Alessandro Fichera, MD FACS FASCRS, Marco Zoccali, MD. Departement of Surgery – University of Chicago Medical Center – Chicago, IL
Transanal Endoscopic Microsurgery (TEM) is a minimally invasive technique which allows the excision of rectal neoplasms with minimal morbidity and mortality.1,2 In the last two decades increasing evidences have been accumulating showing its safety and efficacy in the treatment not only of small benign tumors, but also of more complex lesions and early stage rectal cancers.3-5 Nevertheless, TEM represents a truly powerful tool, whose indications may not be limited just to the removal of rectal neoplasms.
In this video we present a TEM approach in a 21 years-old obese man operated on emergently for recurrent lower gastrointestinal bleeding requiring multiple transfusions. A colonoscopy demonstrated an area of ulcerated mucosa in the rectum without active bleeding; attempts at haemostasis were not successful. Due to persistent bleeding, a repeat colonoscopy was performed, and a haemostatic clip was placed on a visible vessel in the rectum. Bleeding recurred and the patient was taken then to interventional radiology where a selective angiography was performed showing an abnormal ectatic mural vessel in the mid rectum, which was embolized with coils and gelfoam. Active rectal bleeding occurred few hours later, and the surgical team was consulted and decision was made to take the patient to the operating room emergently for attempting surgical control of bleeding. The choice of TEM approach was made on the basis of the presumed location of the lesion.
The patient was placed in lithotomy position and the transanal endoscopic microsurgical device was inserted, after injection of the intersphincteric plane with 0.25% Marcaine with epinephrine. Pneumorectum was established. An area of inflamed, friable mucosa with a clearly visible vessel was visualized anteriorly and slightly to the right, just proximal to the distal rectal valve. After injection of the area with 0.25% Marcaine with epinephrine, a 3-0 Polysorb running suture was placed over it and safely secured, achieving adequate haemostasis. The TEM device was left in place for additional 10 minutes to confirm adequate control of bleeding.
The operative time was 45 minutes. The patient tolerated the procedure well with no intraoperative complications. The postoperative course was uneventful. A low residue diet was tolerated on the first post-operative day. After 72 hours of observation in the absence of rectal bleeding, the patient was discharged on postoperative day 3.
1. Qi Y, Stoddard D, Monson JR. Indications and Techniques of Transanal Endoscopic Microsurgery (TEMS). J Gastrointest Surg. Aug 2011;15(8):1306-1308.
2. Allaix ME, Rebecchi F, Giaccone C, Mistrangelo M, Morino M. Long-term functional results and quality of life after transanal endoscopic microsurgery. Br J Surg. Jun 28 2011.
3. Darwood RJ, Wheeler JM, Borley NR. Transanal endoscopic microsurgery is a safe and reliable technique even for complex rectal lesions. Br J Surg. Jul 2008;95(7):915-918.
4. Kumar AS, Sidani SM, Kolli K, et al. Transanal endoscopic microsurgery for rectal carcinoids: the largest reported U.S. experience(*). Colorectal Dis. Aug 11 2011.
5. Sgourakis G, Lanitis S, Gockel I, et al. Transanal endoscopic microsurgery for T1 and T2 rectal cancers: a meta-analysis and meta-regression analysis of outcomes. Am Surg. Jun 2011;77(6):761-772.
Session Number: VidTV2 – Video Channel Rotation Day 2
Program Number: V101