Endoscopy 2022; 54(01): E11-E12
DOI: 10.1055/a-1346-8903
E-Videos

Endoscopic submucosal dissection for polyps in the anal transitional zone after ileoanal anastomosis in a patient with familial adenomatous polyposis

1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
,
Pedro Barreiro
1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
2  Department of Gastroenterology, Hospital dos Lusíadas, Lisbon, Portugal
,
1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
,
Catarina Félix
1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
,
Iala Costa
1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
,
Cristina Chagas
1  Department of Gastroenterology, Centro Hospitalar de Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
› Author Affiliations
 

A 48-year-old man with a history of familial adenomatous polyposis (FAP) underwent prophylactic restorative proctocolectomy and ileal-pouch anal anastomosis 16 years ago and was subsequently lost to follow-up. He re-presented with rectal bleeding and endoscopy revealed multiple coalescent polypoid lesions (T0-Is + IIa), circumferentially occupying the anal transitional zone ([Fig. 1 a]) and the area of the surgical anastomosis ([Fig. 1 b]). Biopsy specimens showed a tubulovillous adenoma with low grade dysplasia and focal high grade dysplasia. The patient was referred for treatment by endoscopic submucosal dissection (ESD).

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Fig. 1 Endoscopic views showing multiple coalescent polypoid lesions: a in the anal transitional zone; b at the ileoanal anastomosis.

The procedure was performed in the endoscopy unit, with anesthetic support, using a gastroscope (GIF-HQ190; Olympus), FlushKnife BTS (Fujifilm), and IT Knife nano (Olympus). Severe fibrosis was found at the ileoanal anastomosis and multiple staples were identified beneath the tumor, some of which were removed during the procedure ([Fig. 2 a]). En bloc excision of the remaining rectal mucosa was successfully achieved ([Fig. 2 b]; [Video 1]), producing a specimen that measured 75 × 60 × 10 mm ([Fig. 3]). Pathology confirmed a tubulovillous adenoma with low and high grade dysplasia, with free tumor margins. No recurrence, stricture, or changes in bowel habit were noted at follow-up. 

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Fig. 2 Endoscopic views showing: a severe fibrosis and surgical staples visible at the anastomotic site; b the post-endoscopic submucosal dissection ulcer in the anal transitional zone.

Video 1 Endoscopic submucosal dissection for coalescent polyps in the anal transitional zone after restorative proctocolectomy and ileal-pouch anal anastomosis in a patient with familial adenomatous polyposis.


Quality:
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Fig. 3 Macroscopic appearance of the resected specimen, which measured 75 × 60 × 10 mm and showed coalescent polyps.

The ESD technique can remove gastrointestinal neoplasias, even when they are associated with severe fibrosis [1]. Although technically difficult, the authors suggest that ESD is a safe and effective treatment for complete resection of lesions associated with severe fibrosis, as found at the perianastomotic site. Restorative proctocolectomy and ileal-pouch anal anastomosis is the treatment of choice for patients with FAP and profuse adenomas, but may leave residual anal transitional zone mucosa that is prone to adenoma formation (incidence 10 %–51 %) [2]. Long-term annual endoscopic surveillance needs to be emphasized [3]. To the best of the authors’ knowledge, this is the first case of ESD for coalescent polyps located in the anal transitional zone after restorative proctocolectomy and ileal-pouch anal anastomosis in a patient with FAP.

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Catarina O’Neill, MD
Department of Gastroenterology
Centro Hospitalar Lisboa Ocidental
Hospital de Egas Moniz
Lisbon
Portugal   

Publication History

Publication Date:
16 February 2021 (online)

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany


Zoom Image
Fig. 1 Endoscopic views showing multiple coalescent polypoid lesions: a in the anal transitional zone; b at the ileoanal anastomosis.
Zoom Image
Fig. 2 Endoscopic views showing: a severe fibrosis and surgical staples visible at the anastomotic site; b the post-endoscopic submucosal dissection ulcer in the anal transitional zone.
Zoom Image
Fig. 3 Macroscopic appearance of the resected specimen, which measured 75 × 60 × 10 mm and showed coalescent polyps.