Endoscopic submucosal dissection for remnant rectal neoplasm after ileal pouch-anal anastomosis for ulcerative colitis

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.

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.

Fig. 1 The sequence of endoscopic submucosal dissection (ESD). a Endoscopic retroflex view of the lesion. Arrow head shows anastomotic suture line. b The schema of tangential approach using a retroflex maneuver with multi-bending function. c The ulcer bed after performing ESD. d The resected specimen.

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.

Fig. 2 Loupe view and high-power microscopic view of the resected specimen. The microscopic view shows the area outlined by a black square in the loupe view (hematoxylin and eosin stain).

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