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DOI: 10.1055/a-0950-9501
Endoscopic submucosal dissection for remnant rectal neoplasm after ileal pouch-anal anastomosis for ulcerative colitis
Publication History
Publication Date:
30 July 2019 (online)
![](https://www.thieme-connect.de/media/endoscopy/201912/lookinside/thumbnails/1131_10-1055-a-0950-9501-1.jpg)
Restorative proctocolectomy with stapled ileal pouch-anal anastomosis (IPAA) has been a routinely performed surgical procedure for ulcerative colitis (UC); however, tumor development from the remnant rectal mucosa is problematic [1] [2]. Here, we report a case of successful endoscopic submucosal dissection (ESD) for a neoplasm arising from the remnant rectal mucosa after proctocolectomy for refractory UC ([Video 1]).
Video 1 Endoscopic submucosal dissection for a neoplasm arising from a remnant rectal mucosa after proctocolectomy for ulcerative colitis.
Quality:
A 64-year-old woman who underwent restorative proctocolectomy with stapled IPAA for refractory UC 16 years ago was diagnosed with a sessile neoplasm, measuring 40 mm in diameter ([Fig. 1 a]). Endoscopic submucosal dissection (ESD) was proposed as a total excisional biopsy for histopathological assessment, including background mucosa.
![](https://www.thieme-connect.de/media/endoscopy/201912/thumbnails/10-1055-a-0950-9501-i1131ev1.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
The rectal lumen was nonpliable owing to the surgical anastomotic suture and diffuse submucosal fibrosis, and therefore, unlike in the usual rectal ESD procedure, a vertical approach to the muscularis was required. For this we used a multi-bending gastroscope (GIF-2TQ260M; Olympus Medical Systems, Tokyo, Japan), which offered a tangential approach to the submucosal space during a retroflex maneuver ([Fig. 1 b]). Dissection using endo-cut mode was effective, even for the severe fibrotic submucosa. Successful en bloc resection was achieved ( [Fig.1 c, d]). Histopathology revealed a tubulovillous adenoma with R0 resection ([Fig. 2]). Immunohistochemically, the tumor was negative for p53, and no dysplastic lesion was found in the background mucosa. Thus, the lesion was diagnosed as a sporadic rectal adenoma with curative resection.
![](https://www.thieme-connect.de/media/endoscopy/201912/thumbnails/10-1055-a-0950-9501-i1131ev2.jpg)
![Zoom Image](/products/assets/desktop/css/img/icon-figure-zoom.png)
To our knowledge, this is the first report describing tumorigenesis, including sporadic neoplasm, and a detailed technique of rectal ESD after proctocolectomy for UC. Although colorectal ESD for patients with UC is usually difficult because of submucosal fibrosis and adipose tissue deposition [3], successful ESD can help to avoid invasive surgery and preserve the quality of life. ESD is considered useful as a precise and minimally invasive diagnostic procedure for neoplastic lesions in patients with UC, even after proctocolectomy.
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References
- 1 Annese V, Beaugerie L, Egan L. et al. European evidence-based consensus: inflammatory bowel disease and malignancies. J Crohns Colitis 2015; 9: 945-965
- 2 Shergill AK, Lightdale JR, Bruining DH. et al. The role of endoscopy in inflammatory bowel disease. Gastrointest Endosc 2015; 81: 1101-1121
- 3 Suzuki N, Toyonaga T, East JE. Endoscopic submucosal dissection of colitis-related dysplasia. Endoscopy 2017; 49: 1237-1242