Bo Shen, MD, presented a poster on the first successful endoscopic procedure with septectomy to treat a twisted J-pouch at the ACG Scientific Meeting on October 24. This poster was named both a ACG Case Reports Journal Award and Presidential Poster Award winner.

Dr Shen is a professor of medicine in surgery and director of the IBD Center at Columbia University Irving Medical Center, Bronxville, New York.

He noted that a twisted pouch is a rare complication of ileal pouch-anal anastomosis (IPAA) surgery. Very few cases have been reported in medical literature and most patients who have had this complication have been managed surgically “with adhesiolysis and derotation with or without redo of the ileorectal anastomosis.”

There have been no previous reports of endoscopic management of a twisted pouch, Dr Shen stated.

The case reported is that of a 35-year-old woman who underwent 3-stage restorative proctocolectomy with IPAA for medically refractory ulcerative colitis in 2017. One year later, the patient presented with nausea, vomiting, diarrhea and significant weight loss. Computed tomography (CT) revealed the patient had a dilated small bowel with obstruction at the anal anastomosis. A pouchoscopy revealed the patient had a twist in the distal pouch that almost completely blocked the pouch outlet.

The twisted pouch was treated at IBD Center at Columbia University Irving Medical Center with outpatient endoscopic needle-knife septectomy with electroincision of the twisted fold. This was followed by placement of two endoclip spacers. The procedure led to immediate resolution of her symptoms.

A repeat pouchoscopy 2 weeks later revealed a mild outlet stricture that required further endoscopic septectomy. At the 6-month mark, a repeat pouchoscopy showed complete resolution of the obstruction. Annual routine pouchoscopy found a severe circumferential anastomotic stricture, which was treated with endoscopic circumferential stricturotomy with the needle knife. At the patient’s last follow-up in 2021, a pouchoscopy found that the pouch twist remained resolved.

The poster authors concluded that endoscopic septectomy can be offered as a first-line therapy” for pouch twist complications following IPAA surgery.

Reference:
Pokala S, Shen B. C0425 -Endoscopic management of obstructing pouch twist. Poster presentation. Oral paper presentation. Poster session C. Presented at: ACG 2022 Annual scientific meeting and Postgraduate course. Charlotte, North Carolina. October 24, 2022.