I spoke to my surgeon the other day about getting a second j-pouch. (My old one has to go sometime and I’m not keen on a perm ileo.) He mentioned that it would require a hand-sewn something to go inside the previous something.
I was a bit tired that day (actually every day). Can anyone fill in the blanks?
Also, hand sewn is harder than the other type, no? So he would need to have plenty of practice.
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A replacement pouch would frequently be hand-sewn. If anything is wrong with the rectal cuff, or if there won’t be enough cuff remaining then it’s a given. You are correct that it’s a technically more difficult procedure, and because it’s uncommon very few surgeons are well trained in it or do enough to stay in practice. Did your surgeon say anything about doing it himself vs. sending you to someone else? You called ask a question like “how many hand-sewn J-pouch procedures have you done this year?”
My understanding is that the very nature of a redo is technically challenging.
Removing the old pouch, pulling down more of the of the ileum into the pelvis, plus dealing with blood supply makes this situation very complex.
Since most surgeons perform the double staple technique, you really need to find a center of excellence/university hospital that has surgeons well versed/trained in the redo process.
If the United States were an option, there is one surgeon at NYU (Remzi) who I would want to perform this. I hope there is such a resource where you are.
Please let us know what you find out.
@Scott F posted:A replacement pouch would frequently be hand-sewn. If anything is wrong with the rectal cuff, or if there won’t be enough cuff remaining then it’s a given. You are correct that it’s a technically more difficult procedure, and because it’s uncommon very few surgeons are well trained in it or do enough to stay in practice. Did your surgeon say anything about doing it himself vs. sending you to someone else? You called ask a question like “how many hand-sewn J-pouch procedures have you done this year?”
Would the whole thing be hand sewn? I think what he said was about attaching it at the bottom end, maybe the rectal cuff.
He was a bit taken aback when I asked about it. I will see whether there’s anyone who does it more than he does, and how often he does it. (He already said he doesn’t do it frequently.)
I don’t have anything wrong with the rectal cuff, so that’s a positive. I just have megapouch.
@New577 posted:My understanding is that the very nature of a redo is technically challenging.
Removing the old pouch, pulling down more of the of the ileum into the pelvis, plus dealing with blood supply makes this situation very complex.
Since most surgeons perform the double staple technique, you really need to find a center of excellence/university hospital that has surgeons well versed/trained in the redo process.
If the United States were an option, there is one surgeon at NYU (Remzi) who I would want to perform this. I hope there is such a resource where you are.
Please let us know what you find out.
I live in Australia, so no centres of excellence sadly. It’s actually extremely difficult to even find out who does j-pouches except by asking on the Australian Facebook support group.
We buy a lottery ticket every week in the hope of winning a few million dollars so I could visit the US. Last week my dad “won” –.05c!
I forgot to ask the surgeon who he would recommend for a redo, if anyone. I could travel interstate. Will contact him and ask.
He did say about the problem of pulling down the bowel, and how there might not be enough.
I am sort of stuck in purgatory here, with a pouch that doesn’t work well, and extremely sensitive skin plus a cognitive problem that will make an ileostomy difficult if not impossible for me to manage.
I could probably handle a continent ileo (because no adhesives) but the surgeon who was doing them here passed away.
Do you know how they decide whether it’s physically possible to do a redo? One factor is how much small bowel is left. How do they measure that?
And what about the “pulling down” of the ileum? How do they determine whether that is feasible?
I know I should search the medical literature on this, but I’m suffering from low blood flow to the brain at the moment and would appreciate picking people’s brains that are working :-)
I don’t know what methods pouch surgeons use to estimate the probability of anatomic adequacy prior to surgery. They can estimate the amount of bowel left based on prior surgeries, but the reach of the blood supply is apparently the more likely limitation in most cases. They get to test their plans during surgery, of course, and the more skilled surgeons know just how far they can pull the tissue and still get a good result. There must be a “Plan B” in case the anticipated surgery turns out to be infeasible.
Realistically, only a surgeon can properly address the probability and feasibility of a redo and its likely outcome.
what I do know and I agree with Scott here, blood supply will be a concern/issue. When I was interviewing surgeons, one of them told me the mesentery is always a concern, especially on taller men due to the reach issue. I will assume that a redo will need more of a limited supply.
As a side note, when I had my emergency takedown redo, my surgeon was reluctant to give me a temp ileostomy again, because he felt if he cut the blood supply, the pouch would be become nonfunctional. He didn’t and although it is standard practice to divert in a sepsis scenario, I turned out fine and healed.
as you go thru this, think about the fact that plan b might occur during surgery and you could wind up with a permanent end ileostomy.
@Scott F and @New577, thanks for your replies. The two surgeons I have spoken to so far (long story) were both really vague and seemed unwilling to discuss anything until I had a CT scan and pouchoscopy. I didn’t see the point of that because I already have plenty of past CT scans and pouchoscopies, which they had access to, and my bowel certainly hasn’t got shorter since then!
If they have to assess it during surgery, then I wish they would just say so.
(I realise I will need a recent CT scan and pouchoscopy before surgery, if I decide to go ahead with it, but I’m not having them for no particular reason.)
I have low blood flow to the brain which makes it extremely hard for me to think “on the spot” at consultations. I get home and realise I haven’t learnt anything or gotten any answers. I wish I could bring one of you two along!
Surgeons can request things like that.
I had one surgeon request an mri of my small bowel to assess if I had crohn’s, before he would discuss my case any further
every medical report I had sent him prior to consultation had UC as the diagnosis.
this particular surgeon does not perform IPAA on patients with crohns, he wanted to rule it out.
my advice would be to go along with their requests if this is a surgeon you would consider.
in my case, I thought this guy was an arrogant AH, so I ignored his request and took him off my short list.
Good for you, @New577. The two surgeons I saw failed to impress me, so I doubt I will be going back regardless. They both showed signs of poor communication skills.
If they had been able to give me a reason, such as double checking for Crohn’s, and had done a better job at the consultation, that would have been a different story.
As each surgeon wants to look for themselves (fair enough), I won’t bother to get into a pouchoscopy with someone I don’t like for the surgery anyway.
Just out of interest, or for anyone else wondering the same thing as me, here is some information from a paper by Remzi et al in 2015:
Preoperative Evaluation
Patients underwent a comprehensive clinical examination before redo IPAA surgery. Although perioperative evaluation has evolved through the years, in all cases, there was an accurate and detailed history of the presenting symptoms and the prior pouch surgery. For patients referred to us, this included both operative records and pathology reports and usually the pathology slides on which the report was based. Then according to the clinical situation and presumptive diagnosis, we obtained some or all of the following: examination under anesthesia, flexible pouchoscopy, gastrografin enema, magnetic resonance imaging, computed tomography or computed tomography – enterography, and anal physiology testing. Since 2001, preoperative testing has usually been coordinated through our pouch center.
Operative Approach
Patients are placed in the Lloyd-Davies position and both abdomen and perineum are prepared for operation. Ureteral stents are placed in majority of patients. The previous incision is used for laparotomy or a midline incision is made for those previously operated by laparoscopic technique. The pouch is mobilized to the pelvic floor with sharp dissection. The decision on whether to resect the old pouch and create a new one or to repair/revise/reattach the old pouch is made by the operating surgeon and depends on the viability and integrity of the mobilized pouch, the reach of the proposed new pouch, and the cause of pouch failure. Although a handsewn IPAA with mucosectomy was usually performed, a stapled IPAA was done if there was a rectal stump long enough for a linear stapler to be applied below the current anastomosis.
For a handsewn anastomosis, the anus was distracted by a series of anal everting sutures and a mucosectomy performed to a level just above dentate line. The pouch was pulled through the pelvis and anastomosed with a series of interrupted 2/0 polyglycolic acid sutures. If access to the top of the anal canal was difficult, a minimum of 4 sutures were placed, 1 in each of the 4 quadrants, before the pouch was pulled through. As these were tied, the pouch was manipulated into place. The IPAA was sometimes then stented with a 22 F mushroom catheter that was sutured in place and kept until the patient’s discharge from hospital or 4 to 6 weeks after the operation. All but 25 patients had fecal diversion, using either the preexisting ileostomy or a new diverting loop ileostomy. Ileostomy closure was usually scheduled 3 months after redo IPAA surgery. Preclosure contrast enema and intraoperative digital anal examination and pouchoscopy were used to confirm pouch and anastomotic integrity. If any complication was noticed, ileostomy reversal was delayed and the complication treated.
"Transabdominal Redo Ileal Pouch Surgery for Failed Restorative Proctocolectomy: Lessons Learned Over 500 Patients"
Kushami, I’m sorry that you experience cognitive difficulty, especially during medical appointments and trying to remember what was discussed. I have a family member with early dementia so I know a little of what you’re talking about. Tty this for your next medical appointment: get a small notebook and write down any questions you have, and all the answers they give you. If you can’t write down their complicated medical terminology, give them the notebook and ask them to write it for you. Or, ask permission to record the discussion, explaining your diminished blood flow and cognitive issues, and that you need to know exactly what they are saying. No one can refuse a request for help. But take along a notebook just in case someone does not agree to be recorded.
