542 Gut and Liver, Vol. 5, No. 4, December 2011 however, differs from Longo’s procedure in the level of the purse-string suture since the stapled mucosectomy requires the placement of a lower purse-string suture at a distance of 1 cm above the dentate line in order to resect the retained mucosal strip of the rectal cuff as well as the anal transitional zone mu- cosa. In cases where the previous IPAA has been created more than 2 cm above the dentate line, this procedure can be repeated with a new purse-string suture at an appropriate level to ensure complete mucosectomy. An important advantage of using the stapled mucosectomy technique is the preservation of the normal architecture of the resected rectal mucosa which therefore enables the pathologist to perform a thorough histopathologic assessment. In addition to this, this technique overcomes an incomplete surgical field exposure and the difficult manipulation associated with a com- plex mucosectomy surgery, as described earlier. Presumably, the previously reported postoperative complica- tions associated with Longo’s procedure such as pain, bleeding, incontinence, septic complications and stenosis13,14 can also be expected to occur with the stapled mucosectomy. These com- plications are directly related to the operative technique.13 Of particular note, postoperative pain can be regarded as a certain limitation since the purse-string suture is performed too close to the dentate line. The administration of epidural analgesia in the presented case enabled a fine control of postoperative pain. If epidural analgesia is not considered, infiltration of local anes- thetic agents into the dentate line would be helpful in minimiz- ing pain, as previously described for stapled hemorrhoidopexy. Based on our limited experience with only one case, stapled mucosectomy seems to be a technically feasible and clinically acceptable alternative procedure for the removal of potentially diseased rectal mucosa retained after RPC. Further studies as- sessing its efficacy and validating this technique are required. CONFLICTS OF INTEREST No potential conflict of interest relevant to this article was reported. REFERENCES 1. Lovegrove RE, Constantinides VA, Heriot AG, et al. A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg 2006;244:18-26. 2. Holder-Murray J, Fichera A. Anal transition zone in the surgi- cal management of ulcerative colitis. World J Gastroenterol 2009;15:769-773. 3. Remzi FH, Fazio VW, Delaney CP, et al. Dysplasia of the anal transitional zone after ileal pouch-anal anastomosis: results of prospective evaluation after a minimum of ten years. Dis Colon Rectum 2003;46:6-13. 4. Branco BC, Sachar DB, Heimann TM, Sarpel U, Harpaz N, Green- stein AJ. Adenocarcinoma following ileal pouch-anal anastomo- sis for ulcerative colitis: review of 26 cases. Inflamm Bowel Dis 2009;15:295-299. 5. Fujiwara T, Kawarasaki H, Fonkalsrud EW. Endorectal ileal pullthrough procedure after chemical debridement of the rectal mucosa. Surg Gynecol Obstet 1984;158:437-442. 6. Heimann TM, Slater G, Kurtz RJ, Szporn A, Greenstein AJ. Ultra- sonic mucosal proctectomy in patients with ulcerative colitis. Ann Surg 1989;210:787-791. 7. Kusunoki M, Shoji Y, Yanagi H, Yamamura T. Transanal muco- sectomy using an ultrasonically activated scalpel for ulcerative colitis. Surg Today 1999;29:392-394. 8. Forshaw MJ, Buchanan GN, Murali K, Stewart M. Endoscopic transanal rectal mucosal ablation in the surgical treatment of ul- cerative colitis: preliminary results of a novel technique. Dis Colon Rectum 2005;48:1269-1274. 9. Fazio VW, Tjandra JJ. Transanal mucosectomy. Ileal pouch ad- vancement for anorectal dysplasia or inflammation after restor- ative proctocolectomy. Dis Colon Rectum 1994;37:1008-1011. 10. Litzendorf ME, Stucchi AF, Wishnia S, Lightner A, Becker JM. Completion mucosectomy for retained rectal mucosa following restorative proctocolectomy with double-stapled ileal pouch-anal anastomosis. J Gastrointest Surg 2010;14:562-569. 11. Branco BC, Sachar DB, Heimann T, Sarpel U, Harpaz N, Greenstein AJ. Adenocarcinoma complicating restorative proctocolectomy for ulcerative colitis with mucosectomy performed by Cavitron Ultra- sonic Surgical Aspirator. Colorectal Dis 2009;11:428-429. 12. Longo A. Treatment of hemorrhoidal disease by reduction of mu- cosa and hemorrhoidal prolapse with circular suturing device: a new procedure. In: Proceedings of the 6th World Congress of En- doscopic Surgery. Bologna: Monduzzi Publishing Co., 1998:777- 784. 13. Uras C, Baca B, Boler DE. Circular stapled hemorrhoidopexy: experience of a single center with 445 cases. World J Surg 2008;32:1783-1788. 14. Sileri P, Stolfi VM, Palmieri G, et al. Stapled hemorrhoidopexy: a prospective study from pathology to clinical outcome. J Gastroin- test Surg 2007;11:1662-1668.