Salvadora Delgado (Gastrointestinal Surgery Consultor)
Marta Jiménez (Gastrointestinal Surgery Specialist)
Hospital Clínic, Barcelona, Spain
A 79 years old male patient with history of high blood pressure, T2DM, atrial fibrillation and pulmonary thromboembolism (anticoagulated with acenocoumarol), suffered from rectal bleeding so underwent a colonoscopy that showed a polypoid lesion at 15 cm from the anal verge that occupied ¼ of the circumference. Biopsy was compatible with adenocarcinoma, by transrectal ultrasound the tumor was difficult to classify doubting between a T1 or T2 lesion, further investigation was done with MRI that confirmed a T1N0. By rectoscopy the lesion was in the posterior wall of the rectum at 10 cm from the anal verge. The CT Scan ruled out metastasis or pathological lymph nodes. The CEA level was below 5.
The patient has an ASA score of III and overweight (BMI 29,04 Kg/m2) so was proposed to perform a transanal endoscopic microsurgery and define the definitive treatment depending on the pathological findings.
Surgical approach was performed on Lloyd-Davies position, after irrigation of the rectal lumen with iodine solution a Lone Star retractor is placed to ease the setting of the transanal device. A couple of knots are made to fixate the platform and the GealCap is plugged, this seals the rectum and prepares it for insufflation with CO2, the neumorectum is set at 10-12 mmHg.
Now the rectal lumen is distended, the lesion is visible at the posterior wall and the first step is to use the hook to delimitate lateral margins. The next manoeuvre is to open the mucosa and dissect deep to perform full thickness resection of the rectal wall. Traction/contratraction movements are necessary to expose the correct plane, and have to be delicate because the rectal lumen is a limited space.
Once the tumor is resected the surgeon verifies the hemostasia and perform a running suture to close the mucosa.
The patient leaves the hospital one day after surgery. No pain, urinary retention or bleeding occurred. Histological examination found a T2 tumor with 40% of signet ring cells with lymphovascular invasion, in this case radical treatment is mandatory and will be performed by a taTME.