Step 2 in the horizon

Hi ITO, I had a three step as well and I remember feeling just the same way after my first step surgery. I also only had one UC flare, never got into remission...

So regarding the loop, two issues: #1 it is harder to get a loop that sticks out nicely like your end ileo. To some extent this is up to your surgeon but there are also simply a lot of anatomical issues working against you. There will be several feet of small intestine downstream of the loop leading to your j-pouch, and that intestine will literally be pulling down on the stoma, which can cause it to be more flush than intended. #2 as you know the loop ileo is further upstream in your intestine, so your output will be more liquidy and less digested than with the end ileo. For example, I had very formed output from my end ileo -- sometimes it practically looked like regular stool -- but in order to get anything other than pure liquid from my loop ileo, I had to eat a restricted diet and take six Imodium pills per day. As a result of having so much liquid output my wear time decreased and I had to change my appliance setup slightly. I also had to empty my pouch more frequently, even though I was taking so much Imodium. Finally, I developed pretty bad back pain during the time when I had the loop ileostomy. My surgeon was convinced that it was due to the loop ileostomy pulling the intestines out of conformation (basically an unnatural positioning) and putting pressure in unexpected places. Knock wood this has turned out to be true as I'm five weeks post takedown and do not have the back pain anymore.

You should NOT think of the j-pouch as something that you try and then reverse if it doesn't work. J-pouch construction is MAJOR surgery and it changes your body in an irreversible way. J-pouch removal is another MAJOR surgery that is even more likely to have complications. If a j-pouch fails and has to be removed, that is ~12 inches of small intestine that are gone forever. Unlike large intestine, you NEED small intestine and the less you have the worse your quality of life, pretty much full stop. "Trying out" the j-pouch is NOT the right mindset. If you have reason to believe that your j-pouch is more likely to fail for some reason or you're not confident or committed to it, you should NOT move forward with the surgeries. With that said, yes, after a failed j-pouch is excised you will usually return to an end ileostomy. It will behave a bit like a loop because you'll have less small intestine left, but it will have the nice end shape.

I also had blood and mucus from the rectum after Step 1. If the inflammation persists in the rectal cuff, that is called "cuffitis." It's typically treated with mesalamine suppositories just like you're doing now, sometimes with oral mesalamine or rectal steroids as well. I don't know why but cuffitis is not particularly common. I even had some blood in the mucus discharge after Step 2, but since takedown there has been no blood. Chronic cuffitis is one of the complications that can lead to a poor outcome or a failed j-pouch, but it isn't very common.

I really hated my loop ileo. I had extremely high output and spent the entire 8 weeks severely dehydrated - was rehospitalized twice due to that, and then also was in IV hydration at home for just over a month. The doc did the reversal so quickly because my loop just was not cooperative. But it was totally worth it - I am thrilled with my j-pouch, and feel better every single day.