From J Pouch to Ironman in Six Months—My Pre-Race Journey
By Cory Fleming
Almost exactly a year ago, I wrote a blog post about my experience as an athlete with ulcerative colitis and my path to surgery. At the time of that writing, it had been a couple of months since my first of three scheduled surgeries—and, as you’ll find out, one very much unscheduled surgery. The point of the surgeries was to remove my unhealthy colon and reconfigure my insides so that my small intestine would, for the most part, take its place.
I was in relatively high spirits for someone who had just had his entire colon removed, was still facing an uncontrollable amount of internal inflammation, and was dealing with an ostomy. Ideal situation? No. But I was just getting back to exercising (albeit only until the next surgery) and hopeful that, after this run of procedures, I’d be in a much better spot than in the days dealing with ulcerative colitis.
Before that first procedure, I had been training for Ironman Tulsa in May 2023, with hopes to finish among the top five or 10 overall and secure a World Championship qualification. Like all full-distance triathlons, the race was made up of a 2.4-mile swim, a 112-mile bike, and a full 26.2-mile marathon. As detailed in my last post, training at a high level with very active ulcerative colitis was a Herculean—or, better, Sisyphean—effort but I managed pretty well.
Unfortunately, my first surgery came about a month before Ironman Tulsa so I couldn’t get to the starting line. I deferred that race entry to this year and ultimately registered for Ironman Lake Placid, taking place on July 21st, 2024. Ironman Lake Placid is a notoriously difficult full-distance triathlon with a standard swim, one of the most mountainous bike courses on the circuit, and a very hilly marathon. Here’s the tale of what’s gone on since my post a year ago.
A Quick Step Back
To quickly recap the medical bits of my last blog post, I have ulcerative colitis, a chronic and incurable inflammatory bowel disease affecting the colon. Its brutality really can’t be understated. I began experiencing symptoms in May 2020, was diagnosed in April 2021, and about three years later the disease reached a completely unmanageable state—despite trying four of the most efficacious drugs available and all the dietary and other changes you’ll often see suggested. This made the “choice” to have surgery an easy one: I’d have my colon removed and get a J pouch.
A J pouch is what you get from a multi-step surgical operation that, over the course of nine months or so, creates an internal J-shaped pouch out of your small intestine to function, to some degree, as your colon. In the first step, the surgeon removes your entire colon and creates an ostomy. Months later, the surgeon constructs the J pouch but an ostomy remains to divert output away from the pouch so it can heal. In the third and final step, everything is hooked together, the ostomy is removed, and ideally, you’re ready to continue on with a relatively normal life—well, after an infamously rough adjustment period that takes a year or two.
I had the first step performed toward the end of April 2023. Let’s pick up where the last blog post ended: a couple of months after that procedure, during the summer.
Surgeries Two, Three, and … Four?
By the end of June 2023, I was back to exercising—and by August, I was pretty fit. I wasn’t pre-surgery fit, but I could cycle a hilly 100 miles with decent power and run 20 miles at a good clip. This all, however, was temporary because the second round of surgery was coming up. That procedure was originally scheduled for October, but my surgeon moved it up to the end of August because of some unmanaged inflammation that the surgery could address.
The procedure went great and my J pouch was created successfully—figurative high-fives all around the operating table. I felt good, getting up and walking around the hospital only a day after being opened up. But then came the pain—absolutely crushing stomach pain like nothing I’ve experienced in my life (saying that as someone who has broken somewhere in the range of 10 bones).
A couple of days after the procedure, my stomach started to hurt. The pain quickly went from, say, a three out of 10 to a very solid nine. I couldn’t move, sleep, eat, or drink, and no pain medication helped. For three days, I did nothing but groan in pain—holding back full-on screams (for the most part). Every small movement or rock of the hospital bed turned the agony up to 11. At one point, I nearly lost the ability to breathe and for 15 minutes experienced a pain that I imagine was akin to an extremely lucid heart attack.
It wasn’t evident what was wrong with me, and a CT scan didn’t lead to a diagnosis. For good measure, I had an NG tube installed to drain my stomach. (I’m so sorry for anyone who knows what an NG tube is from experience.) On my third day in this state, my surgeon decided to do an emergency exploratory surgery. He finished around midnight.
It turns out my small intestine, for reasons unknown, internally herniated itself, meaning it twisted itself up and blocked anything from getting through. This caused fluids to back up into my stomach in a way that was toxic (thank goodness for the NG tube). A portion of my small intestine died from the herniation, and the rest of it was about to rupture. Fortunately, my surgeon made the call to do this extreme procedure and found the issue just before a rupture, potentially saving my life.
To avoid turning this blog post into something you’d see on PubMed, I’ll only hit the main points. My core was sliced in half, the dead portion of my small intestine was cut out, the healthy ends of the intestine were sewn together, and an ostomy was created so high up in my intestine that I couldn’t process nutrients from food or hydrate adequately from drinking. After a couple of weeks in the hospital, I was sent home with a tube in my arm, into which I’d pump a massive three-liter bag of nutrients and fluid each day for 12 hours. In other words, I survived on a feeding tube. To top it off, my body was attacking the J pouch even though it wasn’t yet attached to my digestive system. This put my odds of reaching the final surgical step and having a functional J pouch at about 35 percent. If the J pouch didn’t work out, I’d need to have a permanent ostomy created.
The next four and a half months—September 2023 to mid-January 2024—were the darkest of my life. I spent half my time each day being “fed” through a tube, faced the specter of a permanent ostomy, was unable to leave my tiny NYC apartment for any meaningful amount of time, suffered the effects of my body’s all-out war on the J pouch, and dealt with a number of issues with the ostomy. Other than a bit of at-home lifting months after that emergency surgery, I couldn’t exercise. I did manage to work from home and keep up with my job throughout this whole period, which I think was quite the feat. Oh, I also got engaged—probably one of the odder proposals, but a bright spot to be sure.
Fortunately, my doctor put me on a couple of high-powered medications that, against the odds, eventually stopped my body from attacking the J pouch. We were able to schedule the final procedure—now, my fourth surgery—for January 11th. The surgery went great, and I recovered much quicker than anyone on my medical team expected. After a couple of weeks, somehow, my body was beginning its initial adjustments to the J pouch and I was trending toward a slight sense of normality. I began eating (simple) solid foods, moving around, and thinking about Ironman Lake Placid in the upcoming July—a thought that was inconceivable only a few weeks earlier.
Six months from J pouch to Ironman is a ridiculous plan for anyone. Among J pouchers, I’m not sure anything like it has ever been done. For me, it was outright absurd in light of the horror show that constituted my past several months. But my sights became set on Lake Placid, and I’ve never been good at letting a goal go.
Getting Back Into It
I was cleared for exercise shockingly fast. I couldn’t do anything strenuous for eight weeks because of the hernia risk that comes along with large surgical incisions, but I was allowed to jog and lightly cycle indoors much sooner. And, once the surgical wounds healed, I could swim.
On February 1st, exactly three weeks after the final surgery, I hopped on my bike for an “easy” 30-minute indoor spin. My heart rate was at its threshold while I was pedaling at a power that my pre-surgery body would hardly have registered as exercise. It’s okay—at least I was training! Getting back to running was even more difficult, seeing as I had hardly walked (or even really stood up) in over five months. By mid-March, I could swim again, and it certainly wasn’t pretty. Nonetheless, after these initial tastes of exercise, I became hellbent on getting myself to the Ironman Lake Placid starting line on July 21st, fit and ready.
I put my nose to the grindstone and built up my training volume. I learned what foods my J pouch best tolerated, what times of day my gut was most cooperative for exercising, how to fuel workouts and recovery without too much discomfort, and how to get decent sleep even with my body only beginning to adjust to its new insides. I advanced my diet slowly under a dietician’s supervision and kept with my regimen of medications. It certainly wasn’t easy—the first year with your J pouch is famed for discomfort, disrupted sleep, and much worse things that I won’t go into (and fortunately experienced only to a small degree).
By the end of April, I was training at a good volume again: over 15 hours per week split between cycling, running, swimming, and a bit of strength training. I was becoming fit aerobically but had no power or speed—no “top end.” Each time I did an effort at what felt like threshold, I’d completely fall apart. My lacking top end didn’t make sense given that my strength and aerobic fitness were progressing so rapidly.
During a routine check-in with my doctor about my J pouch, I asked for a blood test to check my iron levels. Low iron is a common performance inhibitor for endurance athletes, and I figured I was at high risk for iron-deficiency anemia because of all the surgeries and the new gut, which was relearning how to absorb nutrients.
It turns out I was severely anemic. It’s a wonder that I was able to train at all. For those familiar, my ferritin level was five—not 50… just five! The other relevant blood markers were similarly pitiful. My iron stores were depleted and my red blood cells were in rough shape. I was immediately scheduled for five iron infusions throughout May. And they worked. At the end of May, my power on the bike had jumped up 50 or 60 watts and I could run for miles at a pace that I hadn’t been able to sustain for more than a few minutes. I also no longer felt like I was dying each time I went for a swim.
All Systems Go
With a body constantly adapting better to the J pouch, an advancing diet, good iron levels, and functioning red blood cells, I began to feel unstoppable. I bumped my training up to above 20 hours per week and was able to introduce some higher-intensity efforts into my workouts. To support this increase in volume and intensity, I paid close attention to what (and when) I ate and how it made me feel—after all, I needed to take in more than 4000 calories per day to keep myself at a healthy weight, which is a tall order with a months-old J pouch. I optimized everything in my control to keep adapting to the J pouch and progressing my health.
Here’s a big week from June to give an idea of how far I had come, despite all the complications, in only five months since my last procedure:
Monday: Rest
Tuesday: 15-minute core workout, 35-mile bike, 5-mile run off the bike
Wednesday (holiday): 75-mile bike with threshold intervals, 3500-yard open-water swim
Thursday: 15-minute core workout, 8-mile run with threshold intervals, 5-mile light jog later that day
Friday: 3300-yard swim with threshold intervals, 5-mile run
Saturday: 112-mile bike, 6-mile run off the bike
Sunday: 15-minute core workout, 4400-yard swim, 21-mile run with the final 6 at race pace
This totaled 23 hours, split among 11,200 yards of swimming, over 220 miles on the bike, 50 miles of running, and a few short core-strengthening sessions.
I even did a practice race in June to test my gear, fueling, and strategy for Ironman Lake Placid. The race was a locally run half-distance triathlon in Massachusetts called the Patriot Half, made up of a 1.2-mile swim, 54-mile bike (instead of the usual 56 miles), and 13.1-mile half marathon. While keeping some effort in the tank, I managed to race at the pointy end of my age group and finish with a time of 4:30—a full hour faster than I had planned while struggling with anemia back in April.
It’s now July 17th, and I’m 4 days away from Ironman Lake Placid. It’s hard to believe what I’ve gone through and accomplished up to this point—and I haven’t even made it to the starting line yet! I can’t wait to race and I expect a strong result. But even more so, no matter how the race goes, I hope my journey illustrates what’s possible for all those suffering from IBD. I’ve already shattered the preconceived limits of the initial months with a J pouch, and I plan to show what can be accomplished over a lifetime with one.