Alberto Arezzo, MD, Mauro Verra, MD, Alessandro Salvai, MD, Marco A Bonino, MD, Simone Arolfo, MD, Mario Morino, MD. Department of Surgical Sciences, University of Torino.
We present the case of a 77 year old woman who came to the emergency department complaining of bowel obstruction. After x-rays of the abdomen confirmed the presence of air-fluid levels, a CT scan with virtual colonoscopy showed a lesion at the hepatic flexure completely obstructing the bowel lumen and a wide sessile medium rectal neoplasm. The colonoscopy performed in emergency localized the round shaped lesion covered with partially necrotic and partially regular mucosa. An endoscopic ultrasonography with a mini-probe confirmed the suspicion of lipoma without features of malignancy. The lesion appeared sessile, adherent for about half the circumference to the wall. Due to numerous comorbidities, we opted for a conservative treatment tying the lipoma at the base by Endo-loop, with the intention of dropping it by necrosis. The patient restored bowel movements in the immediate hours after PEG solution administration. At 2 weeks a second colonoscopy showed partial revascularization of the lesion, for a second Endo-loop was affixed. After some days the patient evacuated and recovered the tumor which was histologically confirmed a colonic lipoma.
Transanal Endoscopic Microsurgery (TEM) was then performed for the sessile adenoma of the medium rectum, 7 cm large, with endoscopic ultrasound suspicion of submucosal infiltration. A full-thickness excision of the rectum was performed after infiltration into the submucosal layer of indocyanine green 1% at the four cardinal points. Once the mesorectum was open from the intraluminal side, we introduced the near-infrared camera, capable of displaying the lymphatic vessel and glands loaded with indocyanine. Accumulations of fluorescence, likely to be lymph nodes, were removed for histological examination, with confirmation of their nature and of absence of metastases.
Three months later a colonoscopy did not show local recurrence of both rectal lesion and colonic lipoma.
This case demonstrates the effectiveness of the technique of endoscopic ligation and drop in two times or "loop-and-let-go" even in case of bowel obstruction and the feasibility of the technique of sampling of sentinel lymph nodes during TEM in suspected adenocarcinomas of the rectum.