a person can quickly become life-threateningly ill. when levels are dangerously low, medical intervention with supplementation either orally or intravenously becomes necessary. revision, redo, salvage surgery for ipaa pouch failure 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). 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. 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. ipaa repair procedures 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 doesn't impact the pouch's anal anastomosis (and many not even be related to the pouch itself). when a more conservative method won't 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. salvage surgery to redo an ipaa's anal anastomosis 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 isn't 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. salvage surgery to redo an entire ipaa's pouch 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. salvage surgery to rescue a pouch by altering shape 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) doesn't 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 wouldn't be successful but altering it could rescue the pouch situation. salvage surgery converting an anal pouch to koch pouch people can also choose to convert their failed ileo pouch-anal anastomosis (ipaa) to a continent ileostomy such as a koch pouch in some circumstances. pouch removal surgery for failed ipaa pouch 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. quality of life after pouch surgery 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. bowel motions with pouch 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. 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. 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. 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. for pouches that are difficult to evacuate or experience anal seepage, biofeedback therapy can be prescribed. dehydration risk with pouch 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. 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. diet with pouch 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. 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. changes to insurance access for pouchees sometimes people are told when pouch surgery is recommended that they will be 'cured'. this is misleading on a number of levels including when it comes to obtaining various insurance policies. a person will reasonably believe that there is no longer any problem to worry about. however, once a person has an intestinal pouch it may be harder to purchase life insurance, travel insurance, and some health insurance including private insurance upgrades in a country with a national health system. it is also important for people with pouches to know before they opt to undergo pouch surgery that not all countries provide health insurance coverage consistently or without interruption. for example, citizens of countries with nationalized healthcare services lose access if they establish residency abroad. further, in the united states, citizens and residents of the 12 states that still have not taken the obamacare extension won't be eligible for medicaid if they become seriously unwell in certain circumstances including if they are unmarried and do not have children. the treating hospital at time of pouch surgery should inform potential pouch candidates about possible restrictions because restrictions can be related to specific insurers, local rules, national regulations, and/or universal regulations. in most cases if insurance can be obtained after pouch surgery, the premium cost could potentially be higher than if the person did not have a pouch because of the higher cost of care related to having a pouch. while higher prices might only apply in certain circumstances for health insurance, it is almost always the case for life and travel insurance. support for pouch candidates and pouchees 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: crohn's and colitis - australia crohn's and colitis - canada gastrointestinal (gi) society - canada german crohn's disease and ulcerative colitis society - germany european crohn's and colitis organisation - europe crohn's and colitis - uk red lions group pouch support charity - uk crohn's and colitis foundation - us the j-pouch group online community - us united ostomy association (uoa) - us