S2699 Endoscopic Management of Obstructing Pouch Twist

Abstract

Introduction: The twisted pouch is a rare complication of IPAA with few cases being reported in the literature. Most patients have been managed surgically with adhesiolysis and de-rotation with or without redo of the ileorectal anastomosis. Endoscopic management of a twisted pouch has not been previously reported and this report describes the first successful endoscopic treatment of the twisted pouch with septectomy. Case Description/Methods: A 35-year-old female underwent 3-stage restorative proctocolectomy with IPAA for medically refractory ulcerative colitis in 2017. She presented a year later with nausea, vomiting, diarrhoea and significant weight loss. CT revealed a dilated small bowel with obstruction at the anal anastomosis. At our institution she underwent a pouchoscopy which revealed a dilated pouch lumen, a twist in the distal pouch with a nearly completely blocked pouch outlet. The twist was treated with outpatient endoscopic needle-knife septectomy with electroincision of the twisted fold, followed by the placement of two endoclip spacers. The procedure was performed with the patient under conscious sedation, observed for 30 mins and discharged afterwards. This led to immediate resolution of her symptoms. 2-week repeat pouchoscopy revealed a mild outlet stricture, requiring further endoscopic septectomy. 6-month repeat pouchoscopy showed complete resolution of the obstruction. Yearly routine pouchoscopy showed that pouch twist remained to be revolved, but a severe circumferential anastomotic stricture. The latter was treated with endoscopic circumferential stricturotomy with the needle knife. Her last follow-up was in 2021 with the pouch twist remaining resolved on pouchoscopy. (Figure) Discussion: Pouch twist results from poor orientation of the mesentery at surgery or due to adhesions. Severe twisted pouch can lead to acute or chronic pouch obstruction. Acute pouch twist requires timely management to avoid bowel necrosis and obstipation. Twisted pouch commonly presents two to five years after surgery with pouchitis, ulceration, chronic abdominal pain, and incontinence. Diagnosis of this condition typically requires a high degree of suspicion, CT, and gastrografin enema. The patients traditionally are managed surgically with adhesiolysis and derotation and fixing the pouch with or without redo of the ileorectal anastomosis.This case report describes the successful endoscopic treatment of the twisted pouch with septectomy. We believe that endoscopic septectomy can be offered as a first-line therapy.Figure 1.: Left: Initial obstructed twisted pouch Right: Post-endoscopic septectomy.