G&H What are the arguments for and against pouch surveillance?
SH First of all, it should be kept in mind that although total proctocolectomy with ileoanal pouch is curative for colonic and rectal manifestations of disease, patients still have ulcerative colitis for life. Additionally, patients are at risk for ongoing inflammatory complications of the pouch and the residual anal canal, often called the rectal cuff. The main argument against routine surveillance pouchoscopy is the very low rate of pouch neoplasia in the average-risk patient. Our group at Cleveland Clinic looked at approximately 10,000 pouchoscopies in about 3500 patients, and only approximately 0.4% of patients had either dysplasia or cancer. However, that study did not stratify by high-risk patients, which can be generally separated into 3 groups. One consists of those with a history of primary sclerosing cholangitis (PSC), who have an approximately 50% risk of chronic pouchitis. Chronic inflammation is thought to increase the risk of cancer. Another high-risk group consists of those who have undergone colectomy for colorectal dysplasia or cancer, known as ulcerative colitis–associated neoplasia (UCAN). These patients have a field defect (in which all the large bowel mucosa is at risk for neoplasia) as part of the original pathophysiology of why a total proctocolectomy was recommended and performed in them in the first place. The third group consists of those who have chronic pouch inflammation. It is less controversial whether these high-risk patients need pouch surveillance. Most providers recommend routine pouch surveillance in these populations. The majority of cancers in pouch patients are identified after diagnostic pouchoscopy for symptomatic patients, not surveillance pouchoscopy. Cancer that causes symptoms is more likely to be locally advanced and present at a higher stage; therefore, theoretically at least, performing surveillance pouchoscopy, especially in high-risk patients, might allow some cancers to be detected at an earlier stage, which should increase survival. However, this has not been borne out in the literature because of the rarity of pouch cancer overall.
There is another argument for surveying pouches, even in low-risk patients. Pouch patients should receive longitudinal care. Patients need to understand that they should seek out medical care earlier rather than later, when they are experiencing pouch complications. Performing surveillance pouchoscopy allows patients to remain well connected to the team taking care of them.
G&H How frequent should surveillance be?
SH Most high-volume pouch surgeons and centers recommend annual pouchoscopy for high-risk patient groups. Patients with UCAN are definitely a high-risk group. As mentioned, patients with PSC are also at increased risk, and these patients are often the ones who had UCAN as the indication for their proctocolectomy to begin with, so these patients have 2 risk factors. Patients with a long rectal cuff are also at increased risk of neoplasia, as are those with chronic inflammation, chronic cuffitis in particular, and chronic pouchitis, which includes chronic antibiotic-dependent pouchitis and chronic antibiotic-refractory pouchitis, as well as Crohn’s-like disease of the pouch (CLDP). These patients need diagnostic pouchoscopies on a regular basis for their inflammatory complications, aside from neoplasia surveillance, and the fact that they have chronic inflammation puts them at increased risk of having pouch neoplasia. It is controversial whether family history of colorectal cancer is a risk factor. Most would say that it is at least an intermediate risk factor, and a 2- to 3-year interval is typically recommended for that patient population.
Whether average-risk pouch patients need routine surveillance is also controversial in the literature. The evidence is rather weak, which is probably why there are not good guidelines nor consensus on this issue. At Cleveland Clinic, our approach to average-risk patients without risk factors is to typically perform the first pouchoscopy 1 year after surgery and then to space it out to every 3 to 5 years if they are asymptomatic. If patients are symptomatic, the interval can certainly be moved up. On the other hand, if surveillance is performed, for example, every 3 years for the first decade, and everything looks normal without signs of inflammation or dysplasia, surveillance can be spaced out to every 5 years moving forward.
G&H What is the risk of neoplasia following the pouch procedure?
SH Similar to the risk of colorectal cancer in ulcerative colitis patients with long-standing disease, the longer a patient has chronic inflammation, the higher the risk of neoplasia. It is thought that most of these cancers are not going to occur in the first 5 to 10 years, which is a low-risk period. After 10 to 20 years, that risk increases in the setting of chronic inflammation, and providers start to become concerned after 20 to 30 years, even without inflammation, just like we would in patients with quiescent or mild ulcerative colitis.
G&H Where do most cancers arise in these patients, and why is the cuff important?
SH Chronic inflammation is a risk factor, but there is also a complication known as long rectal cuff syndrome where the pouch is not connected to the anal canal during the original operation. The rectal stump has been left long, so it is actually an ileal pouch–rectal anastomosis. Those patients have ongoing ulcerative proctitis and are definitely at increased risk of having ongoing rectal bleeding, stricture formation, and rectal cancer of the retained rectal stump. It is important to keep in mind that when cancer does occur, it can happen both in the body of the pouch (typically a small bowel adenocarcinoma) or in the residual rectal cuff or anal canal (typically rectal adenocarcinoma or a less common tumor such as anal adenocarcinoma or anorectal squamous cell carcinoma).
In my mind, the term rectal cuff is a misnomer. When making a double-stapled pouch in the current era, even with laparoscopic and robotic approaches and modern staplers, the pouch ileoanal anastomosis should be made roughly 2 cm proximal to the dentate line at the anorectal junction. That means removing all rectal tissue and just including the anal canal, hence an ileal pouch-anal anastomosis. Although ulcerative colitis does not affect the anus, patients can develop cuffitis. If patients have a cuff longer than 2 cm, the residual mucosa is at risk. Studies from Cleveland Clinic and other institutions have shown that approximately half of the cancers come from the rectal cuff and the other half from the body of the pouch.
G&H Should a hand-sewn anastomosis or double-stapled anastomosis be used?
SH A double-stapled anastomosis is used in the vast majority of patients these days. One of the reasons for this is the double-stapled anastomosis has marginally better functional outcome. Additionally, the double-stapled technique facilitates surveillance of the anal canal or rectal cuff mucosa because the pouch anal anastomosis is attached to the top of the cuff so the anal canal/rectal cuff can be seen and inspected endoscopically. The question is what to do with patients who have UCAN as the indication for their proctocolectomy. Our long-standing policy at Cleveland Clinic is to obtain multiple circumferential biopsies of what will be the anal canal/rectal cuff, sometimes called the anal transition zone, before the pouch procedure. If that strip of mucosa does not have any dysplasia before the pouch, it is our preference to use a double staple to facilitate surveillance. However, our clinic practice is not standard worldwide. If a patient has dysplasia, cancer, or UCAN as the indication for their proctocolectomy, many good centers routinely perform a hand-sewn anastomosis. When a hand-sewn anastomosis is performed in this situation, it is typically combined with a mucosectomy. The surgeon strips out the lining of the anal canal for approximately 2 cm proximal to the dentate line, pulls the pouch through the stripped lining of the internal anal sphincter, and makes a hand-sewn anastomosis in close proximity to the dentate line. Mucosectomy is not a cure for getting rid of all that mucosa in the anal canal. With a mucosectomy, islands of mucosa can be left behind and probably represent deeper parts of the glands and crypts. In patients who have had UCAN, that is where a cancer is going to develop in the future. Pulling the pouch through the internal sphincter covers up those left-behind islands of mucosa. Unfortunately, there is no ideal way to survey this area because it is buried underneath the hand-sewn pouch anastomosis. These tumors therefore typically present at a later stage when the patients are already quite symptomatic. That is one of the arguments for trying to use a double-stapled approach at the time of the pouch construction.
G&H Which techniques should be used to perform pouch surveillance?
SH This mirrors the colonoscopic and ileocolonoscopic surveillance literature from inflammatory bowel disease (IBD) overall. We are blessed in the current era to have technology such as high-definition white-light pouch endoscopes to perform pouchoscopy. There is a fairly low threshold to perform chromo-pouchoscopy. Typically, I use narrow-band imaging to help any dysplastic lesions pop out and be contrasted against the background mucosa. This is especially important in patients with chronic inflammation of the rectal cuff, cuffitis, or chronic inflammation of the pouch.
There is a fairly standardized approach to pouchoscopy. The BRIDGe group has a nice pouchoscopy template that we utilize at Cleveland Clinic. We use a very algorithmic approach to performing a pouchoscopy, irrespective of whether we are doing it for surveillance or for diagnostic reasons. The first thing is to make sure a good preparation is used. Patients do not need a full polyethylene glycol 3350 (MiraLAX) bowel preparation. What I, and many others, do is keep patients on clear liquids for 24 hours and then have the patients use a gentle milk of magnesia preparation to get rid of any solid residuals. The timing depends on whether patients are going to receive anesthesia. Milk of magnesia is not a clear liquid, so some patients use a half portion, or even less, of polyethylene glycol 3350 because it is a clear liquid if they are going to receive anesthesia. If I am performing pouchoscopy in patients awake in the office, I give them 30 to 60 cc of milk of magnesia a few hours before the procedure. In my opinion, enemas alone typically do not provide good enough bowel preparation of the pouch. We need a very high-quality study with high-quality photo-documentation of the mucosa to find any areas that are suspicious. For that reason, many surgeons favor a cathartic bowel preparation, whether polyethylene glycol 3350 or milk of magnesia.
As for deciding whether to have patients awake in the office vs use conscious sedation or anesthesia, that is largely patient preference. Many older pouch patients have been undergoing pouchoscopies awake in the office for decades already, and that is what they are comfortable with. A lot of the younger generation, especially in the setting of patients with IBD who undergo surgery, often have medical posttraumatic stress disorder. I have a fairly low threshold for offering the procedure with sedation. We want patients to have a good experience and to come back and seek our advice and care when they are having problems.
When performing the pouchoscopy, there are a few key points to keep in mind. Ideally, the distal ileum should be intubated all the way up to and past the loop ileostomy closure site. This is one of the areas that can develop an anastomotic stricture, whether related to Crohn’s-like inflammation or not, so it is important to try to check that area. Dr Benjamin Cohen, one of my colleagues at Cleveland Clinic, routinely obtains consent for endoscopic balloon dilation because providers never know what they are going to find. If an ileostomy anastomotic stricture is found, it can then be balloon dilated on the spot. Next, we inspect the afferent limb above the pouch inlet and typically take biopsies from there, as well as at the pouch inlet itself, and photo-document all of these areas. We also inspect the tip of the J-pouch as well as the pouch body. Many think the pouch anal anastomosis is the most common leak site. However, approximately 50% of pouch leaks are at the tip of the J-pouch, which is the most common spot. Occasionally, these can be occult, and only a little divot and opening can be seen at the corner of the staple line that makes the tip of the J-pouch, known as the dog-ear.
Another issue to think about is the length of the tip of the J-pouch. Ideally, it should be 2 cm or less. Endoscopists need to go up and intubate the tip, especially if it is longer than 2 cm, and then come down into the lower pouch and look at the anastomosis itself for signs of a chronic leak, which would typically be a presacral sinus. Surgeons can often unroof this, although some advanced endoscopists will take a needle knife to it, so that it can be incorporated and epithelialized into the pouch.
Finally, the endoscopist then looks at the residual anal canal/rectal cuff and obtains biopsies from there as well. A tip is to make sure to get biopsies proximal to the dentate line; if the biopsy is distal to the dentate line, the patient will jump off the bed because of pain. Distal to the dentate line is a highly innervated part of the anal canal, whereas proximal to the dentate line there are no pain fibers.
G&H How does surveillance differ for an S-pouch or a Koch pouch?
SH The vast majority of pouches now in the 21st century are J-pouches. S-pouches are reserved for when there is difficulty getting the pouch to reach the anal canal. This is a critical portion of the operation so if there is difficulty, one of the tricks that surgeons fall back on is an S-pouch. That will give us an extra 2 cm of reach, which may be the difference whether we can do an ileoanal anastomosis or not. What providers need to know about the S-pouch is that the efferent limb is 2 cm long. We do not perform S-pouches routinely because the efferent limb between the body of the S-pouch and the anal canal is prone to elongate over time, just like the body of the pouch and the afferent limb of the pouch tend to enlarge over time because of pressure from the closed anal sphincter complex. That is completely normal. However, S-pouch patients can develop efferent limb syndrome, where the 2-cm long out-spout efferent limb of the S-pouch can become elongated and kink off, causing an obstruction between the pouch body and the efferent limb. That should be kept in mind when scoping S-pouches. Also, S-pouches will not typically have a tip of the J. They have a different endoscopic appearance. Other than that, pretty much everything else is the same.
Koch pouches are a form of continent ileostomy, and there are a few extra issues to keep in mind. First, an ileoscope, or even smaller device, is needed to scope these patients, and not just the afferent limb should be assessed, but also the entire reservoir. The reservoir can become quite large, and the endoscopist should be able to look all around it. To do that, the surgeon often has to retroflex the scope in the pouch, which is one of the reasons a smaller scope is needed. When retroflexing, the surgeon should get a good look at the nipple valve on the inside of the reservoir to make sure there is no inflammation or dysplastic lesions. The nipple valve should look stable, and there should not be endoscopic evidence of a slipped nipple valve, which typically leads to patients experiencing symptoms of incontinence from their continent ileostomy.
G&H Do pouches burn out, or do they last forever?
SH They only burn out if the patient has chronic, ongoing, uncontrolled inflammation. Otherwise, pouch survival is very high. Multiple studies have shown that pouch survival at 30 years is approximately 90% to 95%. Approximately half of pouch failures are because of inflammatory complications, such as CLDP. These days, a lot of those complications are managed better with the advanced therapies in the IBD armamentarium. The other half of pouch failures are caused by leaks, and modern technology such as endoluminal vacuum therapy, also called EndoVac (or Endo-SPONGE in Europe), can help, especially with presacral sinuses. My colleagues and I have performed research on conditional pouch survival. If patients make it through the first 3 years without a leak or have a leak that has been successfully treated, pouch survival goes up to 97% or 98%.
G&H How can pouch surveillance be integrated into overall IBD health maintenance?
SH Patients with pouches still have ulcerative colitis, although they may not have any manifestations of it. They have IBD for life and need longitudinal care. This can include checking their bone health, making sure they are up-to-date with vaccinations, and having annual skin checks for squamous cells and other types of skin cancer. As part of bone health assessment, vitamin D levels should be monitored, and patients should undergo bone density scans as recommended. Patients with pouches are at increased risk of having kidney stones. These patients also are at marginal risk of having nutritional and vitamin deficiencies (eg, B12), so providers like to survey patients longitudinally for anemia. We also want to make sure that pouches are functioning well and that patients are not having problems such as pelvic floor dysfunction or mechanical complications of the pouch. Having surveillance pouchoscopies helps keep patients plugged in with their gastroenterologists and/or surgeons to ensure that patients are receiving the longitudinal care they deserve.
G&H What further research is needed?
SH The field needs pouch surveillance consensus guidelines. Additionally, with the advent of artificial intelligence and machine learning algorithms, we are entering the era, not just of big data, but of mega data. Looking at rare pouch cancers throughout the United States or worldwide with dramatically larger numbers at a population or societal level can help us obtain better data with which to base pouchoscopy surveillance recommendations.
Disclosures
Dr Holubar has received research funding from the American Society of Colon and Rectal Surgeons and the Crohn’s & Colitis Foundation.
Suggested Reading
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Alipouriani A, Lavryk O, Lipman J, et al. Ileoanal pouch salvage rates with endoluminal vacuum therapy for early vs late anastomotic leaks. J Gastrointest Surg. 2024;28(12):1976-1982.
Barnes EL, Holubar SD, Herfarth HH. Systematic review and meta-analysis of outcomes after ileal pouch-anal anastomosis in primary sclerosing cholangitis and ulcerative colitis. J Crohns Colitis. 2021;15(8):1272-1278.
Chun H, Holubar SD. Pelvic pouch cancers associated with inflammatory bowel disease. Semin Colon Rectal Surg. 2019;30(1):36-40.
Connelly TM, Lincango E, Holubar SD. Crohn’s of the pouch: now what? Clin Colon Rectal Surg. 2022;35(6):475-486.
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Feinberg AE, Lavryk O, Aiello A, et al. Conditional survival after IPAA for ulcerative and indeterminate colitis: does long-term pouch survival improve or worsen with time? Dis Colon Rectum. 2020;63(7):927-933.
Goldenshluger M, Rieder F, Holubar SD. Pouch salvage of long rectal cuff syndrome: excision of retained rectum and mesorectum with conversion to ileoanal anastomosis. Inflamm Bowel Dis. 2024;30(12):2516-2518.
Holubar S, Hyman N. Continence alterations after ileal pouch-anal anastomosis do not diminish quality of life. Dis Colon Rectum. 2003;46(11):1489-1491.
Holubar SD. Unraveling twisted pouch syndrome: a narrative review of classification, diagnosis, treatment, and prevention. Inflamm Bowel Dis. 2025;31(3):850-856.
Holubar SD, Rajamanickam RK, Gorgun E, et al. Leaks from the tip of the J-pouch: diagnosis, management, and long-term pouch survival. Dis Colon Rectum. 2023;66(1):97-105.
Lavryk O, Maspero M, Holubar SD, et al. Postoperative outcomes of a pelvic pouch procedure: lessons learned over 40 years among 5070 patients. J Gastrointest Surg. 2025;29(4):101938.
Lightner AL, Vaidya P, Vogler S, et al. Surveillance pouchoscopy for dysplasia: Cleveland Clinic Ileoanal Pouch Anastomosis Database. Br J Surg. 2020;107(13):1826-1831.
Maspero M, Liska D, Kessler H, et al. Redo IPAA for long rectal cuff syndrome after ileoanal pouch for inflammatory bowel disease. Tech Coloproctol. 2024;28(1):38.