Ileal Pouch Research Articles

Combining staged laparoscopic colectomy with robotic completion proctectomy and ileal pouch–anal anastomosis (IPAA) in ulcerative colitis for improved clinical and cosmetic outcomes: a single-center feasibility study and technical description

Robotic proctectomy has been shown to lead to better functional outcomes compared to laparoscopic surgery in rectal cancer. However, in ulcerative colitis (UC), the potential value of robotic proctectomy has not yet been investigated, and in this indication, the operation needs to be adjusted to the total colectomy typically performed in the preceding 6 months. In this study, we describe the technique and analyze outcomes of a staged laparoscopic and robotic three-stage restorative proctocolectomy and compare the clinical outcome with the classical laparoscopic procedure. Between December 2016 and May 2021, 17 patients underwent robotic completion proctectomy (CP) with ileal pouch–anal anastomosis (IPAA) for UC. These patients were compared to 10 patients who underwent laparoscopic CP and IPAA, following laparoscopic total colectomy with end ileostomy 6 months prior by the same surgical team at our tertiary referral center. 27 patients underwent a 3-stage procedure for refractory UC (10 in the lap. group vs. 17 in the robot group). Return to normal bowel function and morbidity were comparable between the two groups. Median length of hospital stay was the same for the robotic proctectomy/IPAA group with 7 days [median; IQR (6–10)], compared to the laparoscopic stage II with 7.5 days [median; IQR (6.25–8)]. Median time to soft diet was 2 days [IQR (1–3)] vs. 3 days in the lap group [IQR 3 (3–4)]. Two patients suffered from a major complication (Clavien–Dindo ≥ 3a) in the first 90 postoperative days in the robotic group vs. one in the laparoscopic group. Perception of cosmetic results were favorable with 100% of patients reporting to be highly satisfied or satisfied in the robotic group. This report demonstrates the feasibility of a combined laparoscopic and robotic staged restorative proctocolectomy for UC, when compared with the traditional approach. Robotic pelvic dissection and a revised trocar placement in staged proctocolectomy with synergistic use of both surgical techniques with their individual advantages will likely improve overall long-term functional results, including an improved cosmetic outcome.

Deep Infiltrating Endometriosis Affecting Ileoanal Anastomosis (J-Pouch): Surgical Approach

<h3>Study Objective</h3> To review a patient case of deep infiltrating endometriosis of an ileoanal anastomosis. <h3>Design</h3> Case report. <h3>Setting</h3> Academic institution, Minimally Invasive Gynecologic Surgery and Colorectal combined procedure. <h3>Patients or Participants</h3> 38-year-old with history of ulcerative colitis status post ileoanal anastomosis (J-pouch) with deep infiltrating endometriosis. <h3>Interventions</h3> Robotic-assisted total laparoscopic hysterectomy with bilateral salpingectomy, left oophorectomy, excision of deep infiltrating endometriosis of J-pouch, ureteral ICG injection, and pouchoscopy. <h3>Measurements and Main Results</h3> Patients with endometriosis are at increased risk of co-morbid inflammatory bowel disease. Ileoanal anastomosis is indicated in patients with disease affecting the entire colon and rectum such as ulcerative colitis. The J-pouch is created with an anastomosis of folded terminal ileum following total resection of the colon and rectum. An enterotomy of the pouch and anal anastomosis are then completed, forgoing the need for ileostomy. The primary vascular supply consists of terminal branches of the superior mesenteric artery and is therefore limited. The patient presented with pain and on MRI was found to have deep infiltrating endometriosis of the ileoanal anastomosis approximating 3.2 by 1.0 cm, as well as a left endometrioma. Intra-operatively, the deep infiltrating lesion was identified on the efferent limb on the antimesenteric border of the J-pouch ileum and removed using a shave technique. Care is taken to avoid the vascular supply to the J-pouch on the mesenteric aspect, as no collateral supply is available. An omental pedicle flap was created and secured overlying the pouch to reduce the risk of fistula formation. The patient underwent the procedure without complications. <h3>Conclusion</h3> Patients with endometriosis are at increased risk of comorbid inflammatory bowel disease. Knowledge of J-pouch anatomy is crucial to dissection in cases of endometriosis involvement, including delicate blood supply. The use of an omental flap can be helpful to prevent formation of future adhesions. A multidisciplinary approach is key to patient care.

The Evolution of Pelvic Pouch Surgery: Optimal Pouch Design for an Ileal Pouch Anal Anastomosis.

The history of pouch surgery is rooted in surgical innovation to improve quality of life in patients requiring surgical extirpation of the colon and rectum. From the early straight ileoanal anastomosis to the continent ileostomy to the modern ileal pouch anal anastomosis (IPAA), techniques have evolved in response to pitfalls in design. Optimal IPAA design and construction have changed in response to functional outcomes. Nowadays, restorative proctocolectomy with IPAA is the optimal treatment for patients with ulcerative colitis or familial adenomatous polyposis. The J-pouch with stapled anastomosis has become the preferred procedure. Historical configurations and technical pearls, as described in this article, should be considered by surgeons who regularly care for patients requiring ileal pouch surgery.

Management of Anastomotic Leaks in Ileal Pouch Anal Anastomosis for Ulcerative Colitis.

Anastomotic leaks remain a dreaded complication after ileal pouch anal anastomosis (IPAA). Their impacts can be devastating, ranging from an acute leak leading to postoperative sepsis to chronic leaks and sinus tracts resulting in long-term pouch dysfunction and subsequent pouch failure. The management of acute leaks is intricate. Initial management is important to resolve acute sepsis, but the type of acute intervention impacts long-term pouch function. Aggressive management in the postoperative period, including the use of IV fluids, broad-spectrum antibiotics, and operative interventions may be necessary to preserve pouch structure and function. Early identification and knowledge of the most common areas of leak, such as at the IPAA anastomosis, are important for guiding management. Long-term complications, such as pouch sinuses, pouch-vaginal fistulas, and diminished IPAA function complicate the overall survival and functionality of the pouch. Knowledge and awareness of the identification and management of leaks is crucial for optimizing IPAA success.

Life-threatening bowel complications following anti-tumor necrosis factor antibody therapy for patients with inflammatory bowel disease

Incidence of inflammatory bowel disease (IBD) in Taiwan and the experience of the management of serious complications is much lower than in Western countries. The authors just want to alert readers that anti-tumor necrosis factor (TNF) is not without life-threatening complications. Three serious complications were described, including surgical management and outcomes following the application of anti-TNF monoclonal antibody therapy for IBD. Case 1 involved a 25-year-old man treated with five doses of adalimumab for moderate control of Crohn's disease (CD). Six months later, he experienced severe intestinal obstruction, which necessitated right hemicolectomy with ileocolic anastomosis. He recovered postsurgery. Case 2 involved a 54-year-old man treated with adalimumab for intractable ulcerative colitis. Ten days after the second dose of adalimumab, an emergent subtotal colectomy with ileostomy was performed for a transverse colon perforation with peritonitis. The patient underwent an ileal pouch operation a year later. Case 3 was based on a 16-year-old male patient treated with six doses of an infliximab biosimilar for CD; thereafter, an emergent subtotal colectomy with ileostomy and Hartmann's pouch was performed for peritonitis with the presence of a perforated gastrocolic fistula tract. He had no serious complications following an uneventful recovery period. Creating awareness of serious complications associated with biologic treatments and offering appropriate patient management, including surgical treatment, is beneficial to patients.

Crohn's of the Pouch: Now What?

Total proctocolectomy and ileal pouch anal anastomosis (IPAA) is the gold standard surgical treatment for the majority (∼90%) of ulcerative colitis (UC) patients. In cases of carefully selected Crohn's colitis patients without small bowel or perianal involvement an "intentional IPAA" may be a viable option for disease resection and restoration of intestinal continuity. More commonly, Crohn's is incidentally found either in the resection specimen or, more commonly, when inflammatory complications subsequently arise after pouch construction for UC or indeterminate colitis. These incidental Crohn's pouches may be diagnosed early or late period post-IPAA. Crohn's may manifest within the pouch, in the proximal small bowel, and/or distally in the rectal cuff or anus. Like intestinal Crohn's, Crohn's disease of the pouch may be of an inflammatory, fibrostenosing, or fistulizing phenotype. Treatment depends on the phenotype and includes medical treatment, most commonly in the form of tumor necrosis factor inhibitor medications; however, the newer small molecules offer a potential treatment for these patients. Surgery first entails treating the sequelae of Crohn's and is typically staged. In up to 60% of Crohn's pouches, particularly in fistulizing disease and/or recalcitrant perianal disease, the pouch fails and must be defunctioned or excised. In patients with Crohn's pouches in situ long term, outcomes including quality of life are comparable to patients who underwent IPAA for UC.

Intraoperative Techniques for Gaining Ileoanal Pouch Reach.

Ileal pouch-anal anastomosis allows for reestablishing gastrointestinal continuity in patients after proctocolectomy. The technical elements of pouch creation and gaining reach into the pelvis are demanding and require a variety of surgical maneuvers to achieve a tension-free anastomosis. We present a brief review of the literature discussing various approaches aimed at improving ileal pouch reach into the low pelvis. Although these techniques are used with different frequencies, they serve as important adjuncts to the gastrointestinal surgeons' armamentarium.

Development of a specialist ileoanal pouch surgery pathway: a multidisciplinary patient-centred approach

BackgroundRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the gold standard procedure for ulcerative colitis refractory to medical treatment, as an alternative to permanent end ileostomy. Gaining experience in pouch...

Disease Monitoring of the Ileoanal Pouch: How to Utilize Biomarkers, Imaging, and Pouchoscopy.

Restorative proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis has been associated with multiple short- and long-term complications. In this review, we examine the role of biomarkers, imaging, and pouchoscopy in the assessment of patients after ileal pouch-anal anastomosis, with a particular focus on the emergence of novel biomarkers and techniques for evaluating and risk stratifying patients after this procedure in the hopes of improving outcomes in this specific population. There are indications that that the incidence of pouchitis may be increasing in recent decades. Calprotectin and other non-invasive imaging tests such as ultrasound may offer advantages in distinguishing patients with inflammatory conditions of the pouch from other etiologies. In the search for other biomarkers that may identify patients at risk for inflammatory conditions of the pouch, the stool microbiota and metabolomics may play a key role in identifying those patients at greatest risk for complications. Advances in biomarkers, imaging, and standardized pouchoscopy scoring offer immediate improvements in clinical care and will prompt future research efforts.

When Is It Safe to Construct an Ileal Pouch after Total Abdominal Colectomy in the Acute Setting: An Experience of 300 Consecutive Patients

When Is It Safe to Construct an Ileal Pouch after Total Abdominal Colectomy in the Acute Setting: An Experience of 300 Consecutive Patients

Social Media Influences Redo Pouch Surgery Referral More Than Index Surgeons

Introduction: Redo ileal pouch anal anastomosis (IPAA), the procedure of choice for IPAA, is mainly attempted in specialized centers but referral patterns for redo IPAA are not well known. Social media may be a valuable tool for patients to find surgeons. In our study we evaluated referral patterns of redo IPAA. Methods: All redo IPAA procedures performed at our center for IPAA failure between 09/2016 and 02/2022 were included. Patient demographics, disease characteristics and referral patterns were reported. Results: A total of 141 patients with IPAA failure who had redo IPAA surgery were included. The median age was 40 years. The median time between the index surgery and the redo surgery was 5 years (interquartile range: 2-11). There were 108 ulcerative colitis, 25 indeterminate colitis and 8 familial adenomatous polyposis patients. Referrals for 49 patients were via social media or word of mouth (33.1%), 48 were referred by gastroenterologists (32.4%), 33 by colorectal surgeons (22.3%) and 1 by an oncologist (0.7%). The index case was done by our team in 11 patients (7.4%). A significant majority of patients, 30%, were from outside of our center’s tristate area. Conclusion: Social media and patient-patient interaction was the number one referral source, followed closely by the gastroenterologists. The small number of referrals by the primary surgeon is a source of concern since the majority of redo IPAAs are done to fix surgical failures.

S788 Long-Term Use of Bile Acid Sequestrants to Improve Diarrhea and Abdominal Pain in IBD Patients With Ileoanal Pouch Anastomosis: A Tertiary Referral Center Experience

Introduction: Bile acid (BA) sequestrants are commonly used in IBD following ileocecal resection to treat bile acid malabsorption and associated abdominal pain and diarrhea. There is less experience with use of BA binders in IBD patients following colectomy and ileoanal pouch reconstruction. IBD ileoanal pouch patients frequently experience bouts of diarrhea and abdominal pain and have limited treatment options. We sought to characterize our institutional experience with BA sequestrants to treat abdominal pain and diarrhea in a large cohort of IBD ileoanal pouch patients with a focus on longterm therapy and improvement in patient reported outcomes. Methods: We analyzed a prospective, natural history registry of consented IBD patients followed at a tertiary center (2009-2022). Patients with ileoanal pouch reconstruction following colectomy were identified and individuals with > 2 years of follow up formed the study cohort. BA sequestrants included cholestyramine, colestipol and colesevelam. Patient reported outcomes of diarrhea and abdominal pain, recorded at the time of clinic encounters were organized, and mean scores before and after bile acid binder therapy were compared. Results: There were 132 ileoanal pouch patients with longterm followup (mean age 51.8 + 13.9 years; 42% F; 58% M). BA sequestrants were initiated in 93 individuals and 63 patients (68%) continued therapy for >2 years, forming the multiyear therapy group. Patterns of BA sequestrant use included 48% receiving one, 41% trialing two and 11% using all three agents. The most commonly prescribed were colesevelam (48 patients), cholestyramine (33 patients) and colestipol (22 patients) and switching between BA sequestrants was commonly due to insurance coverage. The mean number of stools per day improved following initiation of BA sequestrants (p< 0.001). Abdominal pain scores also improved with longterm BA sequestrant therapy (p=0.017). Patterns of healthcare utilization improved with longterm BA sequestrant therapy with a reduction in annual patterns of emergency room visits (p=0.007) and hospitalizations (p< 0.001). (Figure) Conclusion: A majority of IBD ileoanal pouch patients benefitted from BA sequestrant treatment, reducing number of bowel movements and abdominal pain over a >2 year period, with a parallel reduction in healthcare utilization. Formal trials of BA sequestrants in the longterm management of chronic ileoanal pouch symptoms in the IBD patient population are warranted.Figure 1.: Results before and after bile acid sequestrants.

S2763 Post-Transplant Lymphoproliferative Disorder Presenting as an Isolated Pre-Pouch Ileal Ulcer in a Liver Transplant Patient With Crohn’s Disease

Introduction: Post-transplant lymphoproliferative disorder (PTLD) can occur in solid organ and hematopoietic cell transplant recipients in the setting of chronic immunosuppression. It often results from Epstein-Barr virus (EBV) affected B-cell propagation. We present a case of PTLD in a liver transplant (LT) patient with Crohn’s disease (CD) on biologic therapy. Case Description/Methods: A 67-year-old male with primary sclerosing cholangitis (PSC) cirrhosis status post living donor LT in 2001 on tacrolimus, multiple skin cancers, recurrent PSC after transplant and pan-ulcerative colitis on sulfasalazine underwent total proctocolectomy with ileo-anal anastomosis in 2013 to 2014 for colonic dysplasia. In 2019, he was diagnosed with moderate-to-severe CD of the J-pouch and pre-pouch ileum, up to 50cm from the entry site. Vedolizumab (VDZ), an α4β7 integrin monoclonal antibody, was initiated with steroid-free clinical response on every four week dosing. Repeat pouchoscopy on VDZ showed pre-pouch ileitis up to 30cm and a large, isolated ulcer in the pre-pouch ileum, 10cm proximal to the ileitis (Figure). Biopsies revealed B-cell lymphoma, consistent with PTLD. Negative EBV-encoded RNA (EBER) in-situ hybridization suggested that this diagnosis was unrelated to EBV exposure. Positron emission tomography (PET) scan did not identify distant disease activity, and bone marrow biopsy was unremarkable. VDZ was stopped due to loss of response, budesonide resumed and R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) was subsequently initiated. Follow-up pouchoscopy showed lymphoma regression but persistent CD activity. Discussion: PTLD typically presents as extra-nodal masses involving the central nervous system, lungs, gastrointestinal tract, liver, skin or allograft within one year of transplant. Immunosuppression reduction is the cornerstone of management; however, more aggressive cases, as in our patient, require systemic therapy. This case highlights a unique presentation of PTLD as an isolated ileal ulcer in a CD patient 19 years post-LT. Interestingly, the ulcer did not appear endoscopically distinct from CD-related ulceration. Furthermore, while malignancy is a potential risk of certain treatments for inflammatory bowel disease (IBD), our patient had never received thiopurines or anti-tumor necrosis factor (TNF) agents, and VDZ has not been associated with an increased risk of B-cell lymphoma. He is currently stable on low dose tacrolimus and budesonide.Figure 1.: Isolated pre-pouch ileal ulcer.

S2563 Upper GI Bleed Caused by Ampullary AVM

Introduction: GI bleed (GIB) is responsible for 1,000,000+ hospitalizations every year, and a mortality rate of 2-10%. Ampullary AVMs are an uncommon etiology of GIB and difficult from a diagnostic standpoint. We present a case of 77-year-old man presenting to emergency department (ED) with acute shortness of breath (SOB) and chest pain (CP), and dark stools for 4 days, found to have acute GIB caused by ampullary AVM. Case Description/Methods: 77-year-old white male presented to ED with acute SOB and CP. Past medical history included aortic regurgitation s/p valve replacement, atrial fibrillation s/p ablation and watchman, chronic anemia with baseline Hgb of 9, HTN, HFpEF, and ulcerative colitis s/p curative total proctocolectomy and ileostomy with modified Kock pouch procedure. Physical exam was unremarkable aside from dark-appearing ileal pouch output. He was not on anticoagulation and denied Pepto-Bismol use. Abnormal labs included Hgb/Hct of 5.1/16.4, BUN:Cr 37:1.93, and hemoccult positive stool from ileal pouch. Presenting symptoms of anemia (CP, SOB) were consistent with lab findings, concerning for GIB in setting of hemoccult positive stool. He received IV Protonix, Rocephin, and 1u pRBCs for acute blood loss anemia secondary to suspected GIB and was admitted to hospitalist. GI was consulted to do EGD, which showed active bleeding around major papilla, suggesting hemobilia. Subsequent CT A/P with contrast showed no clear etiology of bleed, so nuclear medicine bleeding scan was performed. The scan was unremarkable, and he continued to have melena, requiring 2u of pRBCs. Finally, ERCP was pursued to evaluate for potential biliary source. A normal bile duct (BD) was identified via cholangiogram, measuring 10mm without filling defect. Sphincterotomy was performed, followed by BD sweeping using a stone extraction balloon. No blood clots were noted, making hemobilia less likely. However, slow bleeding from inferior aspect of ampulla was visualized. The site was lavaged and appeared to be ampullary AVM (see Figure). Before ablation of AVM, a PD stent was placed to reduce likelihood of post-ERCP pancreatitis. Following procedure, his Hgb normalized, and he stopped having melenic stools. He continued PPI treatment outpatient and is doing well. Discussion: To our knowledge, no case of GIB caused by ampullary AVM is found in the literature. Thus, this case reports a rare finding of ampullary AVM and provides support for endoscopy as diagnostic approach in such patients.Figure 1.: Ampullary AVM.

Inflammatory Bowel Disease and Pregnancy

Inflammatory Bowel Disease and Pregnancy

S910 Iron Deficiency Is Common After Total Proctocolectomy With Ileal Pouch Anal Anastomosis in Patients With Ulcerative Colitis

S910 Iron Deficiency Is Common After Total Proctocolectomy With Ileal Pouch Anal Anastomosis in Patients With Ulcerative Colitis

S853 Factors Affecting Pouchoscopy Bowel Preparation in Patients With an Ileal Pouch Anal Anastomosis

Introduction: Inadequate bowel preparation (prep) limits visualization and can results in the need for repeat endoscopy. There is no standard recommended bowel prep prior to pouchoscopy. We hypothesized that many patients with history of ileal pouch anal anastomosis (IPAA) undergoing pouchoscopy have inadequate prep. We hope that further analysis of patients with, and without, adequate prep will lead to insights informing the development of a standardize prep. Methods: This was a retrospective review of adult patients with inflammatory bowel disease (IBD) or polyposis syndromes (PS) who underwent pouchoscopy at a tertiary referral center between June 2020-March 2022. Patient demographics, clinical characteristics, oral intake prior to pouchoscopy, recommended bowel prep, and endoscopic bowel prep were abstracted. Inadequate bowel prep was defined as “poor” or “fair” and adequate bowel prep was defined as “adequate”, “good” or “excellent” as described by the endoscopist. If the quality of the bowel prep was not described, two independent reviewers performed endoscopic photo review (DF, JK). Pouch age was defined as the time from pouch creation to time of pouchoscopy. χ2 test was used for comparative statistical analysis, a p value < 0.05 was defined as statistically significant. Results: Fifty-six patients underwent 89 pouchoscopy evaluations, 27/56 (48%) were female. IPAA was indicated for IBD in 47 patients [43 ulcerative colitis, 4 Crohn’s disease] and 9 patients with PS. Median age at time of procedure was 43y (range 18-71y), median pouch age was 8y (range 0-36y). Twenty patients (22%) were noted to have inadequate bowel prep compared to 69 (78%) with adequate bowel prep. Table compares these two groups. 17/17 (100%) of procedures done in patients with PS indication had adequate bowel prep compared to 52/72 (72%) in patients who underwent IPAA due to IBD (p=0.014). Other variables were not statistically significant. However, inadequate bowel prep was common with enema prep (9/21) and rare with large volume preps (1/15). Most PS patient used large volume prep. Conclusion: About 1 in 5 of patients with IPAA had inadequate bowel prep, all with a history of IBD. Inadequate bowel was uncommon with a large volume prep and consideration should be given to large volume prep being standard of care. Inadequate prep did not occur in PS patients, perhaps as large volume prep was commonly used by this group. Table 1. - Comparison between patients with inadequate bowel prep and appropriate bowel prep according to clinical and endoscopic characteristics Total = 89 Inadequate bowel prep (20) Adequate bowel prep (69) p value Indication for IPAA IBD (72) 20 52 0.014 Polyposis syndromes (17) 0 17 Sex Female (46) 12 34 0.398 Male (43) 8 35 Pouch age at time of procedure < 5 years (21) 5 16 0.981 5-10 years (28) 6 22 >10 years (40) 9 31 Oral intake 24 hour prior procedure Clear liquid diet (32) 5 27 0.246 Full meal (57) 15 42 Bowel prep Large volume oral bowel prep (16) 1 15 0.408 Low volume oral bowel prep (11) 5 13 Low volume oral prep and enema prep (16) 4 12 Enema prep only (30) 9 21 No bowel prep (8) 1 7 Large volume prep given Yes 1 15 0.086 No 19 54 Large/low volume oral bowel prep completeness Complete bowel prep (100% intake) (31) 5 26 0.455 Incomplete bowel prep (3) 1 2 Procedure timing Morning (60) 11 49 0.178 Afternoon (29) 9 20 Presence of distal pouch stricture Yes (20) 3 17 0.363 No (69) 17 52 Large volume bowel prep = Golytely, Miralax. Low volume bowel prep: Moviprep, Clenpiq, Suprep, magnesium citrate. Enema therapy = tap water or fleet enema.

S2877 Weight Loss Utilizing Endoscopic Sleeve Gastroplasty (ESG), Benefit for Ostomy Reversal in Obese Patient With Ulcerative Colitis (UC)

Introduction: Over the last thirty years, the prevalence of both obesity and inflammatory bowel disease has increased globally. Surgical management in ulcerative colitis (UC) is reserved for medically refractory UC, most typically in a three-stage pattern: initial removal of the colon and creation of an end ileostomy, followed by removal of the rectum and construction of ileal pouch anal anastomosis and diverting ileostomy, followed by reversal of the ileostomy. Proctectomy is particularly difficult in obese patients due to increased visceral adiposity, thickened abdominal wall, adhesions, and reduced mobility secondary to bulky mesentery. Patients with Body Mass Index (BMI) greater than 30 are found to have greater risk for complications in comparison to normal BMI counterparts. Endoscopic sleeve gastroplasty (ESG) is a newer, minimally invasive procedure for the treatment of obesity which endoscopically reduces gastric volume through an endoscopic suturing system. We present a novel case where ESG was used as a tool for weight loss in a patient who encountered delayed ostomy reversal due to morbid obesity. Case Description/Methods: A 39-year-old man with medical history significant for morbid obesity and medically refractory UC became a candidate for proctocolectomy with an ileal pouch anal anastomosis. However, given the patient’s obesity, there was concern of the J-pouch-end ileostomy being unable to reach the patient’s pelvis. Patient underwent a da Vinci assisted laparoscopic subtotal colectomy with end ileostomy in order to preserve the rectum for a potential J-pouch after his weight loss. Post subtotal colectomy and end ileostomy, patient was referred for endoscopic sleeve gastroplasty due to additional weight gain post-op due to symptom mediated inactivity, thereby further delaying his ostomy reversal and placement of ileoanal J-pouch. Patient underwent endoscopic sleeve gastrectomy (ESG) with effective weight loss, anatomically allowing successful ostomy reversal, completion proctectomy, and J-tube construction. (Figure) Discussion: Future studies are required to determine whether ESG weight loss should be an integral initial step of medical management of IBD in obese patients to inevitably avoid surgical intervention. In summary, ESG may be a pivotal modality as a tool for weight loss in patients with UC and morbid obesity who may encounter delayed proctectomy and ostomy reversal, overall helping contribute to decreased surgical morbidity, complications, and faster improvement in overall quality of life.Figure 1.: Clinical management and BMI over patient's clinical course.

S1043 Tofacitinib for the Treatment of Pouch-Related Disorders: A Case Series

S1043 Tofacitinib for the Treatment of Pouch-Related Disorders: A Case Series

Development and Validation of a Symptom-based Scoring System for Bowel Dysfunction After Ileoanal Pouch Reconstruction.

To utilize items identified as priorities by the Patient-Reported Outcomes after Pouch Surgery Delphi consensus study to create a validated tool for quantifying pouch function. The Patient-Reported Outcomes After Pouch Surgery Delphi consensus study identified 7 symptoms and 7 consequences as key domains for evaluating and analyzing ileoanal pouch function. Pouch patients were recruited at inflammatory bowel disease centers and via patient advocacy websites. They were administered a questionnaire-based survey eliciting responses regarding the frequency of a variety of bowel symptoms. Associations between items and quality of life were computed in a score generation cohort of 298 patients by logistic regression modeling. Individual score values were designated to items to create an additive score titled the "Ileoanal Pouch Syndrome Severity Score." Validity was tested in a subsequent cohort of 386 patients using receiver operating characteristic area under the curve. In addition, test-rest validity, convergent validity, and clinical validity were evaluated. After the determination of item weights, the range of possible scores was 0 to 145. Score ranges were then determined as cutoff values for "ileoanal pouch syndrome." The score was then validated on the second patient cohort, with a receiver operating characteristic area under the curve of 0.83. Importantly, worsening severity of Ileoanal Pouch Syndrome score significantly correlated with higher rates of poor quality of life. Lastly, the questionnaire was rigorously validated to show test-retest validity, convergent validity compared with other bowel function scores, and clinical validity. This study developed a patient-centered, clinically useful scoring system that can quantify the range and severity of symptoms experienced by ileoanal pouch patients and their correlation with quality of life.