J-pouch. Selection of patients and how to avoid malfunctions

Indications for a total proctocolectomy with ileal pouch-anal anastomosis are given in patients with a familial adenomatous polyposis (FAP) and in patients with an ulcerative colitis under certain circumstances: therapy-refractory ulcerative colitis, side effects from conservative treatment, malignant transformation and emergency situations, i.e. toxic megacolon or massive bleeding. The preparation follows along anatomic layers and includes in cases of malignant transformation a radical lymph node dissection of the dependent area. When mobilizing the rectum the branches of the hypogastric nerve have to be observed with caution. A total anorectal mucosectomy is discussed controversely. In many centers the transitional zone is preserved due to a better discrimination. The pouch and the pouch-anal anstomosis should be protected by a loop ileostomy.