Ileal pouch-anal anastomosis (IPAA) is a technically demanding procedure. Intraoperatively, great care must be taken to assure a straight superior mesenteric axis. Rarely, twisted pouches are inadvertently constructed, resulting in deviations of expected pouch function, i.e. patients readily able to open their bowels on average 7x/24 hours without pain. Twisted pouches may result in symptoms classified as pouch dysfunction. Herein we describe our quaternary pouch referral center experience with twisted pouch syndrome (TPS).