Endoscopic full-thickness resection for suspected residual rectal neuroendocrine tumor and closure of the defect with a new suturing system

 

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A 51-year-old white man underwent screening colonoscopy and rectal polypectomy. Histological examination showed a 5-mm neuroendocrine tumor (NET) with a positive vertical margin and a proliferation rate of < 2 %. Positron emission tomography with gallium (DOTATOC) was negative, and rectal endoscopic ultrasound showed no evidence of pararectal lymph node metastases or residual lesions, even after the use of contrast (SonoVue; Bracco Imaging, Milan, Italy). The final diagnosis was considered to be rectal NET, G1 N0 R1.

The patient was admitted to our institution to complete the resection. Further endoscopic examination showed a 6-mm rectal scar, approximately 6 cm above the dentate line with no evidence of macroscopic residual tumor ([Fig. 1]). A complete en bloc resection of a 2-cm piece of rectal wall including the mucosal scar was achieved. Initially a circumferential incision was performed with a triangle-tip knife (Olympus, Tokyo, Japan), then the muscle layers, down to the perirectal fat, were resected with the same device and an IT-knife 2 (Olympus) ([Fig. 2]; [Video 1])

Primary closure was achieved using the OverStitch endoscopic suturing system (Apollo Endosurgery, Austin, Texas, USA) ([Fig. 3] and [Fig. 4]; [Video 2] and [Video 3]), which has been available in Europe since 2013 and has demonstrated safety and efficacy in several clinical situations, such as anastomotic dehiscence, fistula, stent migration, and iatrogenic perforations [1], as well as after endoscopic submucosal dissection in humans [2] and full-thickness gastric resection in a porcine model [3]. The procedure was completed without adverse events and the patient was discharged after 3 days.

The resected specimen showed no residual tumor, probably because of the destruction of residual neoplastic cells by the cauterization that was used during the first endoscopic resection ([Fig. 5]).

A follow-up endoscopy 5 months after the procedure showed the presence of a linear scar with a residual metal anchor and its suture thread attached. Nearby a minimal amount of granulation tissue was found to have developed ([Fig. 6]).

Small rectal NETs (G1) can be resected endoscopically and complete resection is the only curative management [4]. This case demonstrated that endoscopic full-thickness resection is safe and effective for achieving a complete resection in the rectum and that the use of the OverStitch system is a good alternative when closing rectal wall defects.

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• References

• 1 Sharaiha RZ, Kumta NA, Kedia P et al. A large multicenter experience with the OverStitch device for endoscopic management of gastrointestinal strictures, defects and stent anchorage in 95 patients. Gastrointest Endosc 2014; 79 Suppl.: AB257
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• 2 Kantsevoy SV, Bitner M, Mitrakov AA et al. Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc 2014; 79: 503-507
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