Why Aren't J-Pouches Done For Crohn's Disease?

In General, J-Pouch Surgery Is Typically Used To Treat Ulcerative Colitis

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Some people with ulcerative colitis have surgery to create an internal pouch of their small intestine, often shaped like a "J.". Image © Lisa J. Goodman / Getty Images

Ileoanal pouch anal anastomosis (IPAA)—or as it's more commonly known, j-pouch surgery—has become the preferred type of surgery for many people who have ulcerative colitis and who require surgery. This type of surgery may also be done for familial adenomatous polyposis (FAP) or certain cases of colorectal cancer. However, for people diagnosed with the other form of inflammatory bowel disease (IBD), Crohn's disease, a j-pouch is usually not considered a viable option.

What's A J-Pouch?

J-pouch surgery is typically done for people with ulcerative colitis either when medical therapy fails and symptoms become unmanageable, or when there are pre-cancerous changes in the colon (large intestine). In a certain number of people with ulcerative colitis, available medications might not help alleviate symptoms, and quality of life might be so poor that surgery is considered. People with ulcerative colitis are at a greater risk of developing colon cancer, and removal of the colon is often recommended when biopsy results from the colon show pre-cancer or cancer.   

In j-pouch surgery, the colon is removed, along with part or all of the rectum. The last section of the small intestine is used to make a pouch—usually in the shape of a "J," but "S" and "W" shapes are also sometimes done. The pouch made from the small intestine is then connected to the anus, which makes elimination of stool more "normal." The surgery is often done in two steps, but may also be done in one or three steps.

Why Isn't This Surgery Typically Done For Crohn's Disease?

With ulcerative colitis, the disease, and associated inflammation, is located in the large intestine. Removing the large intestine, while not a cure, does take away the organ that is most affected by the disease. With Crohn's disease, any part of the digestive tract could be affected by inflammation and even if the large intestine is removed, Crohn's disease could still recur.

In fact, the most common locations for inflammation in people who have Crohn's disease are the ileum and the large intestine. The ileum is the last section of the small intestine, and it is the part that is used to make the pouch in IPAA surgery. The classic rationale is, if the Crohn's disease does affect the pouch, the pouch might "fail" and ultimately need to be removed. There are also patients who have have been diagnosed with ulcerative colitis, had j-pouch surgery, and then later have the diagnosis changed to Crohn's disease (although this is not common).

However, studies about j-pouches in people with Crohn's disease have yielded mixed results. Some studies show that as many as half of patients with Crohn's disease and a j-pouch experienced pouch failure and needed to have more surgery to remove it and create a permanent ileostomy. Yet other studies show that certain carefully selected patients with specific types of Crohn's disease may be able to tolerate j-pouch surgery. With the advent of biologic therapies for IBD (such as Remicade, Humira, Cimzia, Tysabri, and Entyvio), people with Crohn's disease have more treatment options than ever before.

So, IPAA Is NEVER Done In Cases Of Crohn's Disease?

As with most things concerning IBD, there are exceptions. Currently there is a debate amongst key opinion leaders on whether or not certain patients with Crohn's disease can receive a j-pouch and do well with it. There are some cases of people diagnosed with Crohn's colitis or indeterminate colitis who have undergone j-pouch surgery. However, there is a higher risk of complications and subsequent pouch failure in this group of patients. There have been no randomized studies on the j-pouch in Crohn's disease patients that could provide enough quality evidence to end the debate one way or the other.

As with many other controversial topics in IBD, there is no strategy that has been proven to be superior. Any decision about creating a j-pouch for patients with Crohn's disease should only be made by specialty teams at tertiary care centers that are highly experienced and specialized in treating IBD.

Sources:

Braveman JM, Schoetz DJ Jr, Marcello PW, Roberts PL, Coller JA, Murray JJ, Rusin LC. "The fate of the ileal pouch in patients developing Crohn's disease." Dis Colon Rectum. 2004 Oct;47(10):1613-1619.

Brown CJ, Maclean AR, Cohen Z, Macrae HM, O'Connor BI, McLeod RS. "Crohn's disease and indeterminate colitis and the ileal pouch-anal anastomosis: outcomes and patterns of failure." Dis Colon Rectum. 2005 Aug;48(8):1542-1549.

Joyce MR, Fazio VW. "Can ileal pouch anal anastomosis be used in Crohn's disease?" Adv Surg. 2009;43:111-137.

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