This may sound like a really silly, ignorant question, so forgive me in advance for asking it, but what should the diameter of the anastomosis connection be in order to have a GOOD functioning pouch (one that empties easily, no stricture, straining, pain  etc).

I know some people on the board self dilate and I thought as long as you were able to insert up to the first knuckle of your index finger comfortably (sorry if too graphic), this was a good indicator that things should pass easily. I know this is not the case for me as often I am passing stool through an opening the size of a straw or smaller and as a result I have all sorts of other problems going on now like fissures, anal stenosis, cuff inflammation and tremendous pain.

Is there ever really a viable solution to this problem other than a pouch re-do or advancement? I am getting conflicting suggestions from 2 surgeons I have seen and my prior GI on how to best handle this problem.

The last surgeon I saw (who I saw prior to my surgery but did not do my actual surgery), felt the opening was not too bad. He happened to perform the exam on a good week where I was not struggling to empty my pouch and in incredible pain. He was against advancement surgery and suggested I try cortifoam   (been there done that). My original surgeon suggested an advancement and would do it without an temp ostomy  (I can feel the pain already).  My GI felt that because I was experiencing some leakage on occasion, that I should not advance the pouch as one of he things that often occurs over time with a pouch is leakage. When I saw Dr Remzi about a year or so ago, he indicated he would not do a pouch advancement without a temp ostomy as it is very painful surgery and this would reduce the chance of infection also.   

Fast forward two weeks and I am now  in horrific pain, struggling to empty the pouch again, dealing with painful fissures and in transition seeing a new GI doc as mine left the practice. I feel like an orphan with no home as my original surgeon is in NY and I can no longer afford his non covered services and my prior GI, who was excellent, has also gone to NY and his practice/hospital does not accept my insurance. I  do not prefer the surgeon I have seen in my state (re-visited  him as he accepts my insurance and  to see if I could switch to him for surgery if needed). I never chose him originally for my surgery as I was not comfortable with his approach/advice.  He did say he would do the advancement surgery if I wanted, but it was not his recommendation at this time.

I would prefer Dr. Remzi do a salvage surgery but I don't want to run into the same issue that I have going out of state for surgery (several hours away)  if I experience any post op issues, which with my history, I am sure I will encounter. The distance is just not feasible for follow up or post op issues.

Any thoughts/ideas would be greatly appreciated.