Pouch disorders: evidence, gaps, and next steps

Pouch disorders: evidence, gaps, and next stepsThe ileal pouch-anal anastomosis remains a cornerstone of surgical management for ulcerative colitis, restoring bowel continuity while preserving continence and quality of life.However, pouch-related complications are common and multifaceted, often bridging inflammatory, functional, structural, and neoplastic domains.The ECCO Topical Review on Pouch Disorders represents a major step forward in organizing this complex landscape into a unified, pragmatic framework. 1 major strength of the review is its real-world classification that extends beyond 'pouchitis' to include structural and functional problems commonly encountered in daily practice.By embracing a broad framework, the review reflects the complex reality clinicians face: overlapping symptoms and multifactorial drivers that require integrated assessment.The emphasis on multidisciplinary care, encompassing gastroenterologists, surgeons, radiologists, pathologists, specialist inflammatory bowel disease nurses, nutritionists, pelvic floor physiotherapists, and mental health professionals, reflects contemporary practice in high-volume centers and should be seen as the standard to emulate.Equally importantly, the review standardizes definitions across acute versus chronic pouchitis, cuffitis, and Crohn's-like disease of the pouch, providing much-needed consistency in diagnosis, trial eligibility, and treatment endpoints.This shared vocabulary reduces variability between centers and makes comparative studies and treat-to-target care more feasible.The therapeutic sections of the review are practical, summarizing current options for acute and chronic pouchitis, functional syndromes, and structural complications.Inclusion of the EARNEST trial supporting vedolizumab provides timely, high-quality evidence for biologic therapy in pouch disorders. 2he authors also address the crucial role of antibiotics in acute pouchitis, including comparative data favoring ciprofloxacin over metronidazole. 3 Other antibiotics, including rifaximin and various combinations, have been explored in smaller studies, although data remain limited.Importantly, the review distinguishes antibiotic-dependent from antibiotic-refractory chronic pouchitis, clarifying treatment pathways.Despite numerous advancements, the review rightly acknowledges the limitations of current evidence and underscores the need for further rigorous research.The Pouchitis Disease Activity Index (PDAI) and modified PDAI are widely used as scoring systems, though they lack formal validation and consistent application.Similarly, no universally used histological definition or grading system currently exists for pouchitis or Crohn's-like disease of the pouch.However, a recent study by Sedano et al. has proposed and externally validated a composite endoscopic and histologic index for pouchitis, representing