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Background Ileal pouch‐anal anastomosis (IPAA) is a standard surgical procedure for ulcerative colitis (UC) and familial adenomatous polyposis. However, pouch‐related fistulae (PRF) are a significant complication. There is no consensus on the optimal treatment for PRF. Objective This study evaluated the effectiveness of autologous adipose tissue injection (AATI) as a treatment for PRF. Methods Twenty‐one patients with IPAA and a total of 29 PRF were treated with AATI. Patients who did not achieve healing after the first treatment were offered repeated injections. Patients were followed for a median of 16 months after AATI. Outcomes including clinical healing, treatment complications, and recurrence of PRF were registered. Results After a single treatment with AATI, 48% of the fistulae were clinically healed. Repeated treatments increased the healing rate to 69%. An additional 14% responded to AATI by reduced secretion from PRF. The procedure was well tolerated with minimal complications. Conclusion AATI appears to be a safe, minimally invasive, and sphincter‐saving treatment for PRF with promising healing rates. Further studies with larger cohorts are necessary to validate these findings. Key Summary Established knowledge on this subject ◦ Ileoanal pouch‐related fistulae (PRF) occur in 5–10% of patients post‐IPAA and can ultimately lead to pouch failure. ◦ PRF lack consensus regarding optimal treatment, resulting in variable management approaches. Significant and/or new findings of this study ◦ Autologous adipose tissue injection (AATI) demonstrated a 69% clinical healing rate for PRF after repeated treatments. ◦ AATI is sphincter preserving and resulted in minimal complications, indicating it as a safe and minimally invasive treatment option. ◦ Anastomosis‐cutaneous fistulae had the highest healing rates (100%), whereas pouch‐vaginal fistulae were least responsive. ◦ This study highlights ATII as a novel therapeutic modality of ileoanal pouch‐related fistulae.

Lay Summary In a retrospective analysis of the efficacy of vancomycin in treating chronic pouch-related disorders, we found that approximately half of patients demonstrated clinical response at 4 weeks. Additionally, 76% of responders continued to demonstrate clinical response at 3 and 6 months.

Purpose The aims of this study were to assess the effects of a whole diet strategy, a Monash Pouch Diet (MPD), on pouch‐related symptoms, inflammation, quality of life, and stool characteristics in a cohort of patients with symptomatic pouches and a history of pouchitis compared with a typical Australian pouch diet. Methods In this randomized, double‐blind, placebo‐controlled dietary feeding trial, patients with ileoanal pouches received either a Monash Pouch diet or a typical Australian diet for 7 weeks. Clinical scores (Pouch Disease Activity Index, PDAI), pouch symptoms, tolerability, fecal calprotectin, and quality of life were measured pre‐ and post‐intervention. The primary outcome consisted of the proportion of patients achieving symptomatic remission (clinical PDAI ≤ 2). Results All patients on the MPD experienced worsening symptoms, and the trial was terminated early. The majority of the participants reported partial adherence (50%–80%) and poor tolerability (median: 40 mm). Quality of life outcomes were highly variable across dietary arms, and fecal indices showed no consistent trends related to diet. Conclusion This double‐blinded, placebo‐controlled, dietary feeding trial failed to determine the effect of the Monash Pouch Diet on pouchitis but suggests that the design of dietary trials for pouch patients requires careful consideration.

Total abdominal proctocolectomy with ileal pouch–anal anastomosis (IPAA) for ulcerative colitis (UC) is associated with substantial complications despite the benefits of managing refractory and/or neoplasia-associated disease. For the purpose of this review, we focused on the diagnosis of some of the most common inflammatory and structural pouch disorders and their respective management. Pouchitis is the most common complication, and it is typically responsive to antibiotics. However, chronic antibiotic refractory pouchitis (CARP) has been increasingly recognized, and biologic therapies have emerged as the mainstay of therapy. Crohn's-like disease of the pouch (CLDP) can affect up to 10% of patients with UC after IPAA. Medical options are similar to CARP therapies, including biologics with immunomodulators. Studies have shown higher efficacy rates of biologics for CLDP when compared with those for CARP. In addition, managing stricturing and fistulizing CLDP is challenging and often requires interventional endoscopy (balloon dilation and/or stricturotomy) and/or surgery. The implementation of standardized diagnostic criteria for inflammatory pouch disorders will help in advancing future therapeutic options. Structural pouch disorders are commonly related to surgical complications after IPAA. We focused on the diagnosis and management of anastomotic leaks, strictures, and floppy pouch complex. Anastomotic leaks and anastomotic strictures occur in approximately 15% and 11% of patients with UC after IPAA, respectively. Further complications from pouch leaks include the development of sinuses, fistulas, and pouch sepsis requiring excision. Novel endoscopic interventions and less invasive surgical procedures have emerged as options for the management of these disorders.

Lay Summary Chronic disorders of a pelvic pouch may result from structural complications secondary to postoperative surgical complications which manifest as a variety of symptoms. Knowing the crucial pitfalls of pouch construction can guide treatment options in patients suffering from signs of pouch failure.

Waheeb Radman Al-Kubati1– 3 1Department of Surgery, 21st September University, Sana’a, Yemen; 2Department of Surgery, Althowra Modern General Hospital, Sana’a, Yemen; 3Department of Physiology, Sana’a University, Sana’a, YemenCorrespondence: Waheeb Radman Al-Kubati, Email waheebradman@yahoo.comBackground: Low Anterior Resection Syndrome (LARS) is a debilitating complication of sphincter-preserving surgeries, particularly after Total Mesorectal Excision (TME) for very low rectal cancer. LARS adversely impacts bowel function and quality of life, highlighting the need for effective preventive strategies.Objective: This study evaluates advanced reconstructive techniques, including taeniectomy pouch (TP), transverse coloplasty (TCP), colonic J-pouch (CJP), smooth muscle plasty (SMP), and greater omentum transplantation (GOT), in reducing LARS incidence and severity.Methods: This was a single-center randomized controlled trial (RCT) conducted between April 2018 and March 2024, involving 88 patients undergoing total mesorectal excision (TME) for very low rectal cancer. The trial was registered locally at our tertiary referral center. Patients were randomized in a 1:1 ratio to either the control group (straight coloanal anastomosis) or the test group (advanced reconstructive techniques: transverse coloplasty, colonic J-pouch, taeniectomy pouch, or smooth muscle plasty, with or without greater omentum transplantation). Eligible patients had histologically confirmed, well- or moderately-differentiated adenocarcinoma located 1– 6 cm from the anal verge. Propensity score adjustment was applied during analysis to minimize residual confounding. The primary endpoint was the incidence of major Low Anterior Resection Syndrome (LARS; score > 30), assessed by validated questionnaires at 6 weeks, 3, 6, 12, and 24 months postoperatively. Secondary outcomes included stool frequency, continence recovery, and quality-of-life scores. Trial registration: [AMG-HOSP-RCT-2018-003].Results: At six weeks, major LARS occurred in 10% of the test group (95% CI: 4– 23%) versus 80% of controls (95% CI: 68– 88%) (P < 0.001). Mild LARS (score < 20) was observed in 80% of test patients compared to 5% of controls. Stool frequency improved from 4.5/day to 2.7/day within 12 months in the test group, consistently outperforming controls. Major incontinence was recorded in 10% (95% CI: 4– 23%) of test patients versus 80% (95% CI: 68– 88%) of controls. GOT combined with TP or SMP achieved the most favorable outcomes, with faster recovery of anal function and greater LARS score improvement at six weeks post-surgery. Pairwise comparisons confirmed significantly lower stool frequency in both test subgroups at all follow-up points (mean differences − 1.8 to − 0.4 without GOT; − 2.2 to − 0.6 with GOT; all P< 0.0056). Logistic regression identified test group allocation and GOT as strong independent predictors of reduced major LARS, while prior CRT was the most significant risk factor.Conclusion: GOT and other advanced techniques effectively mitigate LARS severity, resulting in enhanced postoperative quality of life. This study demonstrates the potential benefits of neorectal reservoir techniques and GOT in enhancing functional outcomes after TME for very low rectal cancer. The findings provide promising evidence supporting their role in LARS management; however, broader adoption requires validation in larger, multicenter trials with longer follow-up.Plain Language Summary: Patients with very low rectal cancer often undergo total mesorectal excision (TME), a surgery that can lead to a common complication known as Low Anterior Resection Syndrome (LARS). LARS includes problems like frequent bowel movements, urgency, and difficulty controlling stools, which can significantly affect quality of life.This study explored whether using advanced reconstructive techniques during surgery could help reduce these symptoms. These techniques included creating different types of internal pouches—such as a taeniectomy pouch, J-pouch, or transverse coloplasty—as well as using smooth muscle plasty and transplanting the body’s own omentum (a fatty tissue layer from the abdomen) to support healing and function.The results suggest that combining these approaches may improve bowel control and recovery after TME, offering better long-term outcomes for patients.Keywords: low anterior resection syndrome, TME, advanced reconstructive techniques, taeniectomy pouch, J-pouch, transverse coloplasty, smooth muscle plasty, omentum transplantation

INTRODUCTION:There are limited data regarding the natural history after ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC). The principal objectives of this study were to identify 4 key outcomes in the natural history after IPAA within 1, 3, 5, and 10 years: the incidence of pouchitis, Crohn's-like disease of the pouch, use of advanced therapies after IPAA, and pouch failure requiring excision in a network of electronic health records.METHODS:We performed a retrospective cohort study in TriNetX, a research network of electronic health records. In addition to evaluating incidence rates, we also sought to identify factors associated with pouchitis and advanced therapy use within 5 years of IPAA after 1:1 propensity score matching, expressed as adjusted hazard ratios (aHRs).RESULTS:Among 1,331 patients who underwent colectomy with IPAA for UC, the incidence of pouchitis increased from 58% in the first year after IPAA to 72% at 10 years after IPAA. After propensity score matching, nicotine dependence (aHR 1.61, 95% confidence interval [CI] 1.19-2.18), antitumor necrosis factor therapy (aHR 1.33, 95% CI 1.13-1.56), and vedolizumab prior to colectomy (aHR 1.44, 95% CI 1.06-1.96) were associated with an increased risk of pouchitis in the first 5 years after IPAA. The incidence of Crohn's-like disease of the pouch increased to 10.3% within 10 years of IPAA while pouch failure increased to 4.1%. The incidence of advanced therapy use peaked at 14.4% at 10 years after IPAA.DISCUSSION:The incidence of inflammatory conditions of the pouch remains high in the current era, with 14% of patients requiring advanced therapies after IPAA.

Reconstructive ileal-pouch anal anastomosis (IPAA) for ulcerative colitis (UC) is often created in 3-stages: colectomy ​+ ​ileostomy, proctectomy ​+ ​pouch creation with diverting loop ileostomy, then subsequent ileostomy closure. Modified 2-stage IPAA is without pouch diversion, thus avoiding a third operation. This study compares perioperative complications, quality of life (QOL) and functional outcomes of 3- versus modified 2-stage IPAA. Charts were reviewed for adult UC patients undergoing IPAA between 2010 and 2020. QOL and function were assessed with EQ-5D-3L Quality of Life and Pouch Functional Score questionnaires. 152 patients were identified. 43 modified 2-stage and 109 3-stage IPAA were similar for anastomotic leak (9.3% vs. 1.8%, p ​= ​0.06), SSI (34.9% vs. 29.7%, p ​= ​0.51) and ileus (32.6% vs. 33%, p ​= ​0.96). Modified 2-stage had less bowel obstruction than 3-stage IPAA (7.0% vs. 30.1%, p ​= ​0.006). 92 patients returned questionnaires with similar QOL and pouch function. Perioperative complications, QOL and function are similar for 3-stage IPAA and modified 2-stage IPAA. Modified 2-stage IPAA in select patients is safe and has less postoperative bowel obstruction than 3-stage IPAA. •Compared to 3-stage, modified 2-stage IPAA yields similar rates of anastomotic leak.•Compared to 3-stage, modified 2-stage IPAA yield similar rates of pouch failure.•Compared to 3-stage, modified 2-stage IPAA has lower rates of readmission.•Compared to 3-stage, modified 2-stage IPAA has lower rates of bowel obstruction.•Modified 2-stage IPAA has similar pouch function and QoL compared to 2-stage IPAA.

Abstract Background The value of histologic assessment after ileal pouch-anal anastomosis (IPAA) has not been definitively determined. We evaluated the correlation between histology and endoscopic findings, as well as the proportion of patients with inflammation in areas beyond the pouch body on their initial pouchoscopy after IPAA. Methods In a retrospective cohort study, we evaluated patients who underwent IPAA for UC between 2012 and 2020 and subsequently underwent a pouchoscopy with routine biopsies of the pouch body, pre-pouch ileum, and rectal cuff. We compared endoscopic and histologic assessments in each location using χ2 testing and Spearman correlation, as well as the development of pouchitis and Crohn’s-like disease of the pouch (CLDP) in longitudinal follow-up. Results Among 126 patients, the median time to pouchoscopy after IPAA was 384 days, with 82 patients (65%) having inflammation of the pouch body. Significantly more patients with pouch body inflammation had histologic inflammation compared with patients without pouch body inflammation (96% vs 22%, P < .001, r = 0.769). Additionally, 16 patients (13%) were found to have endoscopic inflammation of the pre-pouch ileum with corresponding histologic inflammation in 88%; of these, 31% later developed CLDP. In contrast, 13% of patients with no endoscopic inflammation displayed histologic inflammation, with none later developing CLDP. Forty-six percent of patients had rectal cuff inflammation (correlation with histologic inflammation r = 0.580). Conclusions In our evaluation, the added benefit of histology in the presence of visible endoscopic inflammation for disease activity assessment scores is unclear. The prognostic value of histologic inflammation without endoscopic inflammation warrants a longitudinal study. Lay Summary Endoscopic evaluation after ileal pouch-anal anastomosis should include anatomic areas beyond the pouch body, including the rectal cuff and the pre-pouch ileum. The added benefit of histology in the presence of visible inflammation when assessing disease activity is unclear.