Ertem M, et al: Stapled Mucosectomy after Ileal Pouch-Anal Anastomosis 541 Fig. 3. The anal sphincter complex is seen intact on the postoperative endoanal ultrasound (arrow and arrowhead point to the internal and external anal sphincters, respectively). showed chronic inflammatory reaction within the retained rectal mucosa. The patient had an uneventful post-operative recov- ery and was discharged home on the sixth postoperative day. On follow-up visits, the patient did not complain of any faecal incontinence or nocturnal soiling. The postoperative Wexner incontinence score was 2/month. Endoanal ultrasonography (Fig. 3) and anal manometry performed in the first postoperative month revealed no abnormality of the anal sphincter structure and function, and endoscopic examination of the anal canal and the pouch was normal (Fig. 4). No complications have been observed during a follow-up period of 5 months. DISCUSSION It is well documented that chronic inflammation may lead to dysplasia and dysplasia may ultimately lead to neoplasia in patients with long-standing UC.2 In the presented case, the preoperative colonoscopic biopsy did not reveal any evidence of dysplasia until after the histopathologic examination of the proctocolectomy specimen. Since the presence of dysplasia in the surgical specimen is a primary risk factor for developing dysplasia in the retained rectal mucosa,2 we preferred a cor- rective surgical procedure at the time of the ileostomy closure rather than performing an intensive endoscopic surveillance with regular biopsies. Retained rectal mucosa is considered a disease-bearing tissue and, if left untreated, presents a significant risk for disease per- sistence, recurrence or malignant degeneration in UC patients.10 Thus, the eradication of the rectal mucosa to provide complete surgical care for such patients has been a major concern for surgeons. To date, a number of techniques have been described and these include chemical debridement,5 ultrasonic fragmenta- tion,6 transanal mucosectomy using an ultrasonically activated scalpel7 and endoscopic transanal mucosal ablation with an Fig. 4. Postoperative endoscopic examination of the anal canal (arrow and arrowhead point to the new staple line and the ileal J-pouch, re- spectively). The excised rectal mucosa is shown in the inlet figure. urologic resectoscope.8 However, these techniques either result in ablation of the rectal mucosa or complete mucosal destruc- tion so that the histolopathologic examination can not always be thoroughly assessed.4,11 Another alternative and well-known technique is completion mucosectomy with re-construction of the IPAA. It involves a perineal approach to manually excising the retained anorectal mucosa followed by pouch advancement and neoileoanal anastomosis.9,10 However, this complex tech- nique may pose several challenges with respect to mucosal ex- cision and anastomosis reconstruction. Excessive anal dilation is often necessary to complete the procedure and there is con- siderably more tension on the neoileoanal anastomosis because of the relative lack of mobility of the ileal pouch.9 Furthermore, there is the risk of sphincter mechanism damage due to the excessive manipulation of the anal canal.10 As it is well known, good continence is primarily dependent on the sphincter func- tion and this is essential for the patient’s return to normal daily life. The idea of the stapled mucosectomy technique was born as a result of the aforementioned disadvantages associated with the previous techniques. As clearly seen, stapled mucosectomy has evolved from stapled hemorrhoidopexy, also known as Longo’s procedure,12 which is based on the resection of the rec- tal mucosa and anopexy above the dentate line for the surgical treatment of hemorrhoids. As described, the same principles of Longo’s procedure were applied in the presented case for the circumferential removal of the retained rectal mucosa after pre- vious RPC. From a technical perspective, a proper positioning of the stapler within the anal canal is important to avoid damage to the sphincters. In addition, the stapler must be kept on an ac- cess with the anal canal in order not to result in an asymetrical resection due to the inclination of the stapler. Our technique,