Abstract

Restorative proctocolectomy with ileal pouch-anal anastomosis restores intestinal continuity and generally provides excellent long-term functional outcomes. However, 5–15% of patients experience pouch failure, most commonly due to septic, mechanical, or inflammatory complications. Surgical management of pouch failure is technically demanding and requires a multidisciplinary approach in high-volume, specialized centers. This narrative review synthesizes contemporary evidence on the transabdominal surgical management of pouch failure, with an emphasis on standardized preoperative evaluation, nomenclature. Key topics include predictors of failure, differentiation of Crohn"s-like disease from mechanical etiologies, and technical considerations for pouch reconstruction. The review also emphasizes the importance of a unified team for revisional pouch surgery, involving specialized colorectal surgeons, gastroenterologists, radiologists, physician assistants, dietitians, IBD-specialized psychologists, wound-ostomy nurses, and patient support personnel.