Paul Travers, MD1, Daniela Fluxa, MD1, Rohan D. Patel, MBBS2, Reema Wagh, BS1, Michelle F. DeLeon, MD1, Jami Kinnucan, MD, FACG1, Mihir S. Wagh, MD1 1Mayo Clinic, Jacksonville, FL; 2Mayo Clinic, Camden, DE Introduction: Ileal pouch volvulus (PV), or twisted pouch syndrome, is a rare complication of ileal pouch-anal anastomosis (IPAA), occurring in fewer than 1 in 1000 cases. It results from torsion of the pouch around its mesenteric axis and can lead to ischemia or necrosis if not promptly recognized. Endoscopic decompression is generally the initial treatment; however, failure often necessitates surgical detorsion with pouch pexy. We present a pregnant patient with recurrent PV successfully managed using a novel, minimally invasive endoscopic-surgical approach.
Case Description/
Methods: A 26-year-old woman, 13 weeks pregnant, presented with abdominal pain. Her history included ulcerative colitis, total colectomy with IPAA and diverting loop ileostomy, anastomotic stricture treated via manual dilation complicated by perforation resulting in creation of end-ileostomy, and PV managed with endoscopic decompression.
Repeat pouchoscopy revealed a severe torsional stenosis at the ileorectal anastomosis, with a distended pouch proximal to the twist. This was traversed with the ultra-thin upper endoscope. A long guidewire was placed into the pouch body through the stenosis to allow placement of a Lumen-Apposing Metal Stent (LAMS) without fluoroscopy. A 10 x 10 mm LAMS was deployed across the stenosis and a Foley catheter placed through it for decompression [Fig. 1].
Four weeks later, the patient was brought back for stent removal and for placement of an internal drainage catheter for long-term decompression with minimal need for re-interventions during pregnancy. Under direct endoscopic visualization, a 16 French Malecot tube was placed through the LAMS into the upstream pouch. The LAMS was removed endoscopically over the Malecot, which was confirmed in position on pouchoscopy [Fig. 2]. The tube was cut and sutured in place to have the distal end just proximal to the dentate line (completely internal drain). Discussion: This case illustrates a novel, fluoroscopy-free collaborative approach to recurrent PV in a pregnant patient, combining endoscopic and surgical techniques to avoid more invasive procedures. While endoscopic detorsion is often first-line, it may be insufficient. Surgical intervention, including pouch pexy, is typically the next step but may not be feasible in all patients. This case demonstrates a minimally invasive alternative treatment using Lumen Apposing Metal Stent placement and internal catheter drainage without radiation exposure, with successful short-term outcomes.
Figure: Figure 1. Pouchoscopy. A) Severe ileo-rectal anastomotic stricture. B) Severe torsional stenosis in the pouch C) Placement of a LAMS without fluoroscopy. D) The pouch superior to the stenosis/torsion appeared dilated.
Figure: Figure 2. Follow-up endoscopy. A) 16 French Malecot tube. B) Under direct visualization, the tube was fed through the LAMS into the pouch. B) The LAMS was then endoscopically removed over the tube, which was then sutured in place and shortened to lie just proximal to the dentate line serving as a completely internal drain.
Disclosures: Paul Travers indicated no relevant financial relationships. Daniela Fluxa indicated no relevant financial relationships. Rohan Patel indicated no relevant financial relationships. Reema Wagh indicated no relevant financial relationships. Michelle DeLeon indicated no relevant financial relationships. Jami Kinnucan: Abbvie – Advisor or Review Panel Member, Consultant. J&J – Advisor or Review Panel Member. Lilly – Advisor or Review Panel Member, Consultant. Pfizer – Advisor or Review Panel Member, Consultant. Takeda – Advisor or Review Panel Member, Consultant. Mihir Wagh: Aspero – Consultant. Boston Scientific – Consultant. Creo Medical – Consultant. Fujifilm – Consultant. MicroTech – Consultant. Olympus – Consultant.
Paul Travers, MD1, Daniela Fluxa, MD1, Rohan D. Patel, MBBS2, Reema Wagh, BS1, Michelle F. DeLeon, MD1, Jami Kinnucan, MD, FACG1, Mihir S. Wagh, MD1. P1474 - A Knotty Problem: Untangling Recurrent Pouch Volvulus During Pregnancy, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
