Koike Yuhki, Higashi Koki, Sato Yuki, Yamashita Shinji, Nagano Yuka, Shimura Tadanobu, Kitajima Takahito, Matsushita Kohei, Okugawa Yoshinaga, Okita Yoshiki, Toiyama Yuji
Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
Department of Cancer Genome, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
Surg Case Rep. 2025;11(1). doi: 10.70352/scrj.cr.25-0045. Epub 2025 May 2.
Restorative proctocolectomy with construction of an ileal J-pouch anal anastomosis is an established gold standard procedure for managing ulcerative colitis. One of the reported complications is a residual mucosal bridge as a result of leaving an apical bridge remnant when constructing the ileal J-pouch. However, now that the surgical procedure is well established, such complications rarely occur.
A 12-year-old girl presented to our hospital because of anal pain. She had undergone three-stage surgery for ulcerative colitis refractory to medical therapy, the third stage (stoma closure) having been performed 1 month before the present admission. A computed tomography scan to investigate the possibility of a perianal or pelvic abscess showed no abscess, but revealed what appeared to be a thickening of the wall of the J-pouch, suggestive of pouchitis. Endoscopy revealed a mucosal bridge crossing the anterior and posterior walls of the J-pouch, with a stapler line near the posterior wall's root; however, there was no evidence of pouchitis. While creating the J-pouch (during the second stage of surgery for ulcerative colitis), we had ensured that an apical bridge was eliminated with a linear stapler. Moreover, a contrast enema of the J-pouch during the present admission demonstrated interruption of contrast in the J-pouch. These findings led us to conclude that the mucosal bridge had probably formed postoperatively, after J-pouch creation. The patient underwent endoscopic resection of the mucosal bridge in the J-pouch using an XXS wound retractor transanally. Both ends of the bridge were cut three times with a 5-mm stapler and the bridge was resected. The patient was discharged after surgery, having experienced immediate resolution of anal pain and no complications. Pathological examination of the resected specimen showed that the ileal wall had bent toward the J-pouch lumen with fibrous adherence on the serosal side, indicating that the mucosal bridge had developed unintentionally post-stoma closure. Preoperative computed tomography showed limited pouch expansion, whereas postoperative computed tomography showed sufficient expansion.
If anal pain develops following radical ulcerative colitis surgery (after ileal stoma closure), postoperative mucosal bridge formation should be included in the differential diagnosis.
回肠J袋肛管吻合术的恢复性直肠结肠切除术是治疗溃疡性结肠炎的既定金标准手术。报道的并发症之一是在构建回肠J袋时因留下顶端桥状残余物而形成的残余黏膜桥。然而，鉴于该手术已成熟，此类并发症很少发生。
一名12岁女孩因肛门疼痛到我院就诊。她因药物治疗无效的溃疡性结肠炎接受了三阶段手术，本次入院前1个月进行了第三阶段（造口关闭）手术。计算机断层扫描用于调查肛周或盆腔脓肿的可能性，未发现脓肿，但显示J袋壁似乎增厚，提示有袋炎。内镜检查发现一条黏膜桥横跨J袋的前后壁，后壁根部附近有吻合器缝线；然而，没有袋炎的证据。在创建J袋时（溃疡性结肠炎手术的第二阶段），我们已确保用线性吻合器消除顶端桥。此外，本次入院期间对J袋进行的对比灌肠显示J袋内造影剂中断。这些发现使我们得出结论，黏膜桥可能在创建J袋后术后形成。患者经肛门使用XXS伤口牵开器对J袋内的黏膜桥进行了内镜切除。用5毫米吻合器将桥的两端切割三次，然后切除该桥。患者术后出院，肛门疼痛立即缓解，无并发症。切除标本的病理检查显示回肠壁向J袋腔弯曲，浆膜侧有纤维粘连，表明黏膜桥在造口关闭后意外形成。术前计算机断层扫描显示袋扩张受限，而术后计算机断层扫描显示扩张充分。
如果在根治性溃疡性结肠炎手术后（回肠造口关闭后）出现肛门疼痛，术后黏膜桥形成应列入鉴别诊断。
