TOPLINE

Among patients who underwent endoscopic evaluation and stricturotomy for distal pouch or anastomotic strictures after ileal pouch-anal anastomosis (IPAA), those with diverted ileal pouches had more severe disease: three quarters had concurrent diversion pouchitis, and all had severe or pinhole strictures. Despite this, the procedure achieved a 95.2% technical success rate. This was comparable to the rate observed in patients with nondiverted pouches, with no perforation, bleeding, or death in either group.

METHODOLOGY

• Complications after IPAA are common and can lead to pouch failure requiring long-term fecal diversion — yet the development of inflammation and strictures in diverted pouches and the optimal approach to treating these complications have remained poorly understood.
• Researchers conducted a historical case-control study involving 54 patients (mean age, 47 years; 67% women) with inflammatory bowel disease and a history of IPAA who underwent endoscopic stricturotomy for distal pouch or anastomotic strictures from January 2020 to February 2026; 76% of the patients had ulcerative colitis, and 24% had Crohn's disease.
• They compared 12 consecutive patients with diverted pouches with 42 consecutive control individuals with nondiverted pouches; a total of 123 endoscopic stricturotomy procedures were performed (42 in patients with diverted pouches and 81 in patients with nondiverted pouches); the median follow-up was 15 and 28 months in the groups with diverted and nondiverted pouches, respectively.
• The primary outcome was immediate technical success, defined as achieving endoscopic passage through the stricture.
• Secondary outcomes were diversion pouchitis, stricture characteristics, need for repeat endoscopic treatment or surgery, and adverse events such as bacteremia, bleeding, or perforation. Adverse events were assessed only within 7 days of each procedure.

TAKEAWAY

• Among patients with diverted pouches, 75% had concurrent diversion pouchitis; all patients with diverted pouches had severe or pinhole strictures, whereas only 7.1% of patients with nondiverted pouches had these strictures (P < .001).
• The overall rate of technical success was 98.4% (121/123 procedures), with comparable rates between the diverted and nondiverted groups (P = .115); surgical intervention was needed among 25% of patients with diverted pouches vs 21% of those with nondiverted pouches (P > .99), and endoscopic reintervention was required among 50% vs 43% (P = .748).
• The surgery-free survival rate was 88.9% and 47.4% at 12 and 24 months, respectively, in patients with diverted pouches vs 86.2% at both timepoints in patients with nondiverted pouches (log-rank P = .433).
• Adverse events occurred in two patients: a pelvic abscess with bacteremia in one patient with a diverted pouch and ileus in one patient with a nondiverted pouch; no perforation, bleeding, or deaths occurred across all 123 procedures.

IN PRACTICE

"We, therefore, recommend annual pouchoscopy for diagnosis, surveillance, and endoscopic therapy in patients with a diverted pouch, even when asymptomatic," the authors wrote. "Endoscopic stricturotomy should be considered a viable therapeutic option for diverted pouch strictures before surgical alternatives such as pouch excision or pouch redo as successful treatment may ultimately enable ileostomy closure and restoration of intestinal continuity," they added.

SOURCE

The study was led by Yuanyuan Ge, MD, PhD, of the Center of Inflammatory Bowel Disease, Columbia University Irving Medical Center, New York City. It was published online in Gastro Hep Advances.

LIMITATIONS

The retrospective, single-center design may have introduced a risk for selection and information bias. The small number of patients with diverted pouches limited statistical power and made multivariable analysis infeasible. Patients with diverted pouches were followed up for a shorter duration, possibly underestimating long-term recurrence and complications.

DISCLOSURES

The study did not receive any external funding. Several authors reported having financial relationships — including consulting fees, research grants, speaking fees, and stock ownership by one author — with pharmaceutical companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.