Afferent Limb Syndrome Research Articles

Rendezvous technique and self-expandable metal stent for afferent limb syndrome

Rendezvous technique and self-expandable metal stent for afferent limb syndrome

Endoscopic ultrasonography-guided gastroenterostomy to relieve biliary obstruction due to afferent limb syndrome in complex postsurgical anatomy.

Endoscopic ultrasonography-guided gastroenterostomy to relieve biliary obstruction due to afferent limb syndrome in complex postsurgical anatomy.

A rare case of afferent limb syndrome due to a biliary stone 8 years after a whipple, a case report

Background: Afferent limb syndrome (ALS) is the mechanical obstruction of the afferent limb proximal to the gastrojejunostomy anastomosis that leads to accumulation of bile, pancreatic fluids, and proximal small bowel secretions. It is most commonly associated with Billroth-II and Roux-en-Y gastrojejunostomy. Common causes of obstruction include kinking of the loops, anastomotic narrowing, and adhesions.

S2901 Afferent Limb Syndrome Treated With Non-Cautery-Enhanced Lumen Apposing Metal Stent: An Alternate Approach

Introduction: Afferent limb syndrome (ALS) is a known complication after gastrojejunostomies from mechanical obstruction of the afferent limb (AL). Recently endoscopic ultrasound (EUS) guided gastroenterostomy placement has provided an alternate to surgical correction. However this approach is not always technically possible. We describe a case successfully treated with endoluminal non-cautery enhanced lumen apposing metal stent (LAMS) placement. Case Description/Methods: A 63 year old woman with a history of ileocolonic Crohns disease (diagnosed at age 25), status post multiple surgeries including ileocolic resections and Billroth II gastrectomy, was referred with persistent abdominal pain. She was recently diagnosed with acute pancreatitis with CT concerning for dilated afferent jejunal limb, a luminal stricture near the biliary anastomosis and dilated intra and extra hepatic bile ducts (Figure a). She underwent two deep enteroscopies revealing a stricture in the AL from intra-abdominal adhesion. This was dilated with minimal improvement in symptoms and imaging. After multi-disciplinary discussion it was decided to attempt EUS guided drainage of the AL to promote drainage of pancreatico- biliary secretions. During the procedure a significant amount of food residue was identified in the gastric remnant. The dilated afferent limb was visualized endosonographically adjacent to the posterior stomach at an acute angle. Considering large amount of food in the stomach, difficult angulation to deploy the AXIOS stent and concern for food entering the already obstructed limb after stent deployment it was decided to reconsider this approach. The AL was then explored with a therapeutic upper endoscope with stenosis at 10 cm from the anastomosis. A wire was passed through the stenosis under fluoroscopy. It was decided to place a stent using the 15 x 10 mm LAMS stent system considering short (< 1 cm) stricture. Using non cautery technique both flanges were deployed successfully across the stricture under fluoroscopic and endoscopic guidance with decompression of the AL (Figure b,c). 1 month follow up imaging demonstrated continued decompression of the AL. Discussion: EUS guided gastrojejunostomy has been increasingly used for ALS. However it can be challenging in situations where a good window cannot be identified. In such settings using a traditional luminal route to reach the stenosis and placing a non-cautery enhanced LAMS can provide a viable alternative.Figure 1.: (a) Dilated afferent limb with stricture (arrows), (b) post non-cautery enhanced LAMS deployment, (c) Fluoroscopy image post LAMS deployment

S3531 A Rare Cause of Obstructive Jaundice: Afferent Limb Syndrome

Introduction: Afferent limb syndrome (ALS) is a rare but potentially life-threatening complication of upper gastrointestinal (GI) surgery and reconstruction causing distal obstruction of the biliopancreatic limb with subsequent accumulation of bile, pancreatic fluid, and other small bowel secretions upstream afferent limb dilation. It is imperative to recognize this complication postoperatively as buildup in the small bowel can result in bowel perforation requiring emergency surgery. We present a patient who developed ALS after upper gastrointestinal reconstruction with esophagojejunostomy for the treatment of gastric adenocarcinoma. Case Description/Methods: An 84 year-old female with a past medical history of gastric adenocarcinoma with total gastrectomy and esophagojejunostomy presented to the emergency department with a subacute history of upper abdominal pain and new-onset jaundice. Initial labs were notable for elevated liver chemistries including alkaline phosphate level of 435 U/L (normal 39-117 U/L), alanine transaminase of 62 U/L (normal 6-45 U/L), and aspartate transaminase of 36 U/L (normal 10-25 U/L). Abdominal ultrasound demonstrated markedly dilated common bile and intrahepatic ducts and gallbladder distention without stones. CT scan of the abdomen confirmed the ultrasound findings, but also identified a dilated duodenum with an abrupt transition point in the proximal jejunum suggestive of ALS shown in Figure A. The patient underwent open laparotomy which demonstrated multiple tumor implants. A large implant at the site of the previous jejunojejunostomy was identified as the cause of afferent limb obstruction. A palliative bypass was performed. The patient had a complicated post-operative course. Ultimately, due to the extensive disease burden and ongoing patient discomfort, the patient and their family decided to pursue hospice care. Discussion: ALS is a post-operative complication of upper GI tract surgery that involves mechanical obstruction of the biliopancreatic limb. Patients often present with jaundice. CT scan is the preferred diagnostic modality. First-line treatment involves surgery to relieve the obstruction with revision of the prior anastomosis. Although rare, this diagnosis should be considered in appropriate patients.Figure 1.: A: CT scan with markedly dilated intrahepatic and extrahepatic biliary ductal dilation, distended gallbladder, and markedly dilated duodenum with abrupt transition point in proximal jejunum.

S1807 Pancreatic Neoplasm Presenting as Afferent Limb Syndrome in a Patient With a Remote History of Roux-en-Y Gastric Bypass

S1807 Pancreatic Neoplasm Presenting as Afferent Limb Syndrome in a Patient With a Remote History of Roux-en-Y Gastric Bypass

Nonspecific, Acute Pouchitis in Patients With Familial Adenomatous Polyposis: Less Common Than We Think.

Nonspecific acute pouchitis is common in patients with ulcerative colitis who undergo IPAA, but there is disagreement about the rate at which this occurs in patients with familial adenomatous polyposis. This study aimed to define the rate at which nonspecific acute pouchitis occurs in patients with familial adenomatous polyposis. This study was conducted at a hereditary colorectal cancer center in a large academic medical center. This is a retrospective cohort study using prospectively gathered data. Patients with familial adenomatous polyposis who have had IPAA were included. Symptoms, pouchoscopy and pouch radiography, and pouch biopsy were evaluated. The primary outcomes measured were the presence of nonspecific acute pouchitis and the alternative diagnosis of pouch dysfunction. There were 250 patients with familial adenomatous polyposis who had undergone IPAA; 38 (15.2%) had been labeled as having "pouchitis": 23 men and 15 women. Median age was 55 years (range, 18-90 years). No patient had nonspecific, acute pouchitis as defined by our criteria. In 9 cases, the diagnosis was derived from benign ulcers common in ileal pouches. Stool frequency was the most common symptom associated with the "pouchitis" label, but actual causes for the frequency included poor pouch emptying, poor eating habits, poor bowel habits, and afferent limb syndrome. Median stool frequency was 9, ranging from 4 to 15 per day. Every patient had at least 1 pouch endoscopy, and the median number was 19 per patient (range, 1-21). Nine patients had pouch biopsies to rule out inflammation; all showed chronic active enteritis, a normal finding in ileal pouches. This study was limited by its retrospective nature. We could not confirm any case of nonspecific acute pouchitis in patients with familial adenomatous polyposis. Those caring for patients with familial adenomatous polyposis who have a pouch should seek causes for pouch-related symptoms other than "pouchitis." See Video Abstract at http://links.lww.com/DCR/B666.POUCHITIS AGUDA INESPECÍFICA EN PACIENTES CON POLIPOSIS ADENOMATOSA FAMILIAR: MENOS COMÚN DE LO QUE PENSAMOSANTECEDENTES:La pouchitis aguda e inespecífica es común en pacientes con colitis ulcerativa, sometidos a anastomosis de bolsa ileoanal, pero no hay acuerdo sobre la frecuencia en que se presenta en pacientes con poliposis adenomatosa familiar (PAF).OBJETIVO:Definir la frecuencia en la que se presenta pouchitis aguda inespecífica en pacientes con poliposis adenomatosa familiar.ENTORNO CLINICO:Centro de cáncer colorrectal hereditario en un gran centro médico académico.DISEÑO:Estudio de cohorte retrospectivo utilizando datos recopilados prospectivamente.PACIENTES:Pacientes con poliposis adenomatosa familiar sometidos a bolsa con anastomosis ileoanal.INTERVENCIONES:Síntomas, proctoscopia, radiografía y biopsia de bolsa ileoanal.PRINCIPALES MEDIDAS DE VALORACION:Presencia de pouchitis aguda inespecífica; diagnósticos alternos de disfunción de la bolsa ileal.RESULTADOS:De 250 pacientes con poliposis adenomatosa familiar sometidos a una anastomosis anal de la bolsa ileal; 38 (15,2%), habían sido etiquetados como "pouchitis", 23 hombres y 15 mujeres. La mediana de edad fue de 55 años (rango de 18 a 90 años). Ningún paciente tuvo pouchitis aguda inespecífica según lo definido por nuestros criterios. En 9 casos el diagnóstico se derivó de úlceras benignas frecuentes en bolsas ileales. La frecuencia de las evacuaciones fue el síntoma más común asociado con la etiqueta "pouchitis", pero las causas reales de la frecuencia, incluyeron un mal vaciado de la bolsa, malos hábitos alimenticios, malos hábitos intestinales y síndrome de asa aferente. La frecuencia media de las evacuaciones fue de 9, con un rango de 4 a 15 por día. A cada paciente se le realizó al menos una endoscopia de la bolsa: la mediana fue de 19 por paciente (rango de 1 a 21). A 9 pacientes se les realizó biopsia de bolsa para descartar inflamación: todos mostraron enteritis activa crónica, un hallazgo normal en las bolsas ileales.LIMITACIONES:Naturaleza retrospectiva del estudio.CONCLUSIONES:No pudimos confirmar ningún caso de pouchitis aguda e inespecífica en pacientes con PAF. Aquellos que atienden a pacientes con PAF con bolsa ileal, deben buscar otras causas para los síntomas relacionados con la bolsa que no sean "pouchitis". Consulte Video Resumen en http://links.lww.com/DCR/B666. (Traducción-Dr. Fidel Ruiz Healy).

A125 A NOVEL TECHNIQUE COMBINING EUS AND SPYGLASS DS SYSTEM GUIDANCE FOR BOTH THE DIAGNOSIS AND MANAGEMENT OF AFFERENT LIMB SYNDROME

BackgroundAfferent limb syndrome is obstruction of a biliary-enteric limb following pancreaticoduodenectomy. In the past, treatment was limited to surgery or insertion of a percutaneous transhepatic biliary drainage tube. A more recent approach to treatment is Endoscopic Ultrasound (EUS)-guided gastrojejunostomy using a lumen apposing metal stent (LAMS). It was first described in two single case reports in 2015 and has been growing in its application. We present a case series of 2 patients where afferent limb syndrome was successfully managed with EUS guided gastrojejunostomy using LAMS.Aims1-To demonstrate a novel technique for diagnosis and management of afferent limb syndrome.MethodsCase # 1- 79 year old female post Whipple’s surgery for ampullary carcinoma, presented two years after surgery with significant nausea and vomiting. CT scan showed obstruction of the afferent loop suspicious for local tumor recurrence. Patient underwent EUS-guided gastrojejunostomy with successful insertion of 20 x 10 mm (AXIOS EC, Boston Scientific) stent.Case # 2-. A 51 year old male with pancreatic CA status post Whipple surgery presented with worsening abdominal pain and nausea. CT scan confirmed afferent limb syndrome. He underwent EUS- guided gastrojejunostomy with successful placement of 10 x 10 mm (AXIOS EC, Boston Scientific).ResultsCase #1: Patient improved dramatically within days and resumed oral diet. Fourteen days later, an upper endoscopy was performed in order to assess the stricture via an anterograde approach. The adult Olympus HQ gastroscope was advanced through the AXIOS stent into the afferent limb to the level of the stenosis where a tight stricture was seen. Multiple biopsies taken and were negative for malignancy. Four weeks later, she continued to tolerate oral diet well with no abdominal pain or discomfort.Case # 2: Patient continued to do well clinically 12 weeks post operation. Follow-up upper endoscopy was performed to determine the etiology of the obstruction but due to a sharp angulation, the gastroscope could not be advanced through the AXIOS stent. As such, we advanced an adult Olympus 1T gastroscope down to the site of the AXIOS stent and then utilized the Spyglass DS system to advanced deep into the afferent limb to the level of the stricture and took multiple biopsies for diagnostic purposes.ConclusionsInterventional endoscopic management of afferent limb syndrome has been evolving in the past few years with EUS guided LAMS gastrojejunostomy becoming a well stablished modality. We have demonstrated this technique with subsequent endoscopic anterograde assessment. In one of these cases, this anterograde assessment was performed using the cholangioscope in conjunction with the gastroscope to overcome unfavorable angulated anatomy which to our knowledge has not been described in the literature previously. Funding AgenciesNone

S2454 A Case of Afferent Limb Syndrome: Endoscopic Balloon Dilation to the Rescue

S2454 A Case of Afferent Limb Syndrome: Endoscopic Balloon Dilation to the Rescue

Afferent limb syndrome, biliocutaneous fistula, bilioenterocutaneous fistula, dehiscence of the hepaticojejunostomy: Can we treat all of this endoscopically?

Video 1Afferent limb syndrome, biliocutaneous fistula, bilioenterocutaneous fistula, and dehiscence of the hepaticojejunostomy treated endoscopically.

Endoscopic ultrasound-guided jejunojejunostomy with rendezvous contrast-filling assistance in afferent limb syndrome.

Endoscopic ultrasound-guided jejunojejunostomy with rendezvous contrast-filling assistance in afferent limb syndrome.

Rendezvous for afferent limb syndrome

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgical alterations in the normal biliary anatomy is technically challenging. We describe the case of a 73-year-old patient with an afferent limb syndrome secondary to a Whipple procedure for pancreatic cancer, in which a percutaneous rendezvous technique assisted in the endoscopic metallic stent placement with favorable outcome.

Endoscopic band ligation with hypertonic glucose cushion in the treatment of ileal pouch prolapse.

Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the surgical treatment of choice of patients with ulcerative colitis (UC) or familial adenomatous polyposis who require the removal of the colon. While this reconstructive surgery significantly improves patients’ quality of life, post-operative structural, inflammatory, and functional complications are common. In our Pouch Center, we have noticed a growing number of patients presenting with dyschezia, feeling of incomplete evacuation, and frequent bowel movements. Clinical, endoscopic, and radiographic evaluation of cohorts of patients has identified a cluster of disease phenotypes that are collectively diagnosed with floppy pouch complex (FPC) [1]. Common forms of FPC are pouch prolapse, afferent limb syndrome, and pouch folding. In a survey of 269 surgeons, 35 indicated that they had been taking care of a total of 83 patients with symptoms suggestive of pouch prolapse, such as external prolapse of tissue, sense of obstructed defecation, seepage, and pain [2]. In an early study of 3,176 patients who underwent ileal pouch surgery, 11 were diagnosed with pouch prolapse (0.3%) [3]. The true prevalence may be higher in clinical practice. Pouch prolapse may be mucosal or full-thickness; and anterior, posterior, or circumferential. The treatment of pouch prolapse has traditionally been medical (such as suppositories and creams) and surgical (such as pouch pexy, mesh placement, and excision) [1, 2, 4]. Over the past decade, we have developed a novel endoscopic approach for the treatment of pouch prolapse.

Placing a lumen-apposing metal stent despite ascites: feasibility and safety.

Background and AimsPlacing a lumen-apposing metal stent (LAMS) through ascites carries serious risks, including death from leakage around the LAMS and failure to create a mature fistula between the 2 lumens. However, sometimes no options exist or are equally dangerous. We present 5 patients who underwent LAMS placement despite ascites in 2 different locations.MethodsThis is a retrospective review of 5 patients who underwent LAMS placement despite ascites in 2 different locations from 2016 to 2018.ResultsThree patients with cholecystitis and 2 patients with afferent limb syndrome and severe ascites were treated with a combination of preprocedural and intraprocedural paracentesis. Serum ascites albumin gradient was measured. Weight was recorded daily. Patients were encouraged to sleep at an incline, and periodic paracentesis (every 3-7 days) was performed when ascites reaccumulated over 4 weeks. Median volume of ascites aspirated was 2 L preprocedurally and 300 mL intraprocedurally. Only 1 patient had ascites with a high serum ascites albumin gradient and was treated with diuretics. Technical and clinical success was achieved in all 5 patients without any adverse events over a median follow-up of 28 weeks.ConclusionsIn situations in which no better options remain, LAMS placement appears to be safe after adequate and aggressive treatment of the underlying ascites pre-, intra-, and postprocedurally. Larger studies are needed to establish the safety of this approach.

Afferent limb syndrome after total proctocolectomy and ileal pouch-anal canal anastomosis

BackgroundSmall bowel obstruction (SBO) is a common postoperative complication of ulcerative colitis (UC). There have been a few recent reports of afferent limb syndrome (ALS) as a rare occurrence in cases of SBO. We present a case of ALS with recurrent SBO that was successfully managed surgically.Case presentationWhen this male patient was 55 years old, he underwent laparoscopy-assisted anus-preserving total proctocolectomy, the creation of a J-type ileal pouch, ileal pouch-anal canal anastomosis (IPAA), and creation of ileostomy for intractable UC. Three months later, ileostomy closure was performed. The first onset of SBO was observed 5 months after ileostomy closure. SBO occurred repeatedly, and the patient was hospitalized nine times in approximately 2 years. Each SBO was improved by non-surgical treatment. A computed tomography (CT) scan revealed that the afferent limb was narrowing and twisted, and gastrografin enema confirmed narrowing at the proximal portion of the pouch inlet. Endoscopy showed a sharp angulation at the pouch inlet. We suspected ALS and decided on a surgical policy and performed pouchopexy and ileopexy to the retroperitoneum by suturing with excision of the remaining blind end of the ileum. Endoscopy 3 days after surgery showed neither twist nor stricture in the fixed ileal pouch or the afferent limb. At the time of writing, the patient remains free of SBO symptoms.ConclusionClinicians should consider ALS when examining a patient with recurrent intermittent SBO after IPAA surgery. When ALS is suspected, the patient is indicated for surgery such as surgical pexy.

Su1265 CLINICAL UTILITY OF ENDOSCOPIC ULTRASOUND-GUIDED DEPLOYMENT OF LUMEN-APPOSING METAL STENTS FOR MALIGNANT AFFERENT LIMB SYNDROME; A DESCRIPTIVE ANALYSIS

Endoscopic ultrasound-guided deployment of a lumen apposing metal stent (LAMS) has recently emerged as a favorable interventional modality for the treatment of malignant afferent limb syndrome (ALS). However, data regarding the safety and feasibility of this approach is limited. A systematic literature search was performed of Medline(Ovid) and Embase from inception-July 2019. All studies were screened by two authors to identify studies reporting EUS-guided deployment of LAMS for the treatment of malignant ALS. Due to the expected paucity of data, case reports were included in our analysis. Pooled data was reported as proportions with 95% confidence interval (CI). Overall, we identified 15 reports enrolling 32 patients with a mean age of 62, of whom 16 (50%) were female. A history of pancreatoduodenectomy was reported in 23 (72%) patients (Table 1). The mean time from surgical tumor resection to ALS presentation was 14 months (SD 6.5). The most common cause of ALS was peritoneal carcinomatosis (11; 34%). Prior endoscopic intervention for ALS was performed in 4 (13%) patients. Electrocautery enhanced LAMS insertion was performed in 17 (53%) cases, and a needle knife was utilized in 2 (6%) cases. All patients successfully underwent EUS-guided deployment of a LAMS to create a gastroenterostomy with subsequent symptomatic and biochemical improvement of ALS. The most common anastomosis created was a gastrojejunostomy (22, 69%), followed by a jejunojejunostomy (7, 22%). No adverse events were reported over the study duration. Re-obstruction and reintervention were reported in 3 (9%) and 4 (13%) cases, respectively. Over a mean follow-up period of 98.27 days (95%CI 74.58-121.96), one mortality due to ALS was reported. EUS-guided gastroenterostomy (EUS-GE) by deployment of a LAMS for the treatment of ALS is a technically feasible and clinically favorable intervention, particularly in patients who are poor surgical candidates. A lack of long-term follow up was identified upon systematically analyzing the literature. Future well-designed studies with long-term follow-up are needed to further explore the clinical utility of EUS-GE for the treatment of ALS.

1033 EUS GUIDED GASTROJEJUNOSTOMY (EUS-GJ) USING A NASOBILIARY TUBE (NBT) FOR WATER INFUSION.

EUS-guided gastrojejunostomy (EUS-GJ) with a lumen apposing metal stent (LAMS) is a new, minimally invasive endoscopic approach to treat gastric outlet obstruction (GOO). Clear visualization of the targeted jejunal loop is essential to complete the procedure. Insertion of a dilating balloon catheter or a specialized double balloon enteric tube into the proximal jejunum are the 2 reported techniques to assist identification of the targeted enteric loop for puncture. This study evaluated the technical and clinical outcomes of the use of a naso-biliary tube (NBT) for water distention of the targeted enteric loop to assist EUS-GJ in a large cohort of patients with GOO. A prospectively collected database on patients referred for treatment of GOO or afferent limb syndrome over a 4-year period was retrospectively reviewed. After confirmation of the duodenal stricture, a guidewire was passed into the proximal jejunum. A 7Fr NBT was then advanced over the guidewire under fluoroscopy. The proximal jejunum was infused with water via the NBT using a water pump. The water distended jejunal loop was then identified by EUS and targeted for EUS-GJ creation using a15mm caliber LAMS (“Hot” Axios, Boston Scientific). Clinical success was defined as the ability to tolerate a non-liquid diet post-procedure. The mean follow-up period was 5.7±2.6 months. 45 patients (71.2±1.8yrs; 23M: 22F) underwent EUS-GJ for duodenal strictures causing GOO (n=41; 37 malignancy, 3 inflammatory ulcers, 1 pancreatitis) or for afferent limb syndrome (n=4). In 36/45 (80%) patients, the stricture could not be traversed with a gastroscope, but insertion of the NBT across the stricture was achieved in all cases. Technical success of EUS-GJ was 44/45 (98%) of patients, with no adverse events. Failure in one case was due to LAMS mal-deployment from equipment malfunction. The resultant gastric perforation was immediately closed by endoscopic suturing with uneventful recovery, and EUS-GJ was successfully achieved 2 days later. Overall mean procedural time was 53±3min. Clinical success was achieved in all 4 benign cases (3.5±1.0months follow-up) and 38/41 (93%) malignant cases (6.0±0.7months follow-up). In 3 failed cases, LAMS was upgraded to 20mm calibre (n=2) or a venting PEG was inserted (n=1) to palliate GOO. Of 14 patients who died, 13 (93%) sustained oral intake until death. For the 31 alive patients, EUS-GJ provided good symptom relief in all for 5.4±0.7 months with 1(3%) had LAMS upgraded to 20mm at 6 months due to recurrent GOO symptoms. Use of a NBT to assist EUS-GJ with a 15mm LAMS is associated with high technical success (98%) with no serious adverse events and excellent immediate and intermediate relief of GOO symptoms in both malignant and benign duodenal strictures. Simplicity and low cost are advantages over the balloon assisted methods.

Simultaneous double gastrojejunostomy for afferent and efferent limb syndromes

Afferent and efferent limb syndromes are potential adverse events after partial gastrectomy with a gastrojejunostomy (GJ) reconstruction. Mechanical obstruction of the reconstructed small-bowel loops is often the underlying etiology, and it occurs because of anastomotic narrowing, postsurgical adhesions, and recurrence of the primary disease.1 Afferent limb syndrome usually presents with abdominal pain, bilious vomiting, and cholestasis and may require urgent surgical intervention in the acute setting to prevent bowel necrosis.

Single-step EUS-guided jejunojejunostomy with a lumen-apposing metal stent as treatment for malignant afferentlimb syndrome.

Single-step EUS-guided jejunojejunostomy with a lumen-apposing metal stent as treatment for malignant afferentlimb syndrome.

Lower peripouch fat area is related with increased frequency of pouch prolapse and floppy pouch complex in inflammatory bowel disease patients.

Pouch prolapse is a rare pouch complication which often leads to pouch failure in inflammatory bowel disease (IBD) patients. Its exact cause remains unknown. Floppy pouch complex (FPC) was defined as the presence of any one of the following pouch disorders: pouch prolapse, afferent limb syndrome (ALS), redundant loop, and pouch folding. We aimed to explore the role of peripouch fat area in the occurrence of pouch prolapse and FPC. Pouch patients with available pouchoscopy and abdominal CT scans who were followed up between 2011 and 2017 in Cleveland Clinic were reviewed. Peripouch fat was measured on CT images. Of the 93 included patients, 31 were females; 87 had J pouches and 6 had S pouches. The median duration of pouch was 8.0 (interquartile range [IQR] 5.0-16.5) years. A total of 18 cases (19.4%, 18/93) were identified as FPC, including 12 pouch prolapse, 5 ALS, 1 redundant loop, and 3 pouch folding. Patients with pouch prolapse had lower peripouch fat area (13.6 (9.3-18.5) vs. 27.6 (11.0-46.2)cm2, P = 0.022) than those without. Patients with FPC had lower peripouch fat area (15.4 (11.4-20.6) vs. 27.6 (11.0-46.9)cm2, P = 0.040) than those without. Univariate and multivariate analyses demonstrated that lower peripouch fat area, lower weight, and family history of IBD were independent predictors of pouch prolapse and FPC. A lower peripouch fat area was observed in inflammatory bowel disease patients with pouch prolapse and FPC. Longitudinal studies are needed to further elucidate the role of peripouch fat in the pathogenesis of pouch prolapse and FPC.