regarded surgeon) then I’d opt for the laparoscopic approach.

Scott and Pouchlogic, thank you very much for your advice. I am also inclined towards laparoscopic surgery. But since Dr Remzi operates on large number of failed pouches on a regular basis, I just can’t get over the idea that he might know what NOT to do better than others.

I do not worry much about recovery from open surgery, as I am more focused on long term results and quality of life. I read that laparoscopic causes less adhesions, but small bowel obstruction rate does not seem to differ between open and laparoscopic IPAA... Also, I wonder how common is to have pain due to adhesions and whether there is cure for that. 

GRACEB, Dr Adrian is the father of DR Alexander Greenstein, and is no longer alive. Are you happy with your j-pouch?

I was very sick with Ulcerative Colitis.  I was going to Drs. on Long Island that was not  really paying attention to all my symptoms and my complaining off all symptoms and weight loss.  I searched on computer to find another Dr. who specialize in Ulcerative Colitis.  It was Mt Sinai.  I made appointment with Dr. Itzkowitze. Had all types of testing same day. I was on remacade 2 years prior was not helping me.  I was getting worse. Dr. Itzkowitze sent me to Dr. Greenstein.  They both are wonderful Drs.  I was scheduled for  laproscopic  surgery and my brother in law past away.  I had to post pone my Appt for surgery.  Had surgery 2 weeks later.  I had my first surgery but Dr. Greenstein was going away on vacation 2 days after my first surgery.  I started having problems and the Dr. that was filling in had to give me another surgery  and I remember Dr. Greenstein became angry about his decision he was out of the country.  I have some problems because of that surgery.  I am a patient of Dr. Alexander Greenstein now.  They are all wonderful Drs.  I also go to a Respiratory  Dr. DePalo  at Mt. Sinai.  That is also a wonderful Dr.


You wrote: "I was going to Drs. on Long Island that was not  really paying attention to all my symptoms and my complaining off all symptoms and weight loss."

Same here. I was going to a Dr in Westchester and he failed me big time. I was suffering in pain, crying in his office, all he could do was to prescribe me Zofran, and keep me on Lialda 4 pills a day. I got hospitalized the one day after a visit with him. Then came the surgery.

I was a very mild case of proctitis before that, and in one month with this GI, I progressed to pancolitis, because he kept me on 4 lialda a day until I needed surgery. No steroids, no biologics, nothing... I recommend every IBD patient to stay away from Drs that are not at tertiary centers. They have no idea about IBD, but they think they do.

ELIF   Yes I agree with you.  I often tell myself that I should have been more active knowing my disease.  I was never sick always very healthy and when I was diagnosed with Ulcerative Colitis I trusted the gastro on Long Island.  I should have been more active knowing what this disease can do your body.  It is what it is.  I can't go back.  I have very good Doctors at Mt Sinai.  They actually saved my life.  I really didn't know how sick I was.  I learned that you have to listen to your body, don't take anything for granted.  

ELIF  Also after my surgeries I had really no one that understood what I was going thru. I could not find a support group in my area.  I searched on the computer and found  this site.  It actually saved my sanity.  There are so many people that helped me thru this. I can't thank them enough.    

GRACEB, I am having really hard time choosing a surgeon, and you are right, nobody understands what it is like.

That is why I posted here, to get ideas from people who went through the same. What would you do if you were in my shoes? Open surgery with Remzi, who did hundreds of pouch redo surgeries in his career, or laparoscopic with Alexander Greenstein, who is a great surgeon. This is such a difficult decision... I am afraid I may blame myself for having made the wrong decision for the rest of my life. Just as I now regret not going to Mt Sinai earlier, which could have saved my colon.  In case of a small complication, pain etc, even if it might not have much to do with this decision, I still may regret the decision. What would you do?

Elif, neither surgeon is a bad choice. Either one could turn out well, or you could be unlucky with either one (though that’s much less likely). I can’t stop you from having regrets, but I can tell you that they don’t come from a rational place.

Scott, you are absolutely right.  In fact you are one of the many j-pouchers that helped me thru many problems.  I would write all suggestions down and bring the questions to my gastro.  I thank you and all others for information.  Sometimes they just don't tell you everything.  If it was not for this forum I don't know what I would have done.  I was actually beside myself didn't know where to turn.  Family and friends really don't know what you go through. There are no support groups in my area.  I searched after my surgery.  I was so thankful to find this group.  ELIF  you are on the write site to find information. 

Dr. Remzi performed all 3 stages of my pouch while still at the Cleveland Clinic back in 2008/2009.  This was a first-time pouch and not a reconstruction.  At the time he was still doing them all as open (non-laparoscopic) procedures.  To this day I've experienced very little complication and am very happy with the results.

It took me awhile to realize that having the J- pouch  surgery gave me my life back.  I went thru some tough times.  When I look back it was the only decision I had and I am very happy that I went to Mt Sinai with Dr. Greenstein being my surgeon and Dr. Itzkowitz being my Gastro.

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