Endoscopic Evaluation and Management of Diversion Pouchitis and Strictures: In Comparison With Strictures in Nondiverted Pouches

Postoperative complications after ileal pouch-anal anastomosis are common and may lead to pouch failure requiring long-standing fecal diversion. Patients with diverted pouches can develop diversion pouchitis and strictures; however, the endoscopic features and management of these conditions remain poorly characterized.

This historical case-controlled study included 54 consecutive inflammatory bowel disease patients with ileal pouch-anal anastomosis who underwent endoscopic evaluation and stricturotomy for distal pouch or anastomotic strictures from January 2020 to February 2026. Twelve consecutive patients with diverted pouch strictures were compared with 42 nondiverted controls. Outcomes included pouchitis frequency, stricture characteristics, technical success, endoscopic reintervention, surgery-free survival, and adverse events. Kaplan-Meier and Cox regression analyses were used for survival end points.

Among diverted patients, 75% (N = 9) had concurrent diversion pouchitis. Strictures in diverted pouches were uniformly severe (100% vs 7.1%, P < .001) and longer (median 1.5 vs 1.0 cm, P = .002), with higher Pouchitis Disease Activity Index endoscopic subscores (median 2.0 vs 1.0, P < .001). Overall technical success was 98.4% (121/123 procedures), comparable between groups (95.2% vs 100%, P = .115). Surgical intervention was required in 3 (25%) diverted vs 9 (21%) nondiverted patients (P > .99); endoscopic reintervention occurred in 6 (50%) vs 18(43%) cases, respectively (P = .7). Surgery-free survival at 12 and 24 months was 88.9% and 47.4% in diverted vs 86.2% and 86.2% in nondiverted patients (log-rank P = .433; hazard ratio 1.68, 95% confidence interval 0.45-6.32). Adverse events occurred in 1 diverted (8.33%; abscess) vs 1 nondiverted patient (2.38%; ileus), with no perforation, bleeding, or mortality.

Most diverted pouch patients had concurrent diversion pouchitis with more severe and longer strictures. Despite these differences, endoscopic stricturotomy was feasible and safe with comparable outcomes to nondiverted pouch strictures.