Restorative Proctocolectomy at Tunbridge Wells Hospital

What is restorative proctocolectomy?

Restorative proctocolectomy is an operation that removes your entire colon (large bowel) and rectum, then rebuilds a new way for you to pass stools using part of your small bowel. Surgeons create an internal pouch, often called a J-pouch, so that most people can carry on passing stools through their bottom rather than needing a permanent stoma bag.

What conditions does it treat?

This operation may be recommended if you have:

• ulcerative colitis that has not responded to other treatments, or has caused severe inflammation or damage
• certain types of Crohn's disease affecting your colon
• familial adenomatous polyposis (FAP), an inherited condition that carries a very high risk of colon cancer
• bowel cancer, or a very high chance of developing it
• a bowel that has perforated (developed a hole), lost its blood supply, or is affected by severe constipation or complicated diverticulitis.

What are the benefits of restorative proctocolectomy?

This surgery removes the diseased or high-risk part of your bowel and, if a pouch is formed successfully, can help you avoid a permanent ostomy bag. People who recover without complications generally report a good quality of life afterwards and are able to take part in most of their usual activities.

Are there different types or surgical approaches?

There are several ways this operation can be carried out, and your surgeon will discuss which suits you:

• open surgery, through one larger incision in your abdomen, or laparoscopic (keyhole) surgery, through several smaller incisions, which is generally linked to a faster recovery and less scarring
• a pouch shaped like a J, S or W, made from around 12 inches of your small bowel, though the J-pouch is the most commonly used today
• an anastomosis, or join, that is either stapled or hand-sewn
• surgery carried out in one, two or three stages, depending on how unwell you are and whether you are taking medicines such as steroids. Most people have a two-stage procedure.

If you have a temporary stoma as part of a staged approach, this is usually reversed around 6 to 12 weeks later, once your pouch has had time to heal.

What happens before the operation?

In the weeks before your operation:

• you will discuss the different types of surgery you could have, along with the risks and benefits, with your surgeon
• around two weeks before, you may be asked to stop taking blood-thinning medication, and to eat plenty of fibre and drink plenty of water to keep your bowel as healthy as possible.

In the 24 hours before surgery:

• you will usually be prescribed a bowel preparation to clear out your intestines, which will give you diarrhoea for a while
• you will be asked to stick to a clear liquid diet
• you may be given preventive antibiotics to reduce the risk of infection.

On the day, your blood pressure and breathing will be monitored, you will be given fluids and medicine through a vein in your arm, and you will then be given a general anaesthetic (medicine that puts you into a sleep-like state) before surgery begins.

What happens during the procedure?

1. You are given a general anaesthetic, so you are fully asleep and unaware of the operation, with a tube to help you breathe.
2. Your surgeon accesses your bowel either through one larger incision (open surgery) or several smaller incisions using a camera and instruments (laparoscopic, or keyhole, surgery).
3. They remove the diseased or affected section of your colon and rectum, keeping your anus and anal sphincter intact wherever possible.
4. If you are having a pouch, your surgeon folds around 12 inches of your small bowel into a J, S or W shape to create an internal reservoir, then connects it to your anus.
5. Depending on your circumstances, the pouch may be connected to your anus in the same operation, or you may have a temporary stoma first, with the pouch connected in a later operation once it has healed.
6. Your surgeon closes your incisions, using clips or dissolvable stitches for open surgery, or surgical glue or stitches for keyhole incisions.

What does recovery look like?

In hospital, you will usually stay for around a week after your operation. During this time you will:

• gradually move from a clear liquid diet to a soft diet, and then towards solid food
• receive fluids and nutrition through a vein at first, until your bowel has healed enough for you to drink normally
• be given strong pain medication, adjusted to keep you comfortable, plus a short prescription to take home
• learn how to care for your wound, and, if you have a stoma, how to empty and care for it, usually with help from a stoma care nurse.

At home, recovery continues gradually:

• your bowel habits will be very different at first. You may pass liquid stools around 15 times a day to begin with, settling to around 6 to 8 times a day as your pouch matures over several weeks
• your stools are likely to stay a paste-like consistency, even once you have recovered
• you will reintroduce foods gradually, and may notice that some foods you tolerated before now cause symptoms
• you should avoid heavy lifting or strenuous activity, and you may not be able to drive for a couple of weeks
• full recovery can take several months, and your pouch may take up to 18 months to settle fully.

If you have a temporary stoma, you will usually need a further operation, sometimes called a 'takedown', to connect your pouch and close your stoma. This is often done 6 to 12 weeks later, though it can be longer if your surgery was staged over three operations.

What are the risks and complications?

As with any major operation, there are some general surgical risks, including:

• wound infections at the incision sites
• injury to nearby organs, the bladder, blood vessels or the ureter
• bleeding, or reactions to the anaesthetic
• hernias developing at the incision sites.

There are also some risks specific to this type of surgery:

• an anastomotic leak, where the join between the pouch and anus leaks. This sometimes needs further surgery, or drainage to let it heal
• pouchitis, inflammation of the pouch, which affects up to half of people with a pouch at some point, and is usually treated with antibiotics
• strictures, or narrowing, above, below or in the pouch itself
• pouch fistulas
• nerve damage affecting sexual or urinary function, which usually improves over time
• temporary incontinence, particularly at night when your anal muscles are more relaxed, which usually improves as your muscles strengthen
• malnutrition, dehydration or vitamin and mineral deficiencies, since your colon would normally absorb water and certain nutrients
• an increased risk of infertility in women.

In around 10% of people, the pouch fails within 10 years because of complications and needs to be removed and replaced with a permanent stoma.