Columbia University Irving Medical Center Bronxville, NY
Introduction: Ileal pouch-anal anastomosis (IPAA) is a standard treatment option for patients with medically refractory ulcerative colitis (UC), UC-associated neoplasia, or familial adenomatous polyposis (FA) who require colectomy. However, this procedure is often associated with various adverse sequelae, one such rare complication being pouchocele, a form of floppy pouch complex, which describes the bulging of the anterior pouch wall into the vagina or perineum. Little is known about the management of pouchocele due to it being a rare complication. We describe a case in which a pouchocele was successfully treated with endoscopic banding ligation.
Case Description/Methods: A 53-year-old woman who underwent a staged restorative proctocolectomy and IPAA for medically-refractory UC in 2019 presented with dyschezia, incomplete evacuation, and weight loss of 40 pounds. Barium defecography performed in February 2021 showed difficult evacuation due to an anterior pouchocele and a thick fold projecting into and narrowing the lumen of the pouch posteriorly (Figure 1). The pouchocele was treated with banding (Boston Scientific Corporation, Marlborough, MA, USA) x 7 with submucosal injection of 50% glucose. The pouchocele was further treated in the same manner during additional procedure performed in April 2021 and June 2021. After the 3 sessions of endoscopic therapy, the patient’s symptoms resolved. Repeat defecography in July 2021 showed that the anterior pouchocele became significantly smaller, with minimal associated incomplete evacuation.
Discussion: There are many structural complications following IPAA that can cause mechanical obstruction. Floppy pouch complex refers to disorders in which redundant pouch or bowel leads to luminal angulation or obstruction. Pouchocele often coexists with pouch prolapse, which may be mucosal or full-thickness, and anterior, posterior, or circumferential. Patients can present with symptoms such as dyschezia, incomplete evacuation, weight loss, and frequent passing of stools. These symptoms can affect quality of life. Here, we describe the treatment of a pouchocele using banding with good results. This is a novel treatment and has not previously been described.
