Complete Endoscopic Resection and Perforation Closure of a T1 Rectal Carcinoid Tumor

Abstract

SymbolIntroduction:Rectal carcinoid tumors are typically incidentally found and can be managed endoscopically or surgically. Although rectal carcinoids are often indolent, they can metastasize with a 5-year survival rate of 86% for all stages combined. Endoscopic management by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) versus trans-anal endoscopic microsurgery (TEMS) are the preferred management options depending on the size and clinical features of the lesion.SymbolMethods: A 74-year-old female, with history of hypertension and hyperlipidemia, was found to have an 8 mm submucosal rectal lesion on screening colonoscopy at an outside center. This was biopsied, and the site was tattooed with ink. Pathology revealed a carcinoid lesion. She was referred to our center for further management. Both endoscopic and surgical options were discussed with the patient in detail. She opted for endoscopic resection, due to her concern for sphincter injury with the TEMS approach. Flexible sigmoidoscopy with endoscopic ultrasound (EUS) and endoscopic resection were planned. Sigmoidoscopy showed a 5-6 mm submucosal lesion in the distal rectum with a tattoo mark at the base. Radial EUS exam did not reveal any involvement of the muscularis propria or any perirectal adenopathy. EMR of the lesion was successful using the band ligation EMR device. The entire lesion was resected en bloc and retrieved. Post retrieval, the resection site revealed a focal perforation of the inner circular muscle layer with an adjacent non-bleeding pulsatile vessel. Given the focal perforation and potential for delayed bleeding, seven endoclips were used to completely close the resection defect. The patient recovered uneventfully and was discharged home the same day. Pathology of the resected lesion revealed a well differentiated low grade neuroendocrine tumor with focal submucosal involvement, but without lymphovascular invasion, with negative deep and circumferential margins and a low Ki-67 index. Endoscopic surveillance is planned. Conclusion: Our case illustrates the utility of the band ligation EMR technique for complete en-bloc resection of a T1 rectal carcinoid lesion. The tattoo ink within the resection site likely created focal inflammation and scarring, resulting in involvement of the muscle layer as part of the band-based resection. This increases the risk for perforation at the EMR site. Endoclips allow complete defect closure and also help prophylactically treat vessels within the resection site to prevent delayed bleeding.