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Endoscopic Features Associated with Ileal Pouch Failure

Elder, Kareem MD*,†; Lopez, Rocio MS, MPH*,†; Kiran, Ravi P. MD*,†; Remzi, Feza H. MD*,†; Shen, Bo MD*,†

doi: 10.1097/MIB.0b013e318280e77c
Original Clinical Article

Background: Endoscopic features as predictors in pouch failure have not been studied. A well-constructed J-pouch typically has an “owl's eye” appearance in the proximal pouch body. We hypothesized that loss of the owl's eyes is associated with a high risk for pouch failure. The aim of this study was to evaluate the association between the distorted endoscopic appearance of owl's eyes and pouch failure.

Methods: A total of 711 available pouch endoscopic images from 426 J-pouch patients were reviewed and scored blindly. A scoring system was generated for distorted owl's eyes. Multivariable analyses were performed to assess the link between the endoscopic feature or other variables and pouch failure.

Results: A total of 37 patients (8.7%) developed pouch failure, with a median of 5.0 (interquartile range, 2.0–11.0) years of follow-up. Multivariable analyses showed that 2 or more “beak” abnormalities were associated with failure rates of 33.3%, 44.4%, and 72.2% by 5, 10, and 15 years of ileal pouch-anal anastomosis, respectively (hazard ratio = 3.7; 95% confidence interval, 1.5–9.0). In addition, diagnosis of Crohn's disease or surgical complications, the postoperative use of anti–tumor necrosis factor biologics, and a high cuff endoscopy inflammation score had statistically significant hazard ratios of 3.2, 5.8, and 1.5 for pouch failure, respectively.

Conclusions: Distorted appearance of “beak” portion of owl's eyes along with Crohn's disease of the pouch or surgery-related complications, postoperative use of biologics, and persistent cuffitis were the risk factors associated with pouch failure. The assessment of endoscopic owl's eye structure may provide an additional clue to predict pouch outcome.

Article first published online 29 March 2013

Departments of *Gastroenterology and Hepatology; and

Colorectal Surgery, Digestive Disease Institute, The Cleveland Clinic Foundation, Cleveland, Ohio.

Dr Elder is now with the Department of Internal Medicine, National Guard Health Affairs, King Abdulaziz Medical City, Jeddah, Saudi Arabia.

Reprints: Bo Shen, MD, Department of Gastroenterology and Hepatology/Desk A31, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195 (e-mail:

The authors have no conflicts of interest to disclose.

Received August 23, 2012

Accepted August 31, 2012

© Crohn's & Colitis Foundation of America, Inc.
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