Revisional ileoanal pouch surgery for structural complications: a narrative review

Purpose This narrative review summarises structural causes of pouch dysfunction (PD) and pouch failure (PF) after proctocolectomy with ileal pouch-anal anastomosis (IPAA), focusing on diagnostic pathways and the role of revisional surgery. Methods A narrative synthesis of published literature was performed, including observational studies, cohort data, and expert consensus, to evaluate the aetiology, investigation, and management of structural IPAA complications and techniques for surgical revision. Results Structural causes of PD and PF include strictures, anastomotic leaks, fistulae, afferent limb syndrome, adhesions, prolapse, volvulus, and neoplasia. Diagnosis relies on a stepwise approach combining pouchoscopy, imaging, examination under anaesthesia, functional tests, and histopathology. Management follows a multidisciplinary, escalating strategy prioritising medical and endoscopic interventions such as dilation, stricturotomy, and drainage procedures. Surgery is reserved for refractory or complex disease. Revisional IPAA surgery can preserve pouch function in selected patients, though outcomes depend on underlying indication and pathology. Conclusion Structural PD and PF after IPAA require structured diagnosis and multidisciplinary, stepwise management. Most patients can achieve pouch preservation using endoscopic or revisional approaches, although some ultimately require pouch excision.