The first recorded successful appendectomy was performed in September 1731 by English surgeon William Cookesley on Abraham Pike, a chimney sweep. [ 23 ] [ 24 ]  The second was on December 6, 1735, at  St. George's Hospital  in London, when French surgeon  Claudius Amyand  described the presence of a perforated appendix within the  inguinal hernial  sac of an 11-year-old boy. [ 8 ]  The organ had apparently been perforated by a pin the boy had swallowed. The patient, Hanvil Andersen, made a recovery and was discharged a month later. [ 25 ]


Harry Hancock performed the first  abdominal surgery  for appendicitis in 1848, but he did not remove the appendix. [ 26 ]  In 1889 in New York City,  Charles McBurney  described the presentation and pathogenesis of appendicitis accurately and developed the teaching that an early appendectomy was the best treatment to avoid perforation and  peritonitis .


Some cases of autoappendectomies have occurred. One was attempted by  Evan O'Neill Kane  in 1921, but the operation was completed by his assistants. Another was  Leonid Rogozov , who in 1961 had to perform the operation on himself as he was the only doctor on a remote Antarctic base. [ 27 ] [ 28 ]


On September 13, 1980,  Kurt Semm  performed the first  laparoscopic  appendectomy, opening up the path for a much wider application of minimally invasive surgery. [ 29 ] [ 30 ]


While appendectomy is a standard surgical procedure, its cost has been found to vary considerably in the United States. A 2012 study  analyzed 2009 data from nearly 20,000 adult patients treated for appendicitis in California hospitals. Researchers examined "only uncomplicated episodes of acute appendicitis" that involved "visits for patients 18 to 59 years old with hospitalization that lasted fewer than four days with routine discharges to home." The lowest charge for removal of an appendix was $1,529 and the highest $182,955, almost 120 times greater. The median charge was $33,611. [ 31 ] [ 32 ]  While the study was limited to California, the researchers indicated that the results were applicable anywhere in the United States. Many, but not all, patients are covered by some sort of  medical insurance . [ 33 ]


A study by the  Agency for Healthcare Research and Quality  found that in 2010, the average cost for a stay in the United States involving appendicitis was $7,800. For stays where the appendix had ruptured, the average cost was $12,800. The majority of patients seen in the hospital were covered by private insurance. [ 18 ]


Billroth I , more formally  Billroth's operation I , is an  operation  in which the  pylorus  is removed and the distal  stomach  is  anastomosed  directly to the  duodenum . [ 1 ] [ 2 ]


The operation is most closely associated with  Theodor Billroth , but was first described by  Polish   surgeon   Ludwik Rydygier . [ 2 ]


The surgical procedure is called a  gastroduodenostomy . [ 1 ]


Billroth II , more formally  Billroth's operation II , is an  operation  in which a partial gastrectomy (removal of the stomach) is performed and the cut end of the stomach is closed.  The   greater curvature  of the stomach (not involved with the previous closure of the stomach) is then connected to the first part of the  jejunum  in end-to-side anastomosis.  The Billroth II always follows resection of the lower part of the  stomach  ( antrum ). The surgical procedure is called a partial gastrectomy and gastrojejunostomy. The Billroth II is often indicated in refractory  peptic ulcer disease  and  gastric adenocarcinoma . [ 1 ]


Over the years, the Billroth II operation has been colloquially referred to as any partial removal of the stomach with an end to side connection to the stomach as shown in the picture; however, technically, this picture is a modification of Billroth's operation called a partial gastrectomy with a Kronelein anastomosis where the divided end of the stomach is directly anastomosed to the side of the jejunal loop.


Von Hacker was the first person to refer to the Billroth II partial gastrectomy operation writing from Billroth's clinic in 1885.


A  Collis gastroplasty  is a  surgical procedure  performed when the surgeon desires to create a  Nissen fundoplication , but the portion of  esophagus  inferior to the  diaphragm  is too short. Thus, there is not enough esophagus to wrap. A vertical incision is made in the stomach parallel to the left border of the esophagus. This effectively lengthens the esophagus.  The  stomach fundus  can then be wrapped around the neo-esophagus, thus reducing  reflux  of  stomach acid  into the esophagus.


In fact, gastroplasty can be used when the length of the intra-abdominal esophagus is short and for anti-reflux action such as Nissen fundoplication, it is necessary to increase the intra-abdominal length of the esophagus.
At this time, part of the upper part of the stomach is separated by a stepper, i.e. the stapler fires longitudinally along the esophagus and increases the length of the stomach inside the abdomen.
At this time, a tongue is created from the stomach that can be easily rotated on the new esophagus and all kinds of fundoplication operations such as Nissen fundoplication can be done easily. [ 1 ]
It was devised by John Leigh Collis (1911–2003), [ 2 ]  a British cardiothoracic surgeon, in 1957. [ 3 ]


Coloanal anastomosis  (also known as  coloanal pull-through ) is a  surgical procedure  in which the  colon  is attached to the  anus  after the  rectum  has been removed.


Colonic polypectomy  is the removal of  colorectal polyps  in order to prevent them from turning  cancerous .


Gastrointestinal polyps can be removed endoscopically through  colonoscopy  or  esophagogastroduodenoscopy , or  surgically  if the polyp is too large to be removed endoscopically. The method used to perform colonic polypectomies during  colonoscopy  depends on the size, shape and histological type of the polyp to be removed. Prior to performing polypectomy, polyps can be biopsied and examined histologically to determine the need to perform polypectomy. [ 1 ] [ 2 ]


Prior to resection, assessment of the polyp should include: polyp size,  morphology , location, and accessibility. [ 3 ]  If there are features that suggest of cancer is present in the polyp, then either  endoscopic submucosal dissection  or surgery should be considered. [ 3 ]  If the polyp appears benign, but the risk of progression to cancer is negligible, then resection is not necessary. [ 3 ]


Large sessile polyps are more difficult to remove endoscopically, and polypectomy in these cases has a higher risk of complication. Sessile polyps up to 10mm can often be removed by snare polypectomy. Polyps over 10mm may have to be removed piecemeal by snare polypectomy. The use of electrocautery over a large area has a significant risk of causing colonic perforation; to reduce this chance, and to facilitate the polypectomy, sterile fluid (saline or colloid, with  methylene blue  dye added) can be injected under the base of the polyp to raise it away from the muscular layers of the colon. [ 4 ]


Pedunculated polyps can be removed by snare polypectomy. When the polyp is identified, a polypectomy snare is passed over the polyp and around the stalk of the polyp. The loop of the snare is then tightened to grip the polyp stalk, and the polyp is pulled away from the wall of the colon. An electric current is then passed through the snare loop to cut through the polyp stalk, providing electrocautery at the same time. The polyp can then be retrieved using the snare or an endoscopy basket, and removed by withdrawing the colonoscope.


Polyps may be removed using cold biopsy forceps, cold snare polypectomy, hot biopsy forceps, hot snare polypectomy,  endoscopic mucosal resection , or  endoscopic submucosal dissection . Cold biopsy forceps may be used for small (diminutive) polyps 1-3 mm in size. [ 3 ]  Cold snare polypectomy has the advantage of avoiding the risk of delayed bleeding, postpolypectomy coagulation syndrome, and perforation. [ 3 ]


The most common complications of colonic polypectomy are  bleeding  and colonic  perforation . Rarely,  postpolypectomy coagulation syndrome  may occur following removal of large polyps with  electrocautery . [ 5 ]


A  colostomy  is an opening ( stoma ) in the  large intestine  (colon), or the  surgical procedure  that creates one. The opening is formed by drawing the healthy end of the colon through an  incision  in the anterior  abdominal wall  and  suturing  it into place. This opening, often in conjunction with an attached  ostomy system , provides an alternative channel for  feces  to leave the body. Thus if the natural  anus  is unavailable for that function (for example, in cases where it has been removed as part of treatment for  colorectal cancer  or  ulcerative colitis ), an artificial anus takes over. It may be  reversible  or irreversible, depending on the circumstances.


There are many reasons for this procedure.  Some common reasons are:


Types of colostomy include: [ 1 ] [ 2 ]


Colostomy surgery that is planned usually has a higher rate of long-term success than surgery performed in an emergency situation. [ citation needed ]


A colostomy may be temporary; and  reversed  at a later date; or permanent.


Colostomy or  ileostomy  is now rarely performed for rectal cancer, with surgeons usually preferring primary  resection  and internal  anastomosis , [ 3 ]  e.g. an  ileo-anal pouch . In place of an external  appliance , an internal ileo-anal pouch is constructed using a portion of the patient's lower intestine, to act as a new  rectum  to replace the removed original.


Placement of the stoma on the  abdomen  can occur at any location along the colon, but the most common placement is on the lower left side near the  sigmoid  where a majority of colon cancers occur. Other locations include the  ascending ,  transverse , and  descending  sections of the colon. [ 4 ]


Pouches and the stick-on appliances to which they attach must be changed regularly. Sometimes an odor neutralizer and lubricant is squirted into a new pouch before it is attached. Two types of pouches are available: one disposable and one drainable. Most pouches are opaque and filter out air through a charcoal filter. The recommended practice is to empty such pouches when one-third full. [ 5 ]  Appliances, in contrast with pouches, are usually replaced every three to seven days except in cases where their seals have broken contact with the skin, when they should be replaced immediately. [ 5 ]


Even as long ago as the 1940s, surgeons conducting a  review  at the  Cleveland Clinic  (Jones and Kehm, 1946) [ 6 ]  could summarize the routine care of the permanent colostomy as usually quite satisfactory, stating that after patients recover from the initial worry prompted by the need for a colostomy, most of them learn to manage their colostomy quite well. [ 6 ]  "These patients come from all walks of life and carry on their daily work as usual. One patient stated that he could see no advantage of the normal anus over a colostomy. While this may be somewhat overstated, it is true that most people with a permanent colostomy can live a useful, happy life." [ 6 ]  They found that, just as in anyone else, dietary indiscretion was the usual factor in occasional bowel habit disruption. [ 6 ]  This historical experience has been borne out, as today the conclusion still stands that most patients can successfully manage a colostomy as part of their  activities of daily living .


Jones and Kehm preferred tissue paper as a colostomy cover (held in place with a band or garment) rather than a colostomy bag. [ 6 ]  They found that irrigation of the colostomy varied with each patient's bowel habit but that most patients developed a routine of every-other-day irrigation, whereas a few needed no irrigation. [ 6 ]


People with colostomies must wear an  ostomy pouching system  to collect intestinal waste.  Ordinarily, the pouch must be emptied or changed a couple of times a day depending on the frequency of activity; in general the further from the  anus  (i.e., the further 'up' the intestinal tract) the ostomy is located the greater the output and more frequent the need to empty or change the pouch. [ 7 ]


People with colostomies who have ostomies of the  sigmoid colon  or  descending colon  may have the option of irrigation, which allows for the person to not wear a pouch, but rather just a gauze cap over the stoma, and to schedule irrigation for times that are convenient. [ 8 ]  To irrigate, a  catheter  is placed inside the stoma, and flushed with water, which allows the feces to come out of the body into an irrigation sleeve. [ 9 ]  Most colostomates irrigate once a day or every other day, though this depends on the person, their food intake, and their health.


Parastomal hernia (PH) is the most common late complication of stomata through the  abdominal wall , occurring in 10-25% of patients, [ 10 ]  even up to 50% by some estimates. [ 11 ]   Prolapse  of bowel wall through the stoma occasionally happens and can require reoperation to repair. [ citation needed ]


Clinical  pilates -based exercises have been demonstrated to improve patients' core abdominal strength and to reduce the risk of a hernia worsening. [ 11 ]


Other common complications of colostomy are high output, skin irritation, prolapse, retraction, and ischemia.


A  colostomy reversal , also known as a  colostomy takedown , is a reversal [ 1 ]  of the  colostomy  process by which the colon is reattached by  anastomosis  to the  rectum  or  anus , providing for the reestablishment of flow of  waste  through the  gastrointestinal tract . [ citation needed ]


Indications for the surgery include patient pain or discomfort caused by the colostomy, frequent skin breakdown or infection, and herniation at the colostomy site. The technical aspects of the surgery depend on the amount of remaining colon and rectum.


Cystogastrostomy  is a surgery to create an opening between a  pancreatic pseudocyst  and the stomach when the cyst is in a suitable position to be drained into the stomach. [ 1 ]  This conserves  pancreatic juices  that would otherwise be lost. [ 2 ]  This surgery is performed by a pancreatic surgeon to avoid a life-threatening rupture of the pancreatic pseudocyst. [ 3 ]


Symptomatic pancreatic pseudocysts are an indication a cystogastrostomy needs to be performed.  Pancreatic pseudocysts are chronic collections of  pancreatic  fluid encased by a wall of nonepithelialized granulation tissue and  fibrosis . They can be caused by leakage of the  pancreatic duct , or as a result of inflammatory  pancreatitis . [ 4 ]  Symptoms of this include abdominal bloating, difficulty eating and digesting food, and constant pain or deep ache in the abdomen.  A lump can be felt in the middle or left upper abdomen if a pseudocyst is present.  To further diagnose a pancreatic pseudocyst an abdominal  CT scan ,  MRI  or  ultrasound  can be used. [ 5 ]   Emergency surgery may need to be performed if there is a rupture of the pseudocyst. This can be detected from symptoms of bleeding, shock, fainting, fever and chills, rapid heartbeat, or severe abdominal pain. [ medical citation needed ]


Surgical repair is carried out through an  incision  in the abdomen. After locating the pseudocyst, it is attached to the wall of the stomach and the cystogastrostomy is created. Although it has a high success rate, it is infrequently used because of the recovery period. [ 4 ]


A relatively new and less-invasive method involving  endoscopic ultrasound  (EUS) guidance and  fluoroscopy . A large bore needle is used to access the identified pseudocyst, creating a  fistula  between the cystic cavity and either the stomach or the  duodenum . [ 6 ]  Plastic stents may be placed to facilitate drainage from the pseudocyst. [ 4 ]  The success rate of endoscopic treatment of pseudocysts may be greater than 70%. [ 7 ]


This method is the second of two less invasive surgeries used to drain pseudocysts and can be performed by a single surgeon because of the advanced tools. The pseudocyst is identified and accessed using  laparoscopic techniques . Once the pseudocyst cavity is located, it is entered and aspirated, and an opening is created into the stomach for drainage. Laparoscopic drainage may result in better cosmetic appearance and decreased pain following surgery. [ 8 ]


Cystogastrostomy can lead to  pancreatic abscess [ 9 ]  and pancreatic duct leak. Stents can become blocked, leading to infection of the pseudocyst. [ 6 ]  Other complications include those normally associated with surgery and anesthesia, including bleeding. [ citation needed ]


Jedlicka first described the procedure. [ 10 ]


Enterotomy  is the surgical incision into an intestine. It may be purposeful or a complication of an  abdominal surgery , such as exploratory  laparotomies  or  hernia repair . [ citation needed ]


An enterotomy can be done to remove an obstruction or foreign body from the intestine. [ 1 ]


If an accidental enterotomy is not noticed during surgery, it can take days to become apparent. Surgical repair is required. [ 2 ]


Esophagogastric dissociation  is a surgical procedure that is sometimes used to treat  gastroesophageal reflux , mainly in neurologically impaired children. [ 1 ]  It has been suggested as an alternative to  Nissen fundoplication  for these cases. [ 2 ] [ 3 ]  Preliminary studies have shown it may have a lower failure rate [ 4 ]  and a lower incidence of recurrent reflux. [ 3 ]


An  exploratory  laparotomy  is a general surgical operation where the  abdomen  is opened and the abdominal  organs  are examined for injury or disease. It is the standard of care in various  blunt  and  penetrating  trauma situations in which there may be life-threatening internal injuries. It is also used in certain diagnostic situations, in which the operation is undertaken in search of a unifying cause for multiple signs and symptoms of disease, and in the  staging  of some cancers. [ 1 ] [ 2 ]


During an exploratory laparotomy, a large  incision  is made vertically in the middle of the abdomen to access the  peritoneal  cavity, then each of the  quadrants of the abdomen  is examined. [ 1 ]  Various other maneuvers, such as the  Kocher maneuver , or other procedures may be performed concurrently. Overall operative mortality ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [ 3 ] [ 4 ] [ 5 ]  Recovery typically involves a prolonged hospital stay, sometimes in the  intensive care unit , and may include rehabilitation with one or more therapies. [ 1 ]


A database that tracks exploratory laparotomies performed in the United Kingdom estimates that about 30,000 are done across England and Wales each year out of a population of 59.5 million people. [ 6 ]  Reasons why a patient may require an exploratory laparotomy include:


A vertical cut, or  incision , is made in the middle of the abdomen. This midline incision extends from the  xiphoid process  at the bottom of the chest to the  pubic symphysis  at the bottom of the pelvis.  The fibrous tissue of the  linea alba , which separates the right and the left  abdominal muscles , serves as a guide for where to cut. After opening the  fascia , the abdominal cavity, or  peritoneum , is entered. The surgeon then looks for evidence of injury, infection, or disease. In trauma exploratory laparotomy, any immediate, life-threatening bleeding is first identified and controlled. In these cases, sponges are often packed in the spaces around the  liver  and the  spleen  to slow bleeding until a source can be found. This allows the surgeon to focus on one area at a time by removing the sponges from that  quadrant . [ 1 ]


A systematic approach is taken to examining the abdominal organs for disease. The  small bowel  is "run", or looked at segment by segment, along its entire length from the  ligament of Treitz  to the  terminal ileum . The  gastrocolic ligament  is incised and the  lesser sac  is explored, including the posterior  stomach  and the anterior  pancreas . The surfaces of the  spleen  and the  liver  also are examined for injury. [ 1 ]  If being performed for cancer staging, special attention will be paid during the exploratory laparotomy to the  lymph nodes , which may be  biopsied , or removed and assessed with a microscope or other special tests to see whether they contain cancerous cells indicative of cancer spread. [ 7 ] [ 9 ]


If necessary, several other surgical maneuvers or procedures may be performed.


Based on where and what injury or disease is identified, one or more additional procedures may be performed during an exploratory laparotomy, including:


Depending on the stability of the patient following an exploratory laparotomy, the abdomen may be sutured back together ("primary closure") or one or more tissue layers may be left open ("open abdomen") to facilitate further non-surgical  resuscitation . In cases where the abdomen is left open, a  vacuum dressing , a  saline bag , or towel clips may be placed to protect the internal organs until the patient is stable enough to return to the operating room for definitive closure. [ 1 ]


The likelihood of death after an exploratory laparotomy depends on several factors including the age of the patient, injury or disease severity, other  comorbid  medical conditions, the skill of the surgeon, and what resources are available in the hospital. [ 6 ] [ 17 ]  Overall, the mortality rate typically ranges between 10% and 20% worldwide for emergent exploratory laparotomies. [ 3 ] [ 4 ] [ 5 ]  It is lower for scheduled ( elective ) exploratory laparotomies, since patients are typically less sick and more optimized when procedures are able to be planned ahead of time. [ 18 ]


Like with any major surgery, a variety of  complications  may occur during and after an exploratory laparotomy. These include minor problems, such as  superficial skin infection  or  delayed bowel motility , and major problems, such as bleeding, blood clots in the  legs  or in the  lungs ,  stroke ,  deep intraabdominal infection  which can lead to  sepsis , and  reopening of the wound  due to a failure to heal properly. [ 17 ]  A minority of patients will require reoperation for complications of exploratory laparotomy. [ 1 ]


Most patients spend at least several days in the hospital after having an exploratory laparotomy, sometimes in the  intensive care unit , depending on the severity of the injury, infection, or disease. It can take weeks or months to heal completely. During the recovery period, there may be restrictions on activities such as driving, exercising, lifting, swimming, and showering. Depending on how long they were in the hospital, how severe their illness was, and whether they sustained other injuries or complications, some patients may require rehabilitation with  physical therapy ,  occupational therapy , or  speech-language pathology . [ 1 ]


Exploratory laparotomy originated as a technique for the treatment of acute trauma. In 1881, Dr.  George E. Goodfellow  performed the first documented exploratory laparotomy for a  ballistic injury , however the use of the procedure for blunt trauma has been described previously. [ 19 ]  In 1888, Dr. Henry O. Marcy first discussed using exploratory laparotomy as a means of diagnosing acute nontraumatic abdominal and pelvic problems at the 39th Annual Meeting of the American Medical Association, citing how improvements in safe surgical methods "so greatly increased the utility of the operation". [ 20 ]  Since the early 2000s, the opposite trend has been seen thanks to improvements in laboratory testing;  CT ,  MRI , and other  medical imaging ; and less invasive  laparoscopic  surgical techniques, all of which have made exploratory laparotomy less common for diagnostic purposes outside of the severe trauma setting. [ 21 ] [ 22 ] [ 8 ] [ 1 ]


A  gastrectomy  is a partial or total surgical removal of the  stomach .


Gastrectomies are performed to treat  stomach cancer  and  perforations  of the stomach wall.


For severe  duodenal ulcers , it may be necessary to remove the  lower portion of the stomach  and the  upper portion of the small intestine . If there is a sufficient portion of the upper duodenum remaining, a  Billroth I procedure  is performed, where the remaining portion of the stomach is reattached to the duodenum before the  common bile duct . If the stomach cannot be reattached to the duodenum, a  Billroth II  is performed, wherein the remaining portion of the duodenum is sealed off, a hole is cut into the next section of the small intestine (called the  jejunum ), and the stomach is reattached at this hole. As the pylorus is used to grind food and slowly release the food into the small intestine, removal of the pylorus can cause food to move into the small intestine faster than normal, leading to  gastric dumping syndrome .


Also known as the Reichel–Polya operation, this is a type of posterior gastroenterostomy which is a modification of the Billroth II operation [ 1 ]  developed by  Eugen Pólya  and  Friedrich Paul Reichel . It involves a resection of 2/3 of the  stomach  with blind closure of the duodenal stump, and a  retrocolic gastrojejunostomy .


The most obvious effect of the removal of the stomach is the loss of a storage place for food while it is being digested. Since only a small amount of food can be allowed into the small intestine at a time, the patient will have to eat small amounts of food regularly in order to prevent  gastric dumping syndrome .


Another major effect is the loss of the  intrinsic-factor -secreting  parietal cells  in the stomach lining. Intrinsic factor is essential for the uptake of  vitamin B 12  in the  terminal ileum , and without it the patient will develop a  vitamin B 12  deficiency . This can lead to a type of  anaemia  known as  megaloblastic anaemia  (can also be caused by  folate deficiency , or  autoimmune disease  where it is specifically known as  pernicious anaemia ) which severely reduces red-blood cell synthesis (known as  erythropoiesis , as well as other haematological  cell lineages  if severe enough but the red cell is the first to be affected). This can be treated by giving the patient direct injections of vitamin B 12 .   Iron-deficiency anemia  can occur as the stomach normally converts iron into its absorbable form. [ 2 ]


Another side effect is the loss of  ghrelin  production, which has been shown to be compensated after a while. [ 3 ]  Lastly, this procedure is post-operatively associated with decreased bone density and higher incidence of bone fractures.  This may be due to the importance of gastric acid in  calcium  absorption. [ 4 ]


Post-operatively, up to 70% of patients undergoing total gastrectomy develop complications such as dumping syndrome and reflux esophagitis. [ 5 ]  A meta-analysis of 25 studies found that construction of a "pouch", which serves as a "stomach substitute", reduced the incidence of dumping syndrome and reflux esophagitis by 73% and 63% respectively, and led to improvements in quality-of-life, nutritional outcomes, and body mass index. [ 5 ]


After Bilroth II surgery, a small amount of residual gastric tissue may remain in the duodenum. The alkaline environment causes the retained gastric tissue to produce acid, which may result in ulcers in a rare complication known as  retained antrum syndrome .


All patients lose weight after gastrectomy, although the extent of weight loss is dependent on the extent of surgery (total gastrectomy vs partial gastrectomy) and the pre-operative BMI.  Maximum weight loss occurs by 12 months and many patients regain weight afterwards. [ 6 ]


The first successful gastrectomy was performed by  Theodor Billroth  in 1881 for cancer of the stomach.


Historically, gastrectomies were used to treat  peptic ulcers . [ 7 ]   These are now usually treated with  antibiotics , as it was recognized that they are usually due to  Helicobacter pylori  infection or chemical imbalances in the gastric juices.


In the past a gastrectomy for peptic ulcer disease was often accompanied by a  vagotomy , to reduce acid production.  This problem is now managed with  proton pump inhibitors .


Gastroduodenostomy  is a surgical procedure where the doctor creates a new connection between the  stomach  and the  duodenum . [ 1 ]  This procedure may be performed in cases of  stomach cancer  or in the case of a malfunctioning  pyloric valve .


A  gastroenterostomy  is the surgical creation of a connection between the  stomach  and the  jejunum . The operation can sometimes be performed at the same time as a partial  gastrectomy  (the removal of part of the stomach). Gastroenterostomy was in the past typically performed to treat  peptic ulcers , but today it is usually carried out to enable food to pass directly to the middle section of the  small intestine  when it is necessary to bypass the first section (the  duodenum ) because of duodenal damage. The procedure is still being used to treat  gastroparesis  that is  refractory  to other treatments, but it is now rarely used to treat peptic ulcers because most cases thereof are bacterial in nature (due to  Helicobacter pylori ) and there are many new drugs available to treat the  gastric reflux  often experienced with peptic ulcer disease. Reported cure rates for  H. pylori  infection range from 70% to 90% after  antibiotic treatment . [ 1 ]


Gastropexy  is a  surgical operation  in which the  stomach  is  sutured  to the  abdominal wall [ 1 ]  or the  diaphragm . Gastropexies in which the stomach is sutured to the diaphragm are sometimes performed as a treatment of  GERD  to prevent the stomach from moving up into the chest.


A  Graham patch  is a  surgical technique  that is used to close  duodenal perforations . A piece of  omentum  is used to cover the perforation. This patch is typically used for holes with a size of 5mm or less. [ citation needed ]


An appropriately-sized tongue of tension-free, well-vascularized omentum is used to plug the perforation. The omental patch is held in place by interrupted  sutures  placed through healthy  duodenum  on either side of the perforation. Once the patch is secure, the seal can be tested by submerging the site under irrigation fluid and injecting air into the patient's  nasogastric tube . The absence of air bubbles indicates that the seal is intact. [ 1 ]


Hassab's decongestion operation  is an elective  surgical procedure  to treat  esophageal varices  in patients with  portal hypertension  as a result of  cirrhosis  of the  liver . It was created by Dr.  Mohammed Aboul-Fotouh Hassab , a professor of surgery at  Alexandria University  in  Egypt .


The approach is abdominal.


Heineke–Mikulicz Strictureplasty  is the most common among the conventional  strictureplasties . Emmanuel Lee introduced this strictureplasty for the treatment of  Crohn's disease  in 1976. [ 1 ]  A similar technique for tubercular strictures of the terminal ileum was reported by RN Katariya et al. in 1977 [ 2 ]  This technique is similar to a Heineke–Mikulicz  pyloroplasty  from which it derives its name. [ citation needed ]


The technique is optimal to address short strictures (≤7 cm). This technique is performed by making a longitudinal incision on the antimesenteric side of the bowel, extending from 2 cm proximal to 2 cm distal to the stricture. [ 3 ]  The  enterotomy  is then closed in a transverse fashion in one or two layers. [ citation needed ]


Strictureplasties  are categorized into three groups: Conventional, intermediate, and complex procedures. The Heineke–Mikulicz strictureplasty is the most common among the conventional stricutreplasties, the  Finney strictureplasty  is the most common intermediate strictureplasty, and the most common complex strictureplasty is the  Michelassi strictureplasty . [ citation needed ]


Heller myotomy  is a  surgical  procedure [ 1 ]  in which the  muscles  of the  cardia  ( lower esophageal sphincter  or LES) are cut, allowing food and liquids to pass to the  stomach .  It is used to treat  achalasia , a disorder in which the lower esophageal  sphincter  fails to relax properly, making it difficult for food and liquids to reach the stomach.


It was first performed by Ernst Heller (1877–1964) in 1913.  Then and until recently, this surgery was performed using an open procedure, either through the chest ( thoracotomy ) or through the abdomen ( laparotomy ).  However, open procedures involve greater recovery times. [ 2 ]  Modern Heller myotomy is normally performed using  minimally invasive   laparoscopic  techniques, which minimize risks and speeds recovery significantly. The 100th anniversary of Heller's description of the surgical treatment of patients with achalasia was celebrated in 2014. [ 3 ]


During the procedure, the patient is put under  general anaesthesia . Five or six small incisions are made in the  abdominal wall  and laparoscopic instruments are inserted.  The myotomy is a lengthwise cut along the  esophagus , starting usually about 6 cm above the lower esophageal sphincter and extending down onto the stomach approximately 2-2.5 cm.  The oesophagus is made of several layers, and the myotomy only cuts through the outside muscle layers which are squeezing it shut, leaving the inner mucosal layer intact. This procedure can also be performed robotically.


There is a small risk of perforation during the myotomy.  A gastrografin swallow is performed after the surgery to check for leaks.  If the surgeon accidentally cuts through the innermost layer of the esophagus, the perforation may need to be closed with a stitch.


Food can easily pass downward after the myotomy has cut through the lower oesophageal sphincter, but stomach acids can also easily reflux upward. Therefore, this surgery is often combined with partial  fundoplication  to reduce the incidence of postoperative  acid reflux .  In Dor or anterior fundoplication, [ 4 ]  which is the most common method, part of the stomach (the  fundus ) is laid over the front of the oesophagus and stitched into place so that whenever the stomach contracts, it also closes off the oesophagus instead of squeezing stomach acids into it. In Toupet or posterior fundoplication, the fundus is passed around the back of the oesophagus instead.  Nissen or complete  fundoplication  (wrapping the fundus all the way around the oesophagus) is generally not considered advisable because  peristalsis  is absent in achalasia patients.


This is a somewhat challenging operation, and surgeons have reported improved outcomes after their first 50 patients.  An author search at  Google Scholar  can be used to find studies on a surgeon's past experience with achalasia patients.


After laparoscopic surgery, most patients can take clear liquids later the same day, start a  soft diet  within 2–3 days, and return to a normal diet after one month.  The typical hospital stay is 2–3 days, and many patients can return to work after two weeks.  If the surgery is done open instead of laparoscopically, patients may need to take a month off work.  Heavy lifting is typically restricted for six weeks or more.


The Heller myotomy is a long-term treatment, and many patients do not require any further treatment. However, some will eventually need  pneumatic dilation , repeat myotomy (usually performed as an open procedure the second time around), or  oesophagectomy .  It is important to monitor changes in the shape and function of the esophagus with an annual timed  barium swallow .  Regular  endoscopy  may also be useful to monitor changes in the tissue of the oesophagus, since reflux may damage the oesophagus over time, potentially causing the return of  dysphagia , or a  premalignant condition  known as  Barrett's esophagus .


Though this surgery does not correct the underlying cause and does not eliminate achalasia symptoms, the vast majority of patients find that the surgery greatly improves their ability to eat and drink.  It is considered the definitive treatment for achalasia.


Hemorrhoidal artery embolization  (HAE, or hemorrhoid artery embolization) is a non-surgical treatment of internal  hemorrhoids. [ 1 ]


The procedure involves blocking the abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or  microparticles  to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding. [ 2 ]  It is a  minimally invasive therapy  that can be performed as an outpatient procedure. [ 3 ]


HAE begins when a  catheter  is inserted into the femoral or radial artery through a small incision. The catheter is then carefully navigated through the arterial system with  x-ray  guidance until it reaches the branches of the  superior rectal artery  that supply blood to the hemorrhoidal plexus. [ 3 ]  Once in position,  microparticles  and/or microcoils are injected through the catheter to block these arteries, thereby reducing the blood supply to the hemorrhoids. This causes the hemorrhoidal tissue to shrink over time, alleviating symptoms such as pain, bleeding, and swelling. [ 1 ] [ 2 ] [ 4 ]  Post-procedure, patients are monitored for a brief period to ensure stability before being discharged with instructions for managing any minor discomfort or symptoms that may occur during the recovery period.


HAE offers several benefits as a minimally invasive treatment for symptomatic hemorrhoids. Firstly, HAE effectively reduces blood flow to the hemorrhoidal tissue, leading to significant shrinkage and resolution of symptoms such as pain, bleeding, and prolapse. [ 2 ] [ 4 ]  This approach has been shown to provide long-lasting relief comparable to surgical methods but with potentially lower complication rates and faster recovery times. [ 5 ]  Additionally, HAE is associated with minimal post-procedural pain and allows for quicker return to daily activities, making it an attractive option for patients seeking less invasive treatment options. [ 5 ]  Moreover, its safety profile and efficacy have been supported by clinical trials, demonstrating its potential as a preferred alternative for managing hemorrhoidal disease. [ 6 ] [ 7 ] [ 8 ]  HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%. [ 9 ]


The incidence of adverse events with HAE is very low. Rare arterial access site complications may occur. [ 2 ]   Although minor anal discomfort can occur in a minority of patients, there have been no reports of anorectal complications when embolization is performed primarily with microcoils [ 2 ]


Hernia repair  is a  surgical operation  for the correction of a  hernia —a bulging of  internal organs  or  tissues  through the  wall  that contains it. It can be of two different types:  herniorrhaphy ; or  hernioplasty . [ 1 ]  This operation may be performed to correct hernias of the  abdomen ,  groin ,  diaphragm ,  brain , or at  the site of a previous operation . Hernia repair is often performed as an  ambulatory procedure .


The first differentiating factor in hernia repair is whether the surgery is done open, or laparoscopically. Open hernia repair is when an incision is made in the skin directly over the hernia. Laparoscopic hernia repair is when minimally invasive cameras and equipment are used and the hernia is repaired with only small incisions adjacent to the hernia. These techniques are similar to the techniques used in laparoscopic gallbladder surgery. [ citation needed ]


An operation in which the hernia sac is removed without any repair of the  inguinal canal  is described as a herniotomy. When herniotomy is combined with a reinforced repair of the posterior inguinal canal wall with  autogenous  (patient's own tissue) or  heterogeneous  material such as  prolene  mesh, it is termed hernioplasty as opposed to herniorrhaphy, in which no autogenous or heterogeneous material is used for reinforcement. [ citation needed ]


The Stoppa procedure is a  tension -free type of hernia repair. It is performed by wrapping the lower part of the  parietal peritoneum  with  prosthetic  mesh and placing it at a  preperitoneal  level over Fruchaud's myopectineal  orifice . It was first described in 1975 by Rene Stoppa. [ 2 ]  This operation is also known as "giant prosthetic reinforcement of the  visceral   sac " (GPRVS). [ 3 ]


This technique has met particular success in the repair of bilateral hernias, large  scrotal hernias , and recurrent or rerecurrent hernias in which conventional repair is difficult and which carries a high  morbidity  and failure rate. [ 4 ]  The most recent reported recurrence rate (involving 230 patients with 420 hernias and a maximum of 8 years follow-up) was 0.71%. [ 5 ]  The totally extra-peritoneal repair (TEP) uses exactly the same principles as the Stoppa repair, except that it is performed  laparoscopically . [ 6 ]


Robotic-assisted hernia repair has gained popularity due to its precision, smaller incisions, and quicker recovery times. Using robotic systems, surgeons have greater flexibility and control during the procedure. Although its use is still more expensive and requires specialized equipment, early studies suggest that robotic hernia repair may offer improved outcomes in complex cases, such as large or recurrent hernias. [ 7 ]


A  Hill repair  is an anti- acid reflux  procedure. [ 1 ]   It is similar to the  Nissen fundoplication .  Though far less common owing to a greater degree of difficulty, studies indicate a similar rate of efficacy.  It is performed almost exclusively in the  Pacific Northwest . [ citation needed ]


The  Hofmeister–Finsterer operation  is a partial  gastrectomy , devised by  Franz von Hofmeister , based upon a procedure by  Eugen Pólya . It was later refined by  Hans Finsterer  and became known as the Hofmeister–Finsterer gastrectomy.
Here upper part of the cut end of the stomach is closed and remaining lower portion is anastomosed with jejunum.


In  medicine , the  ileal pouch–anal anastomosis  ( IPAA ), also known as  restorative proctocolectomy  ( RPC ),  ileal-anal reservoir  ( IAR ), an  ileo-anal pouch ,  ileal-anal pullthrough , or sometimes referred to as a  J-pouch ,  S-pouch ,  W-pouch , or a  pelvic pouch , is an  anastomosis  of a reservoir pouch made from  ileum  (small intestine) to the  anus , bypassing the former site of the  colon  in cases where the colon and rectum have been removed. The pouch retains and restores functionality of the anus, with stools passed under voluntary control of the person, preventing  fecal incontinence  and serving as an alternative to a total proctocolectomy with  ileostomy .


During a total proctocolectomy, a surgeon removes a person's diseased colon, rectum, and anus. [ citation needed ]   For the ileostomy, the end of the small intestine is brought to the surface of the body through an opening in the abdominal wall for waste to be removed.  People with ileostomies wear an external bag, also known as an  ostomy system  or stoma appliance, to collect waste which can be emptied and changed as needed.


With an optional ileo-anal pouch procedure, the pouch component is a surgically constructed internal intestinal reservoir; usually situated near where the  rectum  would normally be. It is formed by folding loops of small intestine (the  ileum ) back on themselves and stitching or stapling them together. The internal walls are then removed thus forming a reservoir often referred to as a 'pouch'. The reservoir is then stitched or stapled into anal area where the bottom of the rectum was.  The first pouch anal-anastomosis surgery in the world was performed by British surgeon  Sir Alan Parks  in 1976 at the London Hospital (called the  Royal London Hospital  since 1990).  After the first surgery, he continued to develop the procedure at  St Mark's Hospital  in London along with his colleague  John Nicholls . [ 1 ]


Pouch surgery is elective, meaning it is entirely optional, and should be done on the basis of choice by people who doctors deem suitable for a pouch after medical evaluations.  Pouch surgery is considered reconstructive with the benefit being for quality of life and not disease removal, similar in theory to a breast reconstruction after a mastectomy removes diseased breast tissue.  Before a pouch is created, a person's diseased colon and rectum are removed.  After disease removal, standard medical screening exams for pouch candidates include but are not limited to biopsies, radiology imaging, sphincter function tests, fertility consultations for people of childbearing age with the wish to get pregnant, and psychological support due to intensity of the pouch operations. [ 2 ]


A similar ileal pouch without the anal anastomosis is a  Kock pouch .  A Kock pouch is also called a 'continent ileostomy' because while a person has a pouch constructed inside their body, it is located near the abdominal wall and empties via a stoma from the ileum at the person's convenience. [ 3 ]   A Kock pouch does not restore the anal function.  The procedure was first premiered by Finnish surgeon  Nils Kock  in Sweden during 1969.  It was an evolution in bowel surgery because it created an ileum pouch for storage of waste inside the body eliminating the need for an external bag for waste collection.  An  ileostomy  without a Kock pouch functions constantly, meaning, a patient with ileostomy by itself is incontinent because waste is always moving down the bowel and thus the need for an external appliance bag.  Kock pouch surgery is also elective surgery that only provides a reconstructive benefit after disease removal.  It should be the patient's optional choice based on how a person wants to live their life.


Ileo-anal pouches are constructed for people who have had their  colon  and  rectum  surgically removed due to disease, injury, or infection. Several diseases and conditions may trigger the need for surgical removal. [ 4 ]


There is debate about whether patients with  Crohn's disease  and  indeterminate colitis  are suitable candidates for an ileo-anal pouch due to the risk of the disease occurring in the pouch. Crohn's disease can manifest in many different parts of the digestive tract, so the removal of the colon and creation of a pouch, while alleviating symptoms that occurred in the large intestine plus possibly the rectum, does not eliminate Crohn's disease. [ 6 ] [ 7 ]


Additional contradictions that may prevent a person from being able to undergo pouch surgery include but are not limited to weak sphincter muscles, advanced age (elderly) due to the higher risk of fecal incontinence, pelvic radiation therapy, and women with a history of obstetric complications. [ 8 ]


Ileum pouch surgery (Kock and IPAA) are  reconstructive procedures .  Reconstructive procedures do not cure disease.  Since they are not  curative , reconstructive surgeries are not medically necessary, meaning they are elective operations.  Several words can be used to describe an ' elective surgery ' including optional and patient's choice.  Pouch reconstruction should never be offered as the only option to a person because it is elective and should be a voluntary choice offered alongside other options that are safe for the person's individual circumstances. [ 9 ]


While both  ulcerative colitis  (UC) and  familial adenomatous polyposis  (FAP) patients and are sometimes controversially considered cured of problematic symptoms after pouch creation due to the removal of disease activity in the colon and rectum, there are still many complications that can arise. While life with a pouch is typically viewed by some people plus some medical professionals as a significant improvement compared to life with an ileostomy, patients living with a pouch may still face daily pains and discomforts including the inability to sleep through the night, a changed diet, severe or frequent gas pain, nutrient deficiencies, and the inability to digest certain foods.


With regards to  ulcerative colitis  (UC), the disease is a systemic  immune mediated inflammatory disease , also often referred to as an  autoimmune  condition. [ 10 ]   The main risk UC presents is typically inflammation that causes ulcers in the lining of the colon and rectum.  This common expression happens in the mucosal layer of the intestine that is only present in the colon and rectum (not the small intestine), which is why the disease was named 'ulcerative colitis'.  Therefore, ulcerative colitis is considered 'cured' of the problematic disease activity in the colon and rectum only, after both the large intestine and rectum are removed.  Reasons to remove this mucosal layer include severe discomfort that reduces quality of life, bowel perforation from inflammation, and development of tumors that are cancerous from long-term inflammation.


Even after a person has their colon and rectum removed, the circumstances that created ulcerative colitis still lives on inside that person's body because it is a systemic  immune mediated  condition.  These conditions occasionally manifest in other ways including additional illnesses considered related to ulcerative colitis like  primary sclerosing cholangitis  (PSC) in the liver, the eye condition  uveitis , and certain forms of  arthritis  throughout the body.


It is important to understand that pouch surgery does not cure a patient of ulcerative colitis, removal of the diseased mucosal layer in the colon and rectum cures the disease in the colon and rectum only, if the entire colon and full rectum are removed.  For example, if a rectal remnant remains, UC disease can be retained in the small remnant.  Active disease feels similar to ulcerative proctosis when the full natural rectum was in place.  It is also medically treated the same way ulcerative proctosis was before any surgery.  Even if the entire colon and rectum are removed to stop disease activity in this area, the underlying reasons for the expression of the disease in the large bowel and rectum's mucosal layer remain with the person. [ 11 ]


A pouch should never be offered as the only treatment option due to the fact it is  reconstructive  and not  curative .  People who need to have their colon and rectum removed are usually presented with several options including total proctocolectomy with end ileostomy ("Barbie" or "Ken" butt), colectomy with rectum left in place, pelvic pouch (ileo-anal pouch / IPAA), ileo-rectum anastomosis (IRA), or continent ileostomy such as a Kock pouch, for example, if someone has weak  sphincter  muscles or a diseased anus.  The end decision should always be the patient's choice, based on if their health permits the option to have a good outcome. [ 12 ] [ 13 ]


Pouch surgery comes with a number of well known complications that a person will not be able to imagine as possibilities themselves, therefore, as part of the education and  informed consent  process before pouch creation surgery is scheduled, risks, complications, and safe alternatives need to be communicated. [ 14 ] [ 15 ]   If a person has  indeterminate colitis , they should also be informed before a pouch is recommended and created that their pathology is unknown due to the even higher risk indeterminate folks face. [ 16 ] [ 17 ]


The most common complication of pouch surgery is an umbrella term called pouchitis that encompasses many causes of inflammation of the pouch.  The word 'pouchitis' simply means 'pouch inflammation' similar to 'tonsillitis' meaning 'tonsil inflammation' or 'sinusitis' meaning 'sinus inflammation'.  While ulcerative colitis pouch patients may experience a dysbiosis sparked type of inflammation more than people who get a pouch because of cancer or FAP, pouchitis can be caused by a number of factors in any pouch. [ 18 ]   Pouchitis is grouped into four main categories of origin: inflammatory, mechanical, surgical, or functional.  Pouchitis, meaning pouch inflammation from various root causes, can be a driver of pouch dysfunction for some. [ 19 ]


The surgical procedure for forming an ileal pouch-anal anastomosis (IPAA) was pioneered by  Sir Alan Parks  at the London Hospital, today called the  Royal London Hospital , in 1976.


Parks' pouch surgery was originally envisioned as a quality of life enhancing procedure for people who needed to have their colon and rectum removed.  People who opted to have the procedure would be able to avoid an ileostomy by restoring intestinal continuity with elective, or optional, ileo-anal pouch surgery.  Shortly after performing the world's first few pouch procedures in 1976, Sir Alan along with  John Nicholls  joined  St Mark's Hospital  also in London where they continued to develop the intestinal pouch procedure.  The pair first published details of the procedure in the  British Medical Journal  in 1978 with the article "Proctocolectomy without ileostomy for ulcerative colitis". [ 20 ]


Sir Alan Parks' ileo pouch-anal anastomosis (IPAA), was a surgical advancement from the ileoanal anastomosis procedure developed in the 1940s.  With an ileum-anal anastomosis, the entire colon and rectum were removed.  Next a surgical join (anastomosis) was used to connect the end of the small intestine (ileum) to the anus.  It was described by the German surgeon Nissen in 1934 and American surgeons Ravitch and Sabiston in 1947.  The ileum-anal anastomisis [ check spelling ]  was reported to have a high of frequency of liquid movements making it uncomfortable for many people. [ 21 ]   It was also a surgical advancement from the  Kock pouch  first performed in Sweden by Finnish surgeon  Nils Kock  in 1969 because Parks' ileum pouch-anal anastomosis (IPAA), unlike Kock's 'continent ileostomy' allowed for restoration of anal evacuation.


The original Sir Alan S-pouches had a bit of intestine at the bottom of the design that often made them difficult to evacuate.  Some patients later underwent advancement surgery to remove the extra tip of small intestine and lower the pouch directly onto the anus to remedy evacuation difficulties. [ 22 ]


In 1980, surgeons in Japan published the first study on the J-shaped pouch. J. Utunomiya is created with its creation. [ 23 ]   The J-shaped pouch design eliminated the 'conduit' or bit of intestine at the bottom of Sir Alan Parks' S-pouch formation making it easier for people to empty a J-pouch.  As intestinal pouch surgery became more common, the J-pouch eventually became the dominant shape.  J-pouches are easier for surgeons to construct than the hand sewn S or W formations because the Js are from two loops of ileum plus with the invention of the stapler, Js could be stapled, instead of hand-sewn.  J-pouches are considered faster and easier to make over Ss and Ws. [ 24 ] [ 25 ]


The same year as Sir Alan Parks' unexpected death in 1982, his St Mark's Hospital colleague,  John Nicholls  premiered the W-pouch which was an augmentation of the J-pouch made to expand the pouch's capacity and reduce the person's frequency of bowel movements. [ 26 ]   Nicholls' W-pouch is explained as two J-pouches placed together to make the higher capacity W-pouch.


The W-pouch was entirely hand-sewn and required a very experienced and highly skilled surgeon plus more time in the operating room. [ 27 ] [ 28 ]   A J-pouch was not as technical and therefore, more surgeons could perform the procedure.


In the United States, Australian born colorectal surgeon  Victor Warren Fazio  was a driving force behind the procedure's adaptation into American colorectal surgery offerings.  He established the  Cleveland Clinic 's prestigious pouch practice in 1983 when the clinic performed its first pouch surgery.  In 2002 the Cleveland Clinic opened the world's first pouch center with its "Ileal Pouch Center".


About the same time as the Cleveland Clinic began offering the restorative proctocolectomy procedure (RPC), surgeons at the  Mayo Clinic  in Minnesota also started offering it to suitable patients including Roger R. Dozois who published several early studies on the pouch operation in the United States. [ 29 ] [ 30 ]


By the early 1980s, the ileal pouch procedure had become part of specialist colorectal surgical practices not just in the United Kingdom and United States but worldwide.  Following the unexpected death of  Sir Alan Parks  in 1982, his colleague  John Nicholls  along with the pouch surgery team at  St Marks Hospital  collaborated with a number of leading hospitals globally to share pouch surgery knowledge Zane Cohen is credited with being a leader in Canada's development of pouch surgery. [ 31 ] [ 32 ]  Rolland Parc was a force behind its early evolution in France. [ 33 ]  Gilberto Poggioli is credited with being at the forefront of establishing the pouch a surgical offering in Italy. [ 34 ] [ 35 ] [ 36 ]


It is generally considered best practice to create and manage ileum pouches at a facility that has specialized and experienced clinicians specifically for intestinal pouch care.  Individual doctors and facilities can communicate their level of pouch experience to potential pouchees, people already living with a pouch interested in continued care, or loved ones who care for a person eligible for pouch construction surgery, or for loved ones already with a pouch.  Colorectal ,  coloproctology , and/or  proctology surgeons  should be able to communicate their pouch surgery success and failure rates.  Gastroenterologists  and surgeons should also be able to refer people to pouch specialists for a second opinion on an existing recommendation or for continued pouch care.


Intestinal pouches are considered optional reconstructive procedures to be done by the patient's choice since pouch surgery itself does not cure disease.  Pouch surgery can only take place after disease is removed.  Many national gastroenterology associations including the  British Society of Gastroenterology  (BSG) [ 37 ]  and the European Crohn's and Colitis Organisation (ECCO) [ 38 ]  recommend that pouches should ideally be created at facilities that have specialized pouch centers when possible due to the high level of technical skill required for multidisciplinary management of a pouch.  Numerous studies also show that there is a direct relation between the success of a pouch and the experience a surgeon has with previous pouch creations. [ 39 ] [ 40 ]


In addition to specialized doctors for colorectal surgery, gastroenterology, pathology, radiology, gynecology and urology, fertility, psychology, nutrition, and rehabilitation including physiotherapy, facilities with pouch centers often also have a specialized pouch nurse or pouch nursing team.  The pouch nurse is usually an extension of the IBD nursing team or stoma nurse team.  However, pouch nurses are also trained for pouches created from injury, infection, FAP, cancer and other reasons.  Pouch nurses provide healthcare, advice, and support specific to the concerns of pouch patients before and after surgery. [ 41 ] [ 42 ]


In this elective and reconstructive  surgical procedure , a pouch, or intestinal reservoir, made from  ileum  (small intestine) is attached to the  anus  after the  colon  (large intestine) and  rectum  have been removed.


The entire procedure can be performed in one operation, but is usually split into two or three procedures based on the person's overall health at the time of surgery.


If a colectomy is planned, and not done as an emergency due to severe injury or illness and the person is in good health, some surgeons will recommend a two-step procedure.  When done as a two-step, the first operation (step one) involves a  proctocolectomy  (removal of the large intestine and rectum), and fashioning of the pouch. The patient is given a temporary defunctioning  ileostomy  (also known as a "loop ileostomy"). After a healing period determined by the surgeon based on the individual patient, the second step is performed, in which the ileostomy is reversed. This step is referred to as ileostomy reversal or takedown.  The reason for the temporary ileostomy is to allow the newly constructed pouch to fully heal without waste passing through it, thus avoiding leaks that can lead to infection. [ 44 ]


When a colectomy is performed as an emergency (which can arise from  toxic megacolon  and other complications including infection), or when the patient is extremely ill, the colectomy and pouch construction are performed in separate stages, resulting in a three-part surgery. [ 45 ]


Outside of serious illness, some surgeons also prefer to perform a  subtotal colectomy  (removing all the colon except the  rectum ) first, since removal of the rectum can lead to complications with the anal  sphincters . After the subtotal colectomy, the second operation consists of pouch creation with installation of a double or loop ileostomy to protect the pouch while it heals.  Waste continues to exit through an opening in the abdominal wall.  Then usually three to six months later when surgeons feel the pouch has healed, the loop stoma is reversed and the pouch becomes fully operational restoring intestinal continuity. [ 46 ]


Just as debate continues on which formation of pouch functions best, there is also an ongoing discussion about the pouch's type of anal anastomosis - or method used to attach the pouch to the anal canal.  Both methods have risks and benefits.


The pouch can also be formed as part of a three step procedure for people of childbearing age who have not completed their family planning.  When there is a wish for pregnancy, the process can be paused after subtotal colectomy until family planning is complete if doctors feel remaining disease in the rectum, if any, can be safely managed until removal during pouch creation.


A fall in female fertility was reported in a Danish study by Olsen et al. in 1999 showing a drop after pouch surgery to less than 50% of the normal population. [ 51 ]   There are well researched risks to fertility for both men and women.  Highly specialized pouch centers globally typically offer fertility counselling as part of their patient selection and informed consent process. [ 52 ]


A rare risk to male fertility is nerve damage that impairs or prevents ejaculation.  Risks to fertility for women include removal of the rectum reducing fertility by at least 50%, a dysfunctional pouch sparking a hostile environment in the pelvis preventing embryo implementation in the uterus and scar tissue formation over fallopian tubes blocking ovulation, although, scar tissue formation appears to be less likely with laparoscopic than open surgery. [ 53 ]


Women who choose the option to undergo pouch surgery before childbirth, should also undergo a fertility evaluation before surgery that includes an egg preservation consultation especially if she is over the age of 35 years.  With the pouch surgery potentially reducing fertility, the  in vitro  fertilization  (IVF) treatment a younger woman experiencing pouch related infertility may need to rely on to conceive, may not legally be available to the older woman if she later learns past the cutoff-age that her situation requires IVF to get pregnant.  Most women are not aware of age limits to IVF treatment using their own eggs - especially if they are living, studying, or working away from their hometown or abroad at the time of their operations. [ 54 ] [ 55 ] [ 56 ] [ 57 ]


The general public's lack of widespread knowledge about IVF regulations also applies to child adoption laws.  Most men and women are not aware that some countries place age bans on adopting newborns.  For example, in Germany adoption of an infant is prohibited if a parent is over the age of 40 years.  These adoption age bans combined with the risk of pouch related fertility complications, plus potential IVF age cut-off limits then increases the need for a person to plan to preserve fertility before pouch surgery commences in order to improve chances of later completing a wish for a family. [ 58 ] [ 59 ] [ 60 ]


While most people who undergo elective reconstructive pouch surgery have either no issues or occasional minor discomfort, some pouches experience more serious complications that need medical management with a variety of therapies including medication and/or additional surgery.
 [ 61 ] [ 62 ] [ 63 ]


Pouchitis  is a general term that refers to a wide spectrum of diseases and conditions that cause inflammation of the pouch. It is a common complication after IPAA/RPC. People report many symptoms including abdominal pain or cramps, increased bowel frequency, urgency of movements, strong evacuation urges, daytime incontinence, nocturnal seepage, and/or rectal bleeding. Studies show pouchitis occurs more often in people who got their pouch because of ulcerative colitis rather than familial adenomatous polyposis (FAP) which suggests that the pathogenic (microbial) background of UC may contribute to the development of pouchitis in some pouches. [ 18 ]


Diagnosis of pouchitis:
Pouchitis is diagnosed based on the presence of symptoms together with endoscopic and histological evidence of pouch inflammation. For example, biopsies may be taken during a pouchoscopy (a camera exam like a colonoscopy but for the pouch) to rule out infection from  Clostridioides difficile  infection  (C-diff) or  Cytomegalovirus  (CMV). Treatment of infections usually begins with antibiotics and may also include multi-strain probiotics.


After exams and tests, pouchitis is divided into two categories based on findings: idiopathic or secondary. In idiopathic pouchitis, the cause of inflammation is still unclear. With secondary pouchitis, there is an association with a specific causative or pathogenetic factor. Secondary pouchitis can be classified into subgroups. It is possible to have one or more causes of pouch inflammation at the same time. [ 64 ] [ 65 ]


Antibiotic therapy for pouchitis:
Standard treatment of pouchitis when first reported (acute pouchitis) without any other obvious cause identified such as infection or anal join leak (fistula) is oral antibiotics for two weeks, typically ciprofloxacin 500 mg every 12 hours.  Alternatives to ciprofloxacin for initial therapy include metronidazole 500 mg (twice daily) or tinidazole 500 mg (twice daily). [ 65 ]


For pouches with acute idiopathic pouchitis, response to antibiotic therapy is typically examined clinically by asking the patient if they have experienced an improvement with their symptoms plus looking endoscopically using a pouchoscopy after completing antibiotic therapy. While endoscopic mucosal healing may lag behind symptomatic improvement, mucosal healing is a treatment target for patients with pouchitis. [ 66 ]


Cuffitis:
Cuffitis is inflammation of the retained rectal 'cuff' usually in a stapled pouch-anal anastomosis or the spot where the intestinal pouch was attached to the anus to restore anal evacuation.  Symptoms are typically similar to ulcerative proctosis for ulcerative colitis pouches including burning in the anal canal, a change in bowel movements, and sometimes rectal bleeding. [ 67 ]


Cuffitis diagnosis:
Most expert pouch centers plus national gastroenterology society guidelines worldwide recommend a cuff be no longer than 2 cm with the aim to staple the pouch at the level of the anorectal junction, [ 48 ] [ 68 ]  leaving about 1 cm of rectum or mucus layer behind for the staple to attach the pouch to the anus. [ 69 ] [ 67 ] [ 70 ]   This retained 1 to 2 cm of rectum can therefore, sometimes retain ulcerative colitis in UC pouches.  In contrast, hand sewn pouch-anal anastomosis' typically do not retain any mucus layer but sometimes a cuff is also used and it might cause discomfort for some hand sewn pouches.  Cuffitis is clinically diagnosed by symptoms plus endoscopically (pouchoscopy).


Treatment of cuffitis:
First-line therapy for acute cuffitis due to retained rectal mucosal layer is usually similar to the treatment for ulcerative proctosis that ulcerative colitis patients would have likely used before pouch surgery.  Mesalazine  suppositories or enemas are sometimes prescribed first (brand names include Asacol, Canasa, and Pentasa).  If those do not provide enough relief then treatment might be escalated to corticosteroid suppositories or enemas such as Budesonide.  Biological therapy may be prescribed if all other medical therapies fail to manage cuffitis and the person either is not suitable for or does not want to undergo a revision operation to remove the retained cuff and hand sew the pouch on the level of the dentate line (spot where anal skin changes to rectal mucus layer). [ 67 ] [ 71 ] [ 72 ] [ 73 ]


Crohn's disease of the pouch:
Some people undergoing IPAA/RPC may be later diagnosed with underlying Crohn's disease because the disease likely had not fully expressed itself at the time of surgery.  Crohn's disease of the pouch is associated with high failure rates.  Pouches may experience fistula leaks that cause pelvic sepsis and other complications. [ 74 ]


Treatment of Crohn's disease of the pouch:
If a person later diagnosed with Crohn's disease of the pouch wishes to keep their pouch operational, in some circumstances medical management might be possible.  Typically this is done with the prescription of biologics.  It may take more than one drug prescription to find a suitable biologic that encourages the desired anti-inflammatory response.


Celiac disease:
 Celiac disease  is an autoimmune condition that causes inflammation in the small intestine after gluten is eaten.  It can cause pouchitis symptoms and discomfort.  Some pouches that are celiac initially get misdiagnosed with Crohn's of the pouch.  Celiac disease is typically diagnosed by biopsy of the pouch. [ 75 ] [ 76 ]


Treatment of Celiac disease:
Typically, the first therapy approach to manage Celiac disease in person with an ileum pouch is dietary modification to reduce and/or eliminate gluten.


Other inflammatory conditions including IgG and IgG4:
Immunoglobulin related diseases can also cause problems for a pouch.  The two most common that are biopsied for are IgG and IgG4.  IgG molecules can initiate inflammatory reactions, both good and bad.  When the autoimmune reaction is inappropriate, a pouch might have problems with IgG.
IgG4 is a subclass of IgG.  IgG4 disease is a chronic immune-mediated fibroinflammatory disorder that can manifest with painless enlargement of organs or tumor-like masses. [ 77 ] [ 78 ] [ 79 ] [ 80 ]


Biopsies of the pouch should confirm if an infection is the root cause of pouch inflammation. If an infection from  Clostridioides difficile  (C-diff) or  Cytomegalovirus  (CMV) is found, initial therapy is usually antibiotics. [ 81 ] [ 82 ]  Certain infections such as a  Clostridioides difficile  (C-diff) might also be treated with probiotics just as a C-diff infection in a person who still has their colon would be treated. Probiotics that are prescribed for pouchitis (specifically pouchitis diagnosed as being caused by dysbiosis) are often also prescribed for C-diff. [ 83 ]


The pouch surgery itself can be the reason for some complications. [ 63 ]


Anastomotic leaks:
Anastomotic leaks occur on the lines where the pouch was sutured or stapled.  They usually occur close to the time of surgery but can appear months or years later.  When an anastomotic leak occurs, it can form a fistula or tract of fluid.


Fistulas:
Most fistulas will connect from an anastomotic leak to another area of the body such as a pouch-vagina fistula, perianal fistula, or presacral fistula with pelvic collection.  In some circumstances fistulas develop years after pouch creation due to the development of Crohn's disease.  Fistula's caused by Crohn's disease are often treated with biological therapy while a fistula from an anastomotic leak requires different therapies as biologics rarely help close a leak in a surgical suture or staple line of the pouch.  Different potential treatment options for an anastomotic fistula depend on the leak's location and include but are not limited to ENDO-Vac sponge, needle-knife therapy, draining seton, or cutting seton. [ 84 ] [ 85 ] [ 86 ] [ 87 ] [ 88 ]


Pelvic collection/sinus:
A pelvic collection or collection of fluid anywhere from a leak is called a sinus.  When an anastomotic leak is not treated promptly or does not heal it can cause pelvic sepsis.


Pelvic sepsis:
Pelvic sepsis also called peri pouch sepsis is a main cause of pouch failure and it creates conditions that make major revisionary surgery difficult.


Large or small pouch:
Standard guidelines for J-pouch construction is to use two loops of 15–20 cm ileum.  If the pouch is too small, the pouch will have a small volume.  This will increase the frequency of moments and could also be a cause of pouch failure. [ 63 ]


Pouch prolapse:
A pouch can either tilt or twist when stapled onto the anus causing prolapse. Pouch prolapse is also sometimes referred to as a floppy pouch. [ 90 ]   Pouch prolapse from a pouch being tilted or twisted can also cause pouch fistulas to develop, especially pouch-vagina fistulas.  Prolapse can also happen after the pouch is already in use.  With symptoms for pouch prolapse, a person typically has evacuation difficulties, seepage, pain, nausea, abdominal pain, or overt external prolapse of tissue. [ 91 ]


Strictures or stenosis
Narrowing of the anal canal under the pouch can cause evacuation difficulties.  Anal stricture can be a cause of pouch failure if not managed properly.  Anal stricture is a common complication of pouch surgery.  It is treated with dilatation or stretching under anesthesia.  Some people are also prescribed home dilatation routine using a  Hegar dilator  to manage chronic stenosis that keeps returning after dilatation. [ 92 ]


U-bend:
This happens when the surgeon fires the linear stapler and it malfunctions.  Usually the flaw is not noticed until after surgery is complete during first pouchoscopy.  The pouch is called a "U" bend because instead of stapling the two full sections of ileum together into a "J", the stapler does not create the 'J' but instead retains the shape of a 'U'.


Pelvic floor dysfunction and evacuation difficulties
Pelvic floor dysfunction is a common complication of pelvic surgery.  The Mayo Clinic believes it is an under reported complication of IPAA/RPC surgery with up to 75% of pouch patients experiencing non-relaxing pelvic floor dysfunction.  Biofeedback therapy is the main treatment for pelvic floor dysfunction. [ 93 ]


Cancer is a rare event after a pouch is created.  However, retained rectal mucosa can develop dysplasia over time especially if cuffitis is an ongoing complication.  Cancer can also develop in the pouch when there has been long-term pouchitis (inflammation of the pouch for any reason).  People who got their pouch as a result of bowel cancer may also experience cancer of the pouch. [ 94 ]


Removal of the entire large intestine (colon) and amounts of the terminal ileum at the end of the small intestine leads to fluid and nutritional absorption issues for all pouches.  The colon absorbs water, salts, and some key nutrients.  Dehydration can occur if a person does not get enough fluids.


The importance of ileum is that it absorbs key vitamins and minerals including  B12 ,  potassium , and  magnesium . In medical terms, low potassium is called  hypokalemia .  When a pouch is constructed small amounts of ileum are lost to the stomas and any stoma revisions.  The pouch itself is also made from ileum.  If a pouch is defunctioned (also explained as disconnected and/or pouch failure) the person also loses this extra amount of ileum when the pouch is disconnected from the digestive tract.


People with a pouch are at a further health risk if they experience excessive potassium loss due to things like vomiting, diarrhea, and prescription medications that increase urination. This is because potassium is a key electrolyte that helps regulate the heart and if levels become too low, a person can quickly become life-threateningly ill.  When levels are dangerously low, medical intervention with supplementation either orally or intravenously becomes necessary. [ 96 ]


Intestinal obstruction after ileal pouch-anal anastomosis (IPAA) surgery can occur due to various reasons such as adhesions (scar tissue ), strictures (narrowing at the anastomosis site), and Pouchitis (inflammation of the ileal pouch). [ 97 ]  Perforation at the site of attachment of the ileum to the rectum, or near the J-pouch, is a serious complication. [ 98 ] [ 99 ]  It can occur due to several reasons. But sometimes when pouchitis is not treated well, it gradually weakens the intestinal wall, which can eventually perforate.


When a pouch fails, suitable patients can choose to undergo surgery to repair the pouch or completely redo a pouch's anal-anastomosis or redo the entire pouch (if enough terminal ileum remains to produce a second pouch). [ 100 ] [ 101 ]   The cause of the problem that triggered a person's need for pouch salvage surgery will determine which method an experienced revision surgeon recommends as the surgical approach most likely to produce the best result possible.  Revisional surgeries are considered highly specialized. [ 102 ]   They require a skilled surgeon with complex revisional experience for the best chance at a good result.  Many expert pouch surgeons advocate for early referrals to specialists for best outcomes. [ 103 ]


Sometimes the root cause of pouch dysfunction can be managed with more conservative methods such as using an ENDO-Vac sponge for an anastomotic defect that leaks, needle knife therapy for fistulas and sinuses, or cutting seton for a low lying peri-anal fistula that does not impact the pouch's anal anastomosis (and many not even be related to the pouch itself).  When a more conservative method will not work or an attempt fails, bigger surgicial salvage procedures are then recommended, if the operation will have a chance to succeed and restore quality of life. [ 104 ] [ 105 ]


If a pouch has a troubled anal-anastomosis that leaks and causes sepsis or if a person retained more than the recommended amount of rectum (a rectal cuff of no more than 2 cm follows global colorectal surgery recommendations for an ulcerative colitis person), then an experience surgeon may be able to 'redo' the anal anastomosis by removing excess rectum.  Similarly, if a standard cuff of 1–2 cm was used, a revision surgeon still might be able to remove that and lower the pouch onto the anus.  In this scenario, the surgeon typically tries to save and reuse the existing pouch, but this is not always possible if the pouch is also damaged from complications or has technical flaws.  It might not be possible for an experienced salvage surgeon to redo an anal-anastomosis that has already been hand sewn or has a complication like a fistula or sepsis damage too close to the anus because this presents a surgical situation that is high risk to not heal properly and cause more complications. [ 106 ] [ 104 ] [ 107 ] [ 108 ] [ 109 ] [ 105 ]


If a person's pouch body is troubled, then an experienced pouch surgeon may be able to make a second pouch if the person's previous surgeries retained enough ileum to still safely create a second pouch.  Experienced revision surgeons will not create a second pouch if it risks putting the person into nutritional difficulties (including  short bowel syndrome ) because too much small bowel would be lost. [ 106 ] [ 104 ] [ 107 ] [ 108 ] [ 109 ] [ 105 ]


Occasionally, an experienced revision surgeon may need to alter the shape of the original pouch they are attempting to rescue.  For example, when there is not enough ileum to create a second pouch or if the person's anatomy (mesentery and/or vascular supply) does not allow for the pouch to reach to the anus.  This means the shape of a J-pouch may be transformed into an S, W, or even an H to repurpose functional ileum from the primary, or first pouch surgery, when retaining the original shape would not be successful but altering it could rescue the pouch situation. [ 110 ] [ 111 ] [ 112 ]


People can also choose to convert their failed ileo pouch-anal anastomosis (IPAA) to a continent ileostomy such as a  Kock pouch  in some circumstances. [ 113 ]


If a repair or redo can not be undertaken because of factors like severe disease, or a repeat surgery fails, or a patient wishes to have their pouch removed with undergoing additional surgery, a pouch excision operation can be performed to remove the pouch.  Removal of a pouch is a big operation that comes with complication risks. [ 114 ]


Ileo pouch-anal anastomosis surgery (IPAA) also called Reconstructive Proctocolectomy (RPC) was originally designed and premiered to improve quality of life for people who needed to have their colon and rectum removed because it avoided the need for stool collection in an external bag and restored the anal evacuation route.


The surgical evolution of the anal pouch also empowered people who were forced to lose their colon and rectum because of disease with choice: they could decide to live their life with an ileostomy or undergo reconstructive surgery to restore anal evacuation.


Ileo pouch-anal anastomosis (IPAA) surgery is generally viewed as providing benefits over living with an ileostomy from a total proctocolectomy.  However, not all people may consider extra surgery as a 'benefit' and therefore, some people opt to forgo the pouch option and remain living with an ileostomy after disease removal.  Pouches are the individual's choice based on how a person wants to live their life.


After the colon is removed a person does not have the ability to form solid stool.  Because waste will always be liquid, people experience several movements per day when their pouch's capacity is full.  The aim of pouch surgery is 4-8 movements per day, although, some people experience many more.  The number of movements per day may seem similar to when someone was in an  ulcerative colitis  (UC) flare, for people who got their pouch as a result of UC.  People with a small volume pouch will likely experience more movements. [ 115 ]


Additionally, liquid stool directly from the ileum no longer benefits from the colon removing digestive enzymes before a bowel movement.  This means liquid stool produced by the ileum can be aggressive on the skin around the anus.  Discomfort, including experiencing itching and/or burning around the anus' opening, can be treated with creams, by using a squirt water bottle or hand bidet after each movement to wash away enzymes, or by placing a piece of gauze between buttocks to prevent seepage from irritating the skin around the anus. [ 116 ]


The experience of learning how to use a newly functional anal pouch can be distressing for some.  Sharp pains, explosive moments, and anal seepage are common initial sensations.  Specialized pouch centers often have a pouch nurse that educates a person for how to safely empty the pouch without causing avoidable complications like incisional hernias after reversal or takedown surgery. [ 117 ]


The process of adjusting to life with an anal pouch can take many months.  Mayo Clinic research estimates that up to 75% of people with a pouch might experience some level of pelvic floor dysfunction after pouch surgery. [ 118 ]  For pouches that are difficult to evacuate or experience anal seepage, biofeedback therapy can be prescribed. [ 119 ]


Water and salts are typically reabsorbed into the body by the colon or  large intestine .  However, people with an ileum pouch have lost their entire colon and at least small amounts of  ileum .  Experiences like having sudden  diarrhea ,  vomiting  from sickness,  sweating  in hot weather, sweating from  physical exercise , or from not drinking enough  fluids  can all cause dehydration.  Having an episode of pouchitis, or pouch inflammation, can also cause dehydration for some if the episode causes an increase in bowel movements.


This experiences mean that people with pouches, like people with ileostomies, will require drinking more fluids and eating more salt to not become dehydrated.  Dehydration  can cause feelings of  dizziness ,  physical weakness , and/or  fatigue . People may also notice that urine has changed from light yellow and become darker and more concentrated. [ 120 ]


It is important that people with pouches maintain healthy  fluid  and  salt levels  because chronic dehydration increases the risk for  kidney stones  and even  kidney failure .  If a person becomes severely dehydrated, hospital admission for intravenous administration of fluids to restore hydration safely may be required. [ 116 ] [ 121 ]


Many people with a pouch eat their normal diet after surgery while others have to alter their diet due to discomfort when digesting certain foods.  Others experience more watery output after eating specific foods like processed sugary snacks which may require some people with pouches to use dietary or medical interventions like fiber products or doctor prescribed tablets to control watery stool and prevent dehydration. [ 122 ]


People with a pouch can follow any diet they choose while monitoring their overall nutritional status due to the loss of bowel causing absorption issues.  People diagnosed with vitamin or mineral deficiencies may be prescribed injections or tablets.  Others may be referred to a nutritionist to design meals that provide additional amounts of needed vitamins and minerals. Studies show that some foods may also contribute to pouch inflammation. [ 123 ]


Having an intestinal pouch is considered a rare condition.  Some national organizations and specialist charities usually associated with inflammatory bowel disease (IBD) or ostomies provide some information to people considering or who have chosen to undergo elective pouch surgery. Some of the larger national organizations globally include:


Ileostomy  is a  stoma  (surgical opening) constructed by bringing the end or loop of  small intestine  (the  ileum ) out onto the surface of the skin, or the surgical procedure which creates this opening. [ 1 ]   Intestinal waste passes out of the ileostomy and is collected in an external  ostomy system  which is placed next to the opening.  Ileostomies are usually sited above the  groin  on the right hand side of the  abdomen .


Ileostomies are necessary where injury or a surgical response to disease has meant the  large intestine  cannot safely process waste, typically because the  colon  and  rectum  have been partially or wholly removed.


Diseases of the large intestine which may require surgical removal include  Crohn's disease ,  ulcerative colitis ,  familial adenomatous polyposis , and total colonic  Hirschsprung's disease . [ 2 ]   An ileostomy may also be necessary in the treatment of  colorectal cancer  or  ovarian cancer .  One example is a situation where the cancer  tumor  is causing a blockage (obstruction). [ 3 ]   In such a case, the ileostomy may be temporary, as the common surgical procedure for colorectal cancer is to reconnect the remaining sections of colon or rectum following removal of the tumor provided that enough of the rectum remains intact to preserve  internal / external anal sphincter  function.


In an  end ileostomy , the end of the ileum is everted (turned inside out) to create a spout and the edges are sutured under the skin to anchor the ileum in place.  Permanent ileostomies are usually done this way.  An end ileostomy may be temporary, notably if some of the large intestine was removed and the bowel or overall health is not considered amenable to tolerating further surgery, such as an  anastomosis  to rejoin the small and large intestines.


In a  temporary  or  loop ileostomy , a loop of the ileum is surgically brought through the skin creating a stoma, but keeping the lower portion of the ileum for future reattachment in cases where the entire colon and rectum are not removed but need time to heal.  Temporary ileostomies are also often made as the first stage in surgical construction of an  ileo-anal pouch , so  fecal  material does not enter the newly made pouch until it heals and has been tested for leaks—usually requiring a period of eight to ten weeks. When healing is complete the temporary ileostomy is then "taken down" (or reversed) by surgically repairing the loop of intestine which made the temporary stoma and closing the skin incision. [ 4 ]


People with ileostomies must use an  ostomy pouch  to collect intestinal waste.  People with ileostomies typically use an open-ended (referred to as a "drainable") one- or two-piece pouch that is secured at the lower end with a leakproof clip, or velcro fastener.  The alternative is the closed-end pouch that must be thrown away when full.  Ordinarily, the pouch must be emptied five to eight times a day. [ 5 ] [ 6 ]  If the bag stays empty for more than four to six hours, individuals should contact their healthcare provider, as this may indicate intestinal blockage. [ 6 ]  The pouch and flange (both one and two piece pouches) are usually changed every 2–5 days. [ 7 ]


Ostomy pouches fit close to the body and are usually not visible under regular clothing unless the pouch becomes too full.  It is necessary to measure the stoma regularly as it changes shape after the initial surgery. The stomal- or colorectal-nurse does this initially for a patient and advises them on the exact size required for the pouch's opening. Changes in size and shape can indicate a problem and may signal a need to call a healthcare provider. [ 7 ]


Some people find they must make adjustments to their diet after having an ileostomy. It is important for individuals to consult with their healthcare providers. [ 6 ]   Tough or high- fiber  foods (for example: potato skins, tomato skins, and raw vegetables) are hard to  digest  in the small intestine and may cause blockages or discomfort when passing through the stoma.  Chewing food thoroughly can reduce such problems. [ 6 ]   Some people find that certain foods cause annoying gas or  diarrhea . [ 8 ]   Many foods can change the color of the intestinal output, causing alarm; beetroot, for instance, produces a red output that may appear to be blood. [ 8 ]   Nevertheless, people who have an ileostomy as treatment for  inflammatory bowel disease  typically find they can enjoy a more "normal" diet than they could before surgery.  Correct dietary advice is essential in combination with the patient's gastroenterologist and hospital-approved dietician.  Supplementary foods may be prescribed and liquid intake and output monitored to correct and control output. If the output contains blood, an ileostomate (patient) is advised to visit an emergency department. [ 9 ]


After having ileostomies, people may continue to take baths and showers and have an active lifestyle. [ 6 ] [ 10 ]  These and other topics are important to discuss with healthcare providers. [ 11 ]


Complications can include  kidney stones ,  gallstones , and  post-surgical adhesions . [ 12 ]


In some patients with Crohn's disease, a procedure called an  ileoanal anastomosis  is done if the disease affects the entire colon and rectum, but leaves the anus unaffected. In this procedure, the entire large intestine and rectum is surgically removed, and the ileum is then stitched to the anus to allow fecal matter to go through the ileum just as it did when the patient had a large intestine. This procedure requires a temporary loop ileostomy to allow the anastomosis to heal. With lifestyle adjustments, those who have had this procedure for their Crohn's disease can resume normal bowel movements without artificial appliances. However, there is always the possibility of disease relapse, as Crohn's can affect mouth to anus. [ 13 ]


Since the late 1970s, an increasingly popular alternative to an ileostomy has been the  Barnett continent intestinal reservoir  (or BCIR).  The formation of this pouch (made possible through a procedure first pioneered by  Nils Kock  in 1969), involves the creation of an internal reservoir which is formed using the  ileum  and connecting it through the abdominal wall in a very similar fashion to a standard "Brooke" ileostomy. [ 14 ]   The BCIR procedure should not be confused with a  J-pouch , which is also an ileal reservoir, but is connected directly to the  anus —after removal of the  colon  and  rectum —avoiding the need for subsequent use of external appliances. [ 13 ]  Because continent ileostomies can cause problems and may need redoing, they are not often done. [ 1 ]  However, continent ileostomies can be considered depending on surgeon experience, patient characteristics, and other factors. [ 15 ]


The Barnett continent intestinal reservoir (BCIR) is a type of an appliance-free intestinal  ostomy .  The BCIR was a modified  Kock pouch  procedure pioneered by William O. Barnett.  It is a surgically created pouch, or reservoir, on the inside of the  abdomen , made from the last part of the  small intestine  (the  ileum ), [ 16 ]  and is used for the storage of intestinal  waste .  The pouch is internal, so the BCIR does not require wearing an appliance or  ostomy bag .


The pouch works by storing the liquid waste, which is drained several times a day using a small silicone tube called a  catheter .  The catheter is inserted through the surgically created opening on the abdomen into the pouch called a  stoma .  The capacity of the internal pouch increases steadily after surgery: from 50 cm 3 , when first constructed, to 600–1000 cm 3  over a period of months, when the pouch fully matures.


The opening through which the catheter is introduced into the pouch is called the  stoma .  It is a small, flat, button-hole opening on the abdomen.  Most patients cover the stoma site with a small pad or bandage to absorb the  mucus  that accumulates at the opening. [ 17 ] [ Note 1 ]   This mucus formation is natural, and makes insertion of the catheter easier.  The BCIR requires no external appliance and it can be drained whenever it is convenient. Most people report draining the pouch 2–4 times a day, and most times they sleep through the night. This can vary depending on what kinds and quantities of food eaten. The process of draining the pouch is simple and quickly mastered. The stoma has no nerve endings, and inserting the catheter is not painful. The process of inserting the catheter and draining the pouch is called  intubation  and takes just a few minutes.


Finnish surgeon  Nils Kock  developed the first intra-abdominal continent ileostomy in 1969. This was the first continent intestinal reservoir. By the early 1970s, several major medical centers in the United States were performing Kock pouch ileostomies on patients with ulcerative colitis and familial polyposis.  One problem with these early Kock pouches was valve slippage, [ 18 ]  which often resulted in difficulty  intubating  and an  incontinent pouch . As a result, many of these pouches had to be revised or removed to allow a better  quality of life .


William O. Barnett began modifying the Kock pouch in 1979. He believed in the concept of the continent reservoir, but was disappointed with the valve's relatively high failure rate. Barnett was intent on solving the problem. [ 18 ] [ Note 2 ]  His first change was in the construction of the nipple valve. He changed the direction of flow within this segment of intestine to keep the valve in place. This greatly improved the success rate. [ 17 ] [ Note 3 ]  In addition, he used a plastic material called  Marlex  to form a collar around the valve. [ 18 ]  This further stabilized and supported the valve, decreasing valve slippage. This technique worked well, but after several years, the intestine reacted to the Marlex by forming  fistulae  (abnormal connections) into the valve.  Dr. Barnett continued his investigation in an effort to improve these results.  After much effort, the idea came to him—a "living collar" constructed from the small intestine itself.  This technique made the valve more stable and eliminated the problems the Marlex collars had presented. [ 18 ]


After a test series of over 300 patients, Barnett moved to  St. Petersburg, Florida  where he joined the staff of  Palms of Pasadena Hospital , where he trained other surgeons to perform his continent intestinal reservoir procedure.  With the assistance of James Pollack, the first BCIR Program was established.  Both surgeons further enhanced the procedure to bring it to where it is today.  These modifications included reconfiguring the pouch to decrease the number of  suture lines  from three to one (this allowed the pouch to heal faster and reduced the chance of developing fistulae); and creating a  serosal  patch over the suture lines which prevented leakage. [ 17 ] [ Note 4 ]   The end result of these developments has been a continent intestinal reservoir with minimal complications and satisfactory function. [ 19 ]


Ulcerative colitis [ 20 ]  and familial adenomatous polyposis [ 21 ]  are the two main health conditions that lead to removal of the entire  colon  (large intestine) and  rectum , which leads to the need for an ileostomy. [ 22 ] [ 23 ] [ Note 5 ]


Candidates for BCIR include: people who are dissatisfied with the results of an alternate procedure (whether a conventional Brooke ileostomy or another procedure); patients with a malfunctioning/failed Kock pouch or  IPAA/J-pouch ; and individuals with poor  internal / external anal sphincter  control who either elect not to have the J-pouch (IPAA) or are not a good candidate for IPAA. [ 24 ]


There are, however, some contraindications for having the BCIR surgery. BCIR is not for people who have or need a  colostomy , people with [active]  Crohn's disease , mesenteric  desmoids ,  obesity , advanced age, or poor motivation. [ 25 ]


When Crohn's disease only affects the colon, it may, in select cases, be appropriate to perform a BCIR as an alternative to a conventional ileostomy.  If the small intestine is affected, however, it is not safe to have the BCIR (because the internal pouch is created out of the small intestine, which must be healthy).


A patient must have an adequate length of  small intestine  to be considered a potential candidate.


A 1995 study by the  American Society of Colon and Rectal Surgeons  included 510 patients who received the BCIR procedure between January 1988 and December 1991.  All patients were between 1–5 years post-op with an admitting diagnosis of ulcerative colitis or familial polyposis.  The study was published in  Diseases of the Colon and Rectum  in June 1995. [ 24 ]    The study found that:


The study concluded: "BCIR represents a successful alternative to patients with a conventional Brooke ileostomy or those who are not candidates for the  IPAA ." [ 24 ]


In 1999, American Society of Colon and Rectal Surgeons published a unique study on 42 patients with a failed  IPAA/J-pouch  who converted to the Barnett modification of the Kock pouch (BCIR).  The authors noted that their study was significant in the very large number of patients, [ 26 ]  approximately 6 times more than studied by any previous author. [ 27 ]   The study was published in  Diseases of the Colon and Rectum  in April 1999. [ 27 ]   The study found:


The study concluded: "The continent ileostomy offers an alternative with a high degree of patient satisfaction, to those patients who face the loss of an  IPAA ." [ 27 ]