S5246 A Knotty Problem: Untangling Recurrent Pouch Volvulus During Pregnancy

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 1,000 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: 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 mm × 10 mm LAMS was deployed across the stenosis and a Foley catheter placed through it for decompression. 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 Fr 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. 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 LAMS placement and internal catheter drainage without radiation exposure, with successful short-term outcomes.