Techniques in Coloproctology (2018) 22:379–381
TRICK OF THE TRADE
Sequential endoscopic and surgical removal of giant rectal adenomas
extending to the dentate line
· P. Bauerfeind
· F. Rössler
· M. Turina
Received: 5 February 2018 / Accepted: 5 May 2018 / Published online: 1 June 2018
© Springer International Publishing AG, part of Springer Nature 2018
Large tubulovillous adenomas (TVA) in the low rectum that
extend to or beyond the dentate line are a rare but challeng-
ing entity. Complete endoscopic resection is often not feasi-
ble. In this situation, abdominoperineal resection with end
colostomy is the classic alternative to achieve an oncologi-
cally safe resection. For benign disease however, this repre-
sents an operation with a major long-term impact on quality
of life. In this report, we propose a hybrid technique using
endoscopic submucosal dissection (ESD) of the lower part
of the tumor in the rectum followed by low anterior resec-
tion with total mesorectal excision (LAR/TME) and primary
anastomosis. This approach allowed for complete resection
of large TVAs with high oncological safety in three patients.
Endoscopic and surgical technique
Patients with large adenomas of the rectum that extend to
the dentate line undergo endoscopy with biopsy to exclude
carcinoma, pelvic magnetic resonance imaging (MRI), com-
puted tomography (CT) scan (chest/abdomen) as well as
endorectal ultrasound before endoscopic resection.
If no malignant process is found, the therapy shown in
Fig. 2 is performed. First, the lower part of the adenoma is
removed endoscopically with a submucosal sleeve-shaped
dissection (Figs. 1a, b, 2a), thereby clearing the lowest part
of the rectum (3–6 cm above the dentate line) from any
adenomatous tissue. The submucosal defect reepithelializes
and is checked for complete healing after 3 weeks (Fig. 1c)
prior to the LAR/TME, which will then allow complete
removal of the remaining adenoma tissue (Fig. 2b).
A 63-year-old healthy female presented with rectal bleeding.
The subsequent colonoscopy revealed a giant adenoma in the
lower rectum with low-grade dysplasia. The tumor extended
from the sphincter muscle upwards for a distance of 15 cm.
The diagnostic workup showed no signs of invasive growth
and no distant metastases.
Due to the size of the tumor and its close relationship to
the sphincter the above-mentioned procedure was attempted.
With ESD of the most distal parts of the tumor (Fig. 1a)
approximately 6 cm of the distal rectum could be cleared
from tumor (Fig. 1b). Microscopic examination revealed
TVA with low-grade dysplasia, without invasive carcinoma.
After 6 weeks, complete healing was noted endoscopically
(Fig. 1c). TME with colonic J-pouch anal anastomosis (3 cm
from the anal verge) and diverting loop ileostomy was then
performed. Histological examination confirmed a TVA
with mostly low-grade dysplasia and a small central area
with high-grade dysplasia. All margins were negative for
A 64-year-old male presented with a giant TVA in the low
rectum. MRI showed one area with suspicious inﬁltration,
indicating the presence of invasive adenocarcinoma which
was conﬁrmed by endoanal sonography (uT1b, uN0). We
performed an ESD of approximately 6–7 cm of the lower
rectum, which did not include the site with the presumed
inﬁltration. Approximately 8 cm of the tumor remained.
Histology revealed a TVA with low-grade dysplasia and
no signs of invasive carcinoma. Six weeks later TME with
A. Rickenbacher and P. Bauerfeind are joint ﬁrst authors.
* M. Turina
Department of Surgery and Transplantation, University
Hospital Zürich, Raemistrasse 100, 8091 Zurich,
Department of Gastroenterology, University Hospital Zürich,