Chaya Shwaartz, MD, Alexandra Argiroff, MD, Sanghyun A Kim, MD, FACS. Icahn School of Medicine at Mount Sinai
We present the case of rectal heterotopic gastric mucosa excised using transanal endoscopic microsurgery. The patient is a 36-year-old male who presented with intermittent rectal bleeding. He denied any weight loss. His labs were within normal limits.
On colonoscopy, we found a single, pedunculated, non-bleeding polyp in the mid rectum, about 10cm from the anal verge. He also had internal hemorrhoids. Biopsies of the polyp showed heterotopic gastric mucosa.
His intermittent rectal bleeding was likely from this polyp and possible intermittent ulcers on the surrounding mucosa from the acid secretion. There were no ulcers seen on our exam.
We tried medical treatment with proton pump inhibitors, however, he did not improve and he elected to proceed with surgical excision. Because of the size and location of the lesion, we decided to do transanal endoscopic microsurgery to remove the large polyp.
He was placed in lithotomy position, placed the TEMS platform and insufflated the rectum to 12mmHg. We started by scoring the mucosa around the identified lesion, about 0.5-1cm away from the polyp. Using the “no touch technique,” we were able to lift the polyp on the mucosa up and proceed with a full thickness dissection without grabbing the polyp itself.
After removing the polyp in its entirety, we closed the defect with running 2-0 Vicryl using an Endostitch. We secured the knot using a metal surgical clip, and performed a sigmoidoscopy at the end to confirm adequate closure of the full thickness defect.
The patient did well post-operatively, tolerated diet and was discharged home on post-operative day 1. His final pathology showed anorectal mucosa with heterotopic gastric mucosa and hemorrhoids.
Heterotopic gastric mucosa is rare, but it is the most reported epithelial heterotopia. It is mostly seen in the GI tract, often in a Meckel’s diverticulum. The differential diagnosis with neoplasms is established by biopsy sampling and histology.
There are several treatment options, including nonsurgical treatment with proton pump inhibitors and H2 blockers, but they are only temporarily effective. Endoscopic snare resection or submucosal dissection are options for excision of a smaller lesion. However, surgical excision is needed for larger polyps. Transanal endoscopic microsurgery is a safe and effective method for excising these lesions in the rectum.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 80715
Program Number: V185
Presentation Session: Video Loop
Presentation Type: VideoLoop