Fluoroscopic Defecography Characterization of Floppy Pouch Complex with Clinical and Endoscopic Correlations

Author(s): Hong Yun Ma, Hyunjoong William Kim, Sakshi Khurana, Stuart Bentley-Hibbert, Bo Shen.

Background: For patients with medically refractory ulcerative colitis, proctocolectomy with ileal pouch-anal anastomosis is often performed. This surgery generally improves the quality of life for patients but there are also many pouch-associated complications, including but not limited to infections/inflammations, leaks, fistulas, neoplasia, and obstruction. A new emerging disease category for patients with ileal pouches is known as floppy pouch complex (FPC), which is obstruction resulting from a redundant pouch or loop of bowel. Dynamic fluoroscopic defecography is a common tool for diagnosing structural and functional complications of the pouch. We aimed to provide image-rich case-based radiologic characterization of FPC as well as related pouch-associated complications.

Methods: All patients with a J-pouch who presented for at least one dynamic fluoroscopic defecography examination at our institution were included in the study. Fluoroscopic defecography images were re-interpreted and systematically classified by three radiologists. Retrospective chart review was performed to gather additional data. The diagnosis of FPC, including afferent limb syndrome, pouch intussusception, pouch prolapse, Pouchcele, and pouch twist, was confirmed clinically, endoscopically and/ or fluoroscopically, which were characterized radiographically.

Results: There were 94 patients who underwent 98 dynamic fluoroscopic defecography between December 2013 and November 2022. Average duration of pouch in our patient cohort was 10 years at the time of the fluoroscopic defecography. A total of 77 patients (79%) were not able to completely expel the contrast from the J-pouch. Approximately 73% of examinations demonstrated at least one abnormal categorizable imaging finding and 35% of examinations demonstrated two or more abnormalities. The most common imaging findings seen on fluoroscopic defecography were Pouchcele (N = 27; 28.6%), pouch prolapse (N = 21; 22.3%), and afferent limb abnormalities (N=14; 14.9%).

Conclusion: Most fluoroscopic defecography examinations in patients with J-pouch were abnormal, some with multiple abnormalities. Most common J-pouch dysfunctions captured on fluoroscopic defecography include Pouchcele, pouch prolapse, afferent limb angulation, and stricture. Fluoroscopic defecography provides real-time evaluation of pelvic pouchpouch with true temporal resolution, which plays a unique role in aiding the diagnosis of floppy Pouch Complex.