Successful Endoscopic Closure of Late Ileal Pouch Stump Perforation Using Conventional Through-the-Scope Clips After...

Ileal pouch stump perforation is an extremely rare late complication after ileal pouch-anal anastomosis (IPAA), and most reported cases have required operative management. Endoscopic closure with conventional through-the-scope (TTS) clips has rarely been described in this setting, particularly when advanced closure devices are limited by anatomy. A 50-year-old man with familial adenomatous polyposis (FAP) presented with lower abdominal pain seven years after total proctocolectomy with handsewn IPAA. Computed tomography (CT) showed a localized pelvic abscess and small foci of free air adjacent to the ileal pouch stump, consistent with localized perforation. Because he was hemodynamically stable and had no generalized peritonitis, initial conservative treatment was performed. Fluoroscopy-assisted pouchoscopy identified a small stump defect with localized contrast leakage. Over-the-scope clip deployment was considered unsafe because of a severe pouch-anal anastomotic stricture; therefore, conventional TTS clips were applied in a zipper fashion. Recurrent leakage on planned second-look endoscopy was treated successfully with additional TTS clips. Complete closure was confirmed endoscopically and radiologically, and no recurrence was observed during 10 months of follow-up. This case suggests that, in carefully selected stable patients with localized ileal pouch stump perforation and a small identifiable defect, repeated conventional TTS clip closure after initial infection control may be a practical minimally invasive alternative to surgery when over-the-scope clip delivery is technically difficult.