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. 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. a j-pouch wasn't as technical and therefore, more surgeons could perform the procedure. adaptation of ipaa surgery in the united states in the united states, australian born colorectal surgeon dr. 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 dr. roger r. dozois who published several early studies on the pouch operation in the united states. global diffusion of ipaa 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 professor 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. dr. zane cohen is credited with being a leader in canada's development of pouch surgery. professor rolland parc was a force behind its early evolution in france. dr. gilberto poggioli is credited with being at the forefront of establishing the pouch a surgical offering in italy. specialized pouch centers 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. gastroenterology guidelines 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) and the european crohn's and colitis organisation (ecco) 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. specialized staffing at pouch centers 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. ipaa surgical procedure 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. a j-pouch is two 15 to 20 cm sections of the small intestine formed into a j-shaped pouch in order to replace the function of the rectum and store stool until it can be eliminated. j-pouches can either be hand sewn or stapled. most j-pouches today are constructed using linear staplers. an s-pouch is a hand sewn formation consisting of three 15 cm limbs of terminal ileum to construct the s shaped pouch with a with a 2 cm exit conduit at the bottom. the s-pouch was the first pouch formation originally premiered by sir alan parks in 1976 in london. it was later found that the 2 cm conduit caused some people evacuation difficulties. some people who received the earlier s-pouch design with the conduit, later underwent revision surgery to remove the conduit, if they experienced evacuation difficulties. further, the s-pouch design was eventually advanced to remove the conduit since it was determined that the conduit caused some people with s-pouches, but not all, evacuation difficulties. the w-pouch is a hand sewn pouch formation constructed using four loops of 12 cm length terminal ileum. the w-pouch was created by professor john nicholls in the early 1980s at st mark's hospital in london as an augmentation of the s and j pouches with the aim to reduce frequency of movements. unlike the s-pouch, it does not have an exit conduit at the bottom. it is essentially a combination of two js to create the larger capacity w. the w-pouch is anastomosed directly to the anus the same as the j-pouch. one-step ipaa surgery 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. two-step ipaa 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. three-step ipaa surgery 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. 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. anal anastomosis technique in ipaa 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. hand sewn: surgeons typically use this type of anal anastomosis to remove all of the rectal mucosal layer, although very small islands may still remain. a hand sewn anal anastomosis may be necessary when ulcerative colitis, fap, or cancer patients retain disease in the anal canal to remove all remaining disease. when a hand sewn anastomosis is performed, it is typically placed at level called the dentate or pectinate line which is the transitional line between anal canal skin and colorectal mucosal layer. it is technically more demanding for a surgeon to perform a hand sewn anal anastomosis than a stapled anal anastomosis. stapled: a stapled anal anastomosis is done using a tool that seals the pouch to the anal canal. unlike with a hand sewn anastomosis that usually does not leave any mucosal layer, a staple pouch will retain 1–2 cm of rectal mucosal layer because the staple needs something to 'grab' to anastomose the pouch. this retained 1–2 cm of rectum is referred to as the 'cuff'. the cuff can retain disease and cause minor or more serious complications for some pouches. the ideal location for the staple is considered it be 1 cm above the dentate line at the level of the anorectal junction. the dentate line is the point where anal skin changes to the colonic mucosal layer that covers the rectum and large intestine or colon. numerous studies have been published over the years showing that excessive length of the cuff can be a contributor to pouch failure due to retained disease and/or pouch dysfunction. stapled anal anastomosis' are considered easier to perform than hand sewn which typically take more time and skill. fertility concerns and preservation for ipaa 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. fertility reduction after ileum pouch surgery 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. 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. fertility risks for men and women 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. pouch surgery and ivf age limits 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 invitro fertilization (ivf) treatment a younger woman experiencing pouch related infertility many need to rely on to conceive, many 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 aren't 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. pouch surgery and adoption age limits 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. pouch complications and disorders for ipaa 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. inflammatory disorders examples: pouchitis, cuffitis, crohn's disease of the pouch,