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TRANSANAL ENDOSCOPIC MICROSURGERY – EXCISION OF A GIANT VILLOUS ADENOMA

Camylle St-Laurent, MD, FRCSC, MSHc, Francois Letarte, MD, FRCSC, MHSC. CHU de Quebec

This video presentation is about a transanal endoscopic microsurgery used for the excision of a giant villous adenoma. A 68 years old woman, with no previous medical history, presented in the emergency room with complaints of fatigue and dizziness. The blood tests revealed hyponatremia, severe hypokalemia and an acute kidney failure. Multiple investigations were conducted which initially led to the conclusion of a renal tubulopathy. A thorough questionnaire later revealed the presence of mucoid discharge per rectum that had been occurring for a period of few months. The following digital rectal examination showed the presence of a large soft mass. Hence, a Mckittrick-Wheelock syndrome was suspected.

A colonoscopy was then performed and a large circumferential villous adenoma involving the entire rectum was confirmed, extending from the dentate line up to the rectosigmoid junction. The lesion appeared benign and biopsies confirmed tubulovillous adenoma. The patient was then referred to the colorectal surgical team. After discussion, transanal excision using TEM was scheduled but the patient was also consented for the possibility of conversion to a a transabdominal approach with low anterior resection and coloanal anastomosis with loop ileostomy.

Submucosal dissection was used rather than a full thickness excision in order to avoid the necessity to close the huge deficit. Infiltration of the submucosal plane with a normal saline solution with epinephrine was used to elevate the lesion from the muscular layer and faciliate dissection. Because of its size, fragmentation of the specimen was necessary to maintain adequate visualization and allow complete removal. By the end, the tumor was fully resected with a small area of mesorectal transgression, but an overall satisfying result.

Post-operatively, the patient recovered fully with normal anorectal function and was discharged 7 days later due to atrial fibrillation. She presented to the emergency six weeks later with symptoms of partial obstruction secondary to small focal area of rectal stricture. Three endoscopic ballon dilations were easily performed over two months. Five months later, she is free of any symptoms with normal gastrointestinal function.


Presented at the SAGES 2017 Annual Meeting in Houston, TX.

Abstract ID: 95528

Program Number: V310

Presentation Session: Video Loop Day 3

Presentation Type: VideoLoop

42

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