BACKGROUND Creation of a small intestinal reservoir after ileal pouch-anal anastomosis (IPAA) results in an improved quality of life because of significantly diminished stool frequency. However, a number of complications associated with the pouch may jeopardize these sphincter-sparing procedures and occasionally result in permanent ileostomy. This study was conducted to assess the incidence, risk factors, clinical characteristics, management strategies, and outcome of pouch-related complications after IPAA. METHODS Data on all patients undergoing IPAA with a J pouch between 1983 and Spring 1997 were prospectively gathered. Patients with pouch-specific complications were identified, and both inpatient and outpatient records analyzed in detail. When necessary, telephone contact was made to update functional data. Other parameters evaluated included age, gender, diagnosis, medication history, diagnostic modalities, laboratory values, time course, management strategies, reoperative procedures, and final results. RESULTS Some 510 IPAA procedures were performed between 1983 and Spring 1997; 87% of patients had inflammatory bowel disease. Operative mortality was 0%. In the entire series, 27 (5.3%) had complications related to the J pouch. Of those, 22 (81%) had ulcerative colitis and were on a mean dose of 32 mg/day of prednisone. Computed tomography scan made the diagnosis in 18 (67%) and the mean white blood cell count on admission was 14,400. In 11 (41%), the complications occurred after IPAA whereas in the other 16 (59%) it occurred after ileostomy closure. In 5 (19%), the complication resolved with intravenous antibiotics and percutaneous drainage, and 22 (81%) required reoperation. Proximal (11, or 41%) and distal (8, or 30%) pouch leaks or cuff abscesses were the most common complication and accounted for 19 (70%) of the complications observed. In this series, 3 patients (11%) had complications severe enough to warrant J pouch excision, and 1 patient had a permanent ileostomy without excision. Overall pouch excision/ failure in this series was 0.78%. CONCLUSIONS Complications involving the J pouch are a seemingly unavoidable part of sphincter-sparing surgery for colonic mucosal diseases. However, if therapy is timely, aggressive, and judicious for these complex patients, pouch loss should be uncommon and long-term results acceptable.