Transanal Endoscopic Microsurgery (TEM): Approach to Rectal Sleeve Resection

Saleh M Eftaiha, MD, Johan Nordenstam, MD, PhD. University of Illinois at Chicago

Background: We present a case of transanal endoscopic microsurgery (TEM) in an approach to rectal sleeve resection. A 46 year old man, with a history of immunosuppression, status post pancreas and kidney transplant, presented with a circumferential rectal stricture 7 cm from the anal verge, discovered on flexible sigmoidoscopy for concern of ischemic colitis. He recently had an endovascular repair of an aortic aneurysm (EVAR) with possible occlusion of the inferior mesenteric artery. The rectal stricture was biopsied three times showing no malignancy, however a sessile serrated adenoma was present. Due to the possibility of a malignant stricture not suitable for dilation, we proceeded with transanal endoscopic microsurgery for a sleeve resection of the mid rectum inclusive of the stricture. This occurred 2 months after his EVAR procedure.

Intervention: In lithotomy position, a long beveled operating proctoscope was inserted. The posterior resection margin was marked with electrocautery and a full thickness circumferential rectal sleeve resection through to the mesenteric fat was completed. Intraoperative frozen section was negative for malignancy. The reconstruction was done transanally and began with approximation of the proximal and distal rectal edges with three 2-0 vicryl interrupted sutures at the right and left lateral edges and along with the posterior edge. A running 2-0 PDS suture was used to close the circumferential defect, completing the hand sewn end to end intra-rectal anastomosis. Final pathology resulted in non-specific acute on chronic inflammation, negative for adenoma, dysplasia, and carcinoma. Post surgical endoscopy at 2 and 6 months revealed a healed anastomosis. Endoscopy at 12 months was significant for biopsy proven benign inflammatory ulceration on the anastomosis. The patient continues for follow up and is doing well.

Conclusion: Transanal endoscopic microsurgery is safe and feasible for rectal sleeve resection with transanal end to end hand sewn anastomosis. It offers another option in the surgeons’ armamentarium for less invasive means to resect a questionable malignancy, avoiding a low anterior resection in this particular patient. 

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