Combined ESD-TAMIS approach for local excision of recurrent low rectal lesion: a case report

Introduction

Current techniques for en-bloc local excision of advanced polyps or superficially invasive rectal neoplasia include endoscopic submucosal dissection (ESD) and transanal minimally invasive surgery (TAMIS). The American Gastroenterological Association, European Society of Gastrointestinal Endoscopy, Japanese Gastroenterological Endoscopy Society, and US Multi-Society Task Force recommend ESD for en-bloc resection over snare-based techniques where lesion morphology is suspicious for submucosal invasion (large non-granular or depressed lesions >20 mm in size, lesions with Vi type pit-pattern, large protruded-type lesions suspicious for early carcinoma), has submucosal fibrosis (from prior biopsy or prolapse), or is a residual or recurrent early carcinoma after prior resection (1-4). ESD allows adequate histologic evaluation and margin assessment. TAMIS is a surgical technique combining transanal access port with single-port laparoscopic technology to allow en-bloc local excision of rectal lesions with full thickness excision; this is a method for local excision appropriate for cT1N0 rectal cancers without high-risk pathologic features; or non-invasive neoplasia not amenable to endoscopic techniques (5-7).

Both ESD and TAMIS are technically challenging, but have unique advantages (8). We report a case of a large recurrent lateral spreading tumor in the low rectum extending proximally from the dentate line that employs the advantages of both ESD and TAMIS in a combined approach to local excision. We present this article in accordance with the CARE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-23-45/rc).

Case presentation

A 78-year-old female, with no first-degree family history of colorectal cancer, was referred to the St. Michael’s Hospital Advanced Therapeutic Gastroenterology team for consideration of ESD for a recurrent rectal polyp. Receiving referrals from endoscopists across the country, St. Michael’s Hospital is the only Canadian center of excellence recognized by the World Endoscopy Organization. Over 10 years, this lesion had undergone multiple interventions with multiple endoscopists and surgeons with clear residual and recurrent adenoma. Prior attempts included snare-based polypectomy techniques, piecemeal excisions, fulguration, and surgical transanal excisions. Previous pathology revealed villous and tubulovillous adenoma without high-grade dysplasia or invasive disease. Six months following her last transanal excision, follow up sigmoidoscopy demonstrated a mixed laterally spreading tumor in the distal rectum, occupying 90% of the circumference of the lumen, involving dentate line and extending 7 cm proximally. The lesion was Paris IIa + Is, with surface mucosal pattern in keeping with Japanese NBI expert team (JNET) classification 2A + 2B suspicious for high-grade dysplasia. Of note, apart from occasional mucoid discharge, she is otherwise asymptomatic and has no changes to her baseline bowel habits and reports good baseline continence.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Treatment

Due to the presence of significant scarring, the polyp was deemed not suitable for ESD by an advanced therapeutic endoscopist with over 5 years of experience in ESD and >300 cases. The severe fibrosis and size of the lesion makes resection by ESD extremely difficult and time consuming. Upfront TAMIS was considered, however, two technical considerations made a direct TAMIS approach challenging: (I) the margins of this lesion were subtle and difficult to decern without high-definition white light endoscopy and narrow band imaging (NBI); (II) the distal extent at the dentate line made access by TAMIS difficult. Traditional transanal approach was also considered, however was quickly rejected as the patient had multiple attempts of transanal excisions in the past with no success. Without further options for local excision of this distal rectal lesion, the only other alternative was considering abdominoperineal resection. A permanent colostomy was not within the interests of the patient.

A multidisciplinary case conference between surgical oncology and the advanced therapeutic gastroenterology teams developed a plan for combined ESD-TAMIS to utilize the technical advantages of both approaches. With informed consent, the patient was brought to the operating room.

In the operating room, under general anesthesia, the patient was placed in the lithotomy position. The therapeutic gastroenterology team began with endoscopic evaluation of the lesion using an Olympus HQ190 gastroscope fitted with a clear cap. Detailed examination of the lesion was performed with white light endoscopy and NBI, for accurate identification of lesion margins (Figure 1). Margin was demarcated circumferentially with diathermy with a 5 mm margin. Submucosal injection was performed using Voluven, methylene blue and dilute epinephrine (1:100,000). A circumferential incision was performed at the dentate line using the Dual knife J (Olympus, Tokyo, Japan) (Figure 2A). Once the submucosal plane was entered, the dissection was continued for 3 cm proximally from the dentate line margin to enable placement of the TAMIS platform.

Figure 1 Preoperative assessment of the lesion with white light endoscopy and NBI. NBI, narrow band imaging.

Figure 2 Combined ESD with TAMIS for local excision of recurrent large rectal lesion. (A) ESD incision: margin demarcation and initial dissection with ESD. (B) Post ESD-TAMIS excision: full surgical thickness resection of lesion and submucosal fibrosis. (C) Pinned specimen. ESD, endoscopic submucosal dissection; TAMIS, transanal minimally invasive surgery.

The perineum and anus were prepped and draped in sterile fashion using betadine. After anus was dilated with a TAMIS dilator, the TAMIS platform was then inserted and secured with silk suture. The previously initiated dissection was then continued, and full thickness surgical resection using electrocautery to the mesorectal adipose tissue was achieved. The extent of TAMIS resection was guided by the endoscopically created margin incision. The defect was left open due to size of defect and limited mobility of tissues this low in the rectum (Figure 2B). The lesion was pinned and sent for pathology (Figure 2C). There was one cautery incision within the lesion which occurred during the resection due to folding of the large lesion, but the circumferential margin was clearly grossly normal as defined by the initial endoscopic margin incision.

Outcomes and follow-up

Post-operatively, the patient remained in hospital overnight for observation and was discharged the following morning. At our institution, patients following TAMIS are routinely discharged the same day or on post-operative day one depending on patient comorbidities and/or events during the operation. On the morning of discharge, the patient was well and meeting all discharge criteria. A combined ESD-TAMIS approach enabled an efficient successful excision of the large, circumferential, recurrent lesion with adequate margins. Final pathology revealed tubulovillous adenoma with high-grade dysplasia, extensive submucosal fibrosis, and negative for malignancy. The deep margin was negative; the lesion was present at one lateral margin, and after tumor board discussion was felt to be related to the intraoperative incision across the lesion described above as opposed to a true positive margin.

Of note, the patient returned to the emergency room on post-operative day 3 with low grade fevers (38 ℃), general malaise, and mild leukocytosis (12×10⁹/L). Computed tomography (CT) revealed mild rectal inflammation in keeping with postoperative change. This was successfully managed with a course of antibiotics. The patient then recovered well at home. One month postoperatively, the patient developed decreased stool output and bloating. A stricture at the location of excision was identified endoscopically. The stricture has been successfully managed with serial digital and balloon dilatation. At follow-up flexible sigmoidoscopy at 4 months following resection, there have been no endoscopic features of residual polyp (Figure 3). With regards to her bowel function, she requires no further dilatation, and her bowel movements are well managed with daily Restoralax.

Figure 3 Post-operative flexible sigmoidoscopy: stricture after 2 dilations.

Discussion

Both ESD and TAMIS enable en-bloc local excision of rectal neoplastic lesions, and each has unique strengths and limitations. The presented case highlights a combined ESD-TAMIS approach to employ the advantages of each technique for a lateral spreading lesion extending from the dentate line with significant submucosal fibrosis from multiple prior procedures and no signs of invasive disease.

The ESD component of the case offered several advantages. Firstly, endoscopic evaluation with high-definition white light endoscopy and NBI enabled careful delineation of the margin of the lesion to ensure clear lateral margins. Secondly, given that the lesion involved dentate line, submucosal dissection for the distal few centimeters from dentate line was vital, to allow seating of the TAMIS platform. The TAMIS component of the case offered direct manipulation of the lesion, with submucosal dissection and full thickness dissection off the mesorectal adipose tissue in areas of submucosal fibrosis in a time-efficient manner, and at the same time facilitating direct hemostasis control.

ESD has shown promising results in the management of colorectal lesions. Several guidelines have been published in recent years to identify lesions appropriate for ESD resection (1-4). In a 2017 systematic review of 97 studies evaluating the efficacy of ESD, the authors found a R0 resection rate of 82.9%, en-bloc resection rate of 91% and the need for surgical revision in 1.1% of cases (8). Current literature reports local recurrence after ESD resection up to 2%, with higher recurrence in lesions located in the rectum, >50 mm in diameter, piecemeal resection and positive horizonal margin (4,9). Destruction of the lesion architecture via sampling, tattooing, and previous incomplete resections may lead to fibrosis and architectural distortion, thereby making ESD challenging. Furthermore, ESD is associated with a steep learning curve, long procedure times, therefore limiting its wide uptake (1).

TAMIS is a minimally invasive surgical technique that provides a versatile platform for rectal procedures employing a transanal access port and use of laparoscopic camera and instruments (5). Compared with ESD for local excision, TAMIS allows for full thickness excision allowing for resection of lesions that invades deeper into the submucosa and lesions with extensive fibrosis or scarring. However, the setup of TAMIS requires an access platform that seats above the anorectal ring, making it impossible to access lesions with distal extent below this. Most commonly, when lesions are distal, the distal margin is incised using standard transanal retractors and electrocautery to facilitate performing a TAMIS (10). The use of a combined ESD-TAMIS approach was only described once by a group in Japan (11). The authors successfully used the combined approach for a resection of an intramuscosal low-grade adenoma with sessile polyp (Paris Is), 3 cm in size, just above the dentate line (11). The authors concluded that the combined approach has a low complication rates and is useful in treating anorectal lesions extending to the dentate line. Similarly, we believe that the combined approach minimizes the disadvantages of ESD and TAMIS alone, while maximizing the advantages of each approach.

The case presented above demonstrates a combined ESD-TAMIS approach for a large recurrent lesion with significant fibrosis and extends distal to the dentate line. We acknowledge that despite presence of severe fibrosis and size of the lesion, ESD may be possible in the hands of an advanced endoscopist. However, the procedure would have been extremely time consuming, taking many hours longer compared to the combined approach. Here, ESD was utilized to accurately identify lesion margins, mark out the circumference of the lesion, and provide endoscopic access to the dentate line. It allowed wide margins and access to the distal part of the lesion that would otherwise be too challenging for TAMIS alone. TAMIS was then used to allow full thickness resection in areas with fibrosis and allow for completion of the resection of a large lesion in a timely fashion. Given the extent of the local excision, stenosis of the resection area occurred, but this was successfully treated with dilation. The patient had obtained good bowel function with daily Restoralax after 2 dilations. This combined approach prevented the need for surgical segmental resection by abdominoperineal resection with permanent colostomy.

Conclusions

We describe the combined use of ESD with TAMIS for the local excision of a large, recurrent lesion with extensive fibrosis extending to the dentate line that would otherwise require abdominoperineal resection with permanent colostomy.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-23-45/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-23-45/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-23-45/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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