Rectal Lesions Research Articles

Clip Closure and PuraStat for Prevention of Clinically Significant Delayed Bleeding after Colorectal Endoscopic Submucosal Dissection: A Prospective, Observational Study

Background and aims. Clinically significant delayed bleeding (CSDB) may complicate endoscopic colorectal submucosal dissection (ESD). We aimed to assess the efficacy of preventive measures for CSDB. Methods. We assessed the results of a prospective registry of colorectal ESD for laterally spreading lesions. We evaluated the effect of clip closure and PuraStat application on the prevention of CSDB. Results. A total of 40 patients with 41 colorectal ESDs were included. ESD was successful in 38 lesions (92.7%), 35 with R0 resection (92.1%) and 33 with curative resection (86.8%). CSDB occurred in 3 of 38 lesions (7.9%, 95% CI [1.7–21.4%]), exclusively after rectal ESD (3 of 22 rectal lesions vs. 0 of 16 colonic lesions, p = 0.249). Clip closure was more frequently used after colonic ESD (12 of 16 colonic lesions vs. 2 of 22 rectal lesions, p < 0.001) and was not protective for CSDB in the univariate analysis, even though no events occurred after clip closure (0 of 14 lesions with clip closure vs. 3 of 24 lesions without, p = 0.283). PuraStat was more frequently applied after ESD for rectal lesions (16 of 22 rectal lesions vs. 2 of 16 colonic lesions, p < 0.001) and was not protective for CSDB, with all three events occurring after PuraStat application (3 of 18 lesions with PuraStat application vs. 0 of 20 lesions without, p = 0.097). Conclusions. CSDB occurred exclusively after rectal ESD, and no predictive factors were identified in the univariate analysis. Clip closure and PuraStat application were not protective for CSDB.

Surgeon assessment of significant rectal polyps using white light endoscopy alone and in comparison to fluorescence-augmented AI lesion classification

PurposePerioperative decision making for large (> 2 cm) rectal polyps with ambiguous features is complex. The most common intraprocedural assessment is clinician judgement alone while radiological and endoscopic biopsy can provide periprocedural detail. Fluorescence-augmented machine learning (FA-ML) methods may optimise local treatment strategy.MethodsSurgeons of varying grades, all performing colonoscopies independently, were asked to visually judge endoscopic videos of large benign and early-stage malignant (potentially suitable for local excision) rectal lesions on an interactive video platform (Mindstamp) with results compared with and between final pathology, radiology and a novel FA-ML classifier. Statistical analyses of data used Fleiss Multi-rater Kappa scoring, Spearman Coefficient and Frequency tables.ResultsThirty-two surgeons judged 14 ambiguous polyp videos (7 benign, 7 malignant). In all cancers, initial endoscopic biopsy had yielded false-negative results. Five of each lesion type had had a pre-excision MRI with a 60% false-positive malignancy prediction in benign lesions and a 60% over-staging and 40% equivocal rate in cancers. Average clinical visual cancer judgement accuracy was 49% (with only ‘fair’ inter-rater agreement), many reporting uncertainty and higher reported decision confidence did not correspond to higher accuracy. This compared to 86% ML accuracy. Size was misjudged visually by a mean of 20% with polyp size underestimated in 4/6 and overestimated in 2/6. Subjective narratives regarding decision-making requested for 7/14 lesions revealed wide rationale variation between participants.ConclusionCurrent available clinical means of ambiguous rectal lesion assessment is suboptimal with wide inter-observer variation. Fluorescence based AI augmentation may advance this field via objective, explainable ML methods.

Regression of a rectal lesion in a patient with Lynch syndrome after treatment with pembrolizumab

Regression of a rectal lesion in a patient with Lynch syndrome after treatment with pembrolizumab

Endoscopic Submucosal Dissection of a Large Rectal Lesion by Using a Novel Traction Device to Facilitate Traction Adjustments

Endoscopic Submucosal Dissection of a Large Rectal Lesion by Using a Novel Traction Device to Facilitate Traction Adjustments

Comparing advanced platforms for local excision of rectal lesions.

Transanal surgery facilitates organ preservation in select patients with benign and early malignant rectal lesions to avoid the functional consequences of radical surgery. The transanal endoscopic microsurgery (TEM) platform created a standard for local excision with lower margin positivity and recurrence rates than traditional transanal excision. The single-port robot (SP r) presents a promising alternative transanal platform. The goal of this study was to compare perioperative and pathologic outcomes of TEM and SP r for excision of rectal lesions. A review of consecutive patients who underwent local excision of rectal lesions at a tertiary referral center from 1/2001 to 5/2022 was performed. Cases were stratified into TEM or SP rTAMIS in a 1:1 propensity score-matched cohort, adjusting for all baseline characteristics. Clinical, tumor-specific, and perioperative outcomes were compared using χ2, and Mann-Whitney U-tests. The main outcomes were oncologic quality measures, complications, and operative time. Matching resulted 50 patients in each cohort. Groups had similar age, gender, body mass index, comorbidity, diagnosis, lesion characteristics, and neoadjuvant chemoradiation rates. There were no intraoperative complications in either cohort. Three SP rTAMIS cases were converted intraoperatively; there were no conversions in TEM. SP rTAMIS had significantly shorter operative times than TEM (mean 104 vs. 245, p = 0.027). The rates of positive distal margins (2% TEM, 0% SP rTAMIS) and piecemeal resection (4% TEM, 0% SP rTAMIS) were similar. SP rTAMIS had significantly lower postoperative morbidity rates than TEM (9% vs. 20%, p = 0.031). There was no mortality in either cohort. SP robotics provided high-quality outcomes similar to TEM for local excision of rectal lesions. SP robotics had faster operative time with comparable clinical and oncologic outcomes to TEM. These early data are promising for expanding use of SP robotic platforms.

Robot-Assisted Radical Prostatectomy in PIRADS 5 Lesions Without Prior Biopsy: Is Biopsy Really Necessary in This Cohort?

Introduction: Conventionally, confirmation of clinically significant prostate cancer (csPCa) (Gleason grade group ≥ 2) involves an initial multiparametric magnetic resonance imaging (mpMRI) followed by biopsy. Prostate biopsy incurs inherent risks of infection, bleeding, patient discomfort, and a 6-week delay before robot-assisted laparoscopic radical prostatectomy (RALP). We explored the feasibility of immediate RALP in men with PIRADS 5 lesions without preceding biopsy. Methodology: After obtaining institutional review board approval, a prospective analysis was conducted on 235 patients with PIRADS 5 lesions on mpMRI from December 2018 to February 2023. Patients were divided into 2 groups as follows: Group NoBiopsy (biopsy not done before RALP, cases, n = 118) and Group YesBiopsy (biopsy done before RALP, controls, n = 117). Baseline preoperative, intraoperative, and postoperative parameters were analyzed. Functional outcomes were monitored at 1, 3-, 6-, 9-, and 12-months follow-up post-RALP. Statistical analysis was performed using SPSS and STATA. Results: Ninety-five percent of cases and 87.17% controls had csPCa on final pathology post-RALP. Multivariable analysis did not find significant association between biopsy status and csPCa. Abnormal digital rectal examination (DRE), family history, preoperative PSA, and MRI lesion volume predicted csPCa. Significant differences were observed in console time (NoBiopsy vs. YesBiopsy, 60 ± 10 vs. 70 ± 9 minutes, p < 0.001) and estimated blood loss (80 ± 20 vs. 100 ± 30 mL, p < 0.01) between groups. At 6 months post-RALP, 96% of men in Group NoBiopsy were continent, compared with 88% of men in Group YesBiopsy (p < 0.04). All men in the study cohort were continent (0 pads) at 12 months post-RALP. Ninety-eight percent of cases and 92% of controls at 9 months and 12 months, respectively, were able to have penetrative sex with or without PDE-5 inhibitors post-RALP. Conclusion: RALP without antecedent prostate biopsy in men with PIRADS 5 lesions demonstrated substantial csPCa detection rates and superior functional outcomes, warranting further validation.

Early Surveillance Endoscopy Should Be Performed Selectively After Transanal Endoscopic Microsurgery for Rectal Lesions.

Introduction Local recurrence (LR) rates after transanal endoscopic microsurgery (TEM) are unclear, and the utility of early postoperative surveillance for low-risk lesions is unknown. This study aimed to define LR after TEM for benign polyps and invasive adenocarcinoma, describe risk factors for LR, and evaluate the utility of early surveillance endoscopy. Methods This retrospective cohort study was conducted at two hospitals in Winnipeg, Manitoba, Canada. Adult patients who underwent TEM between 2009 and 2020 were evaluated for inclusion. The primary outcome was the rate of LR on surveillance endoscopy. Other outcomes included risk factors for LR and diagnostic yield of surveillance endoscopy. Results Among 357 patients who underwent TEM for benign polyps, LR was 10.5% (95% confidence interval (CI) 5.8-15.2) at three years. Positive margin was correlated with LR on multivariate analysis (hazard ratio (HR) 8.01, 95% CI 2.78-23.08). TEM defect closure was associated with lower LR on multivariate analysis (HR 0.19, 95% CI 0.06-0.59). Among 124 patients who underwent TEM for rectal adenocarcinoma, LR was 15.0% (95% CI 6.0-24.0) at three years. The first surveillance endoscopy had a 1.4% yield for low-risk patients (benign lesion, negative margins, and closed TEM defect) and 6.9% for all others. Conclusions LR at three years after TEM was 10.5% for benign polyps and 15.0% for adenocarcinomas. Early surveillance endoscopy can be considered low yield in some patients after TEM, which can be informative for shared decision-making regarding whether to proceed with early endoscopy in a low-risk subgroup of patients.

Anatomical outcomes and complications of sacrocolpopexy using Surelift Uplift mesh: A multicentric observational study.

The study evaluated the anatomical and functional outcomes, as well as the safety data of laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP) using a lightweight macroporous mesh. A multicentric observational study was developed including five expert centers between March 2011 and December 2019. Inclusion criteria were female patients with symptomatic ≥stage II POP (POP-Q classification), who underwent a LSC. A lightweight and macroporous mesh device (Surelift Uplift) was used. Baseline anatomical positions were evaluated using POP-Q stage. The anatomical outcomes and procedural complications were assessed during the postoperative period. Primary outcomes were anatomical success, defined as POP-Q stage ≤I, and subjective success, defined as no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse. A total of 325 LSCs were analyzed with a median patient age of 66 (interquartile range [IQR] 61-73). After a median follow-up of 68 months (IQR 46.5-89), anatomical success was found in 88.9%, whereas subjective success was seen in 98.5% of the patients. Recurrent prolapse presented as cystocele (1.5%). Reported complications were bladder (4.6%) or rectum lesions (0.6%), de novo urinary incontinence (12.9%), and mesh extrusion (1.2%). LSC provides significant clinical improvement and excellent anatomical results, with a low risk of serious complications for women with ≥2 grade POP in a real clinical practice setting.

Substratifying the risk of covert malignancy in significant rectal polyps: Outcomes from a specialist multidisciplinary team (MDT).

A treatment strategy for patients with a significant polyp or early colon cancer (SPECC) of the rectum presents a challenge due to the significant rate of covert malignancy and lack of standardized assessment. For this reason, NICE recommends multidisciplinary meetings to improve outcomes. The primary aim of the present study was to report the performance of our specialist early rectal cancer (SERC) multidisciplinary team (MDT) in correctly substratifying the risk of cancer and to discuss the limitations of staging investigations in those patients with "poor outcomes". This was a retrospective review of patients referred to our SERC MDT from 2014 to 2019. Lesions were assigned by the MDT to three pre-resection categories (low, intermediate, high) according to the risk of covert malignancy. Resection method and final histology were compared to the pre-resection categories. Of 350 SPECC lesions, 174 were assessed as low-risk, 108 intermediate-risk and 68 high-risk. The cancer incidence was 4.8%, 8.3% and 53%, respectively (15.5% overall). Eight lesions were categorized as low-risk but following piecemeal resection were found to be malignant. Five lesions, three of which were categorized as high-risk, were ultimately benign following conventional surgery. One pT1sm1 cancer, removed by anterior resection, may have been treated by local excision. A total of 83% of malignant polyps were triaged to an en bloc resection technique and surgical resection avoided for nearly all benign lesions. However, 12 patients from this cohort were deemed to have a poor outcome because of miscategorization. Further comparative research is needed to establish the optimum strategy for rectal SPECC lesion assessment. There is currently no consensus for staging significant polyps of the rectum. This paper reports the effectiveness of a specialist early rectal cancer MDT to correctly risk-stratify significant rectal polyps. It underscores the importance of accurate categorization for treatment decision-making, while acknowledging the limitations of current staging modalities.

Improved deep learning for automatic localisation and segmentation of rectal cancer on T2-weighted MRI.

The automatic segmentation approaches of rectal cancer from magnetic resonance imaging (MRI) are very valuable to relieve physicians from heavy workloads and enhance working efficiency. This study aimed to compare the segmentation accuracy of a proposed model with the other three models and the inter-observer consistency. A total of 65 patients with rectal cancer who underwent MRI examination were enrolled in our cohort and were randomly divided into a training cohort (n = 45) and a validation cohort (n = 20). Two experienced radiologists independently segmented rectal cancer lesions. A novel segmentation model (AttSEResUNet) was trained on T2WI based on ResUNet and attention mechanisms. The segmentation performance of the AttSEResUNet, U-Net, ResUNet and U-Net with Attention Gate (AttUNet) was compared, using Dice similarity coefficient (DSC), Hausdorff distance (HD), mean distance to agreement (MDA) and Jaccard index. The segmentation variability of automatic segmentation models and inter-observer was also evaluated. The AttSEResUNet with post-processing showedperfect lesion recognition rate (100%) and false recognition rate (0), and its evaluation metrics outperformed other three models for two independent readers (observer 1: DSC = 0.839 ± 0.112, HD = 9.55 ± 6.68, MDA = 0.556 ± 0.722, Jaccard index = 0.736 ± 0.150; observer 2: DSC = 0.856 ± 0.099, HD = 11.0 ± 10.1, MDA = 0.789 ± 1.07, Jaccard index = 0.673 ± 0.130). The segmentation performance of AttSEResUNet was comparable and similar to manual variability (DSC = 0.857 ± 0.115, HD = 10.0 ± 10.0, MDA = 0.704 ± 1.17, Jaccard index = 0.666 ± 0.139). Comparing with other three models, the proposed AttSEResUNet model was demonstrated as a more accurate model for contouring the rectal tumours in axial T2WI images, whose variability was similar to that of inter-observer.

Infection with mpox virus via the genital mucosae increases shedding and transmission in the multimammate rat (Mastomys natalensis).

The 2022 mpox virus (MPXV) outbreak was sustained by human-to-human transmission; however, it is currently unclear which factors lead to sustained transmission of MPXV. Here we present Mastomys natalensis as a model for MPXV transmission after intraperitoneal, rectal, vaginal, aerosol and transdermal inoculation with an early 2022 human outbreak isolate (Clade IIb). Virus shedding and tissue replication were route dependent and occurred in the presence of self-resolving localized skin, lung, reproductive tract or rectal lesions. Mucosal inoculation via the rectal, vaginal and aerosol routes led to increased shedding, replication and a pro-inflammatory T cell profile compared with skin inoculation. Contact transmission was higher from rectally inoculated animals. This suggests that transmission might be sustained by increased susceptibility of the anal and genital mucosae for infection and subsequent virus release.

Rectal duplication cyst presenting with change in bowel habits and rectal bleeding: A case report and literature review

We present a rare case of rectal duplication cyst (RDC) in an adult patient who presented with chronic fluctuating bowel habits and rectal bleeding. A faecal immunochemical test (FIT) and a faecal Calprotectin level showed negative results, and no previous abdomen-pelvis CT scan or MRI was identified. A Colonoscopy was performed, showing a benign rectal lesion causing colonic intraluminal compression leading to rectal ulceration and prolapse, and solitary rectal ulcer syndrome was suspected. A Transanal Minimally Invasive surgery (TAMIS) was performed to excise the lesion, with histopathology findings consistent with a rectal duplication cyst. The patient had no intraoperative complications and made an uneventful recovery. A systematic literature review showed 30 30 adult Rectal supplication cyst case reports. In conclusion, The most common presentation of RDC is anal pain and rectal bleeding. The diagnosis of RDC is challenging, and it requires Surgical resection to confirm the diagnosis.

Transrectal contrast-enhanced ultrasound-guided transperineal core-needle biopsy versus endoscopic forceps biopsy in the diagnosis of complex rectal lesions.

The preoperative pathological diagnosis of rectal lesions is crucial for formulating treatment plans. For subepithelial lesions (SELs) and larger lesions with necrosis of the rectum, endoscopic forceps biopsy (EFB) cannot provide an accurate pathological diagnosis in most cases. By comparing the efficacy and safety of transrectal contrast-enhanced ultrasound-guided transperineal core-needle biopsy (TRCEUS-TP-CNB) and EFB, this study explored the value of TRCEUS-TP-CNB in the diagnosis of complex rectal lesions, such as SELs. A retrospective, cross-sectional study was conducted with 32 consecutive patients with complex rectal lesions admitted to our hospital from May 2016 to June 2022. Clinical, ultrasound, and pathological data were collected from these patients who underwent EFB followed by TRCEUS-TP-CNB. The success rate of EFB was 21.88% (7/32) and that of TRCEUS-TP-CNB was 93.75% (30/32). No significant complications were observed for either biopsy method. Factors affecting the success rate of EFB included the lesion width (cm) (1.90±0.62 vs. 4.26±2.40, P<0.001) and lesion thickness (cm) (1.29±0.51 vs. 2.96±1.75, P<0.001). The success rate of TRCEUS-TP-CNB was not affected by these factors. In the paired study of TRCEUS-TP-CNB and EFB, the times of samples per person (1 vs. 2.14±0.90, P=0.015), number of specimens per sample (8.27±1.93 vs. 3.31±1.67, P<0.001), lesion width (cm) (3.79±2.42 vs. 1.90±0.62, P=0.001), and lesion thickness (cm) (2.64±1.75 vs. 1.29±0.51, P=0.001) were the factors affecting the difference of the sampling success rate. In the SELs, the success rate of EFB was 10% (1/10) and that of TRCEUS-TP-CNB was 100% (10/10), and the difference between the two groups was statistically significant (P=0.004). TRCEUS-TP-CNB is an effective biopsy method for complex rectal lesions. The success rate of EFB is lower in the larger lesions. Compared with EFB, TRCEUS-TP-CNB required fewer times of samples be taken and obtained more specimens. For larger lesions and SELs of the rectum, TRCEUS-TP-CNB is expected to become one of the preferred biopsy methods.

What shall we do with yellowish rectal lesions during screening colonoscopy?

What shall we do with yellowish rectal lesions during screening colonoscopy?

Solitary fibrous tumor occurring in the colon as submucosal mesenchymal lesion: report of two cases and review of the literature.

Solitary fibrous tumor (SFT) is a rare mesenchymal neoplasm most often arising from the pleura and rarely in extra-pleural locations, including the gastrointestinal tract. We describe two cases of a SFT presenting as submucosal colonic lesion and review the literature on this lesion. One submucosal lesion was localized in the cecum and was 10mm in size. The second lesion presented as a 17mm submucosal rectal lesion. Both lesions presented as well-circumscribed submucosal lesions arranged in short fascicles, blending with abundant collagenous stroma. In both cases, the spindle cells were positive for CD34, STAT6 and CD99, and molecular studies showed NAB2:STAT6 fusion supporting the diagnosis of SFT. Both patients are alive and well 10 and 5years post-excision, respectively. In conclusion, SFT can occur in the colon as a submucosal lesion and should be included in the differential diagnosis of colonic mesenchymal lesions.

Diagnostic advantages of transrectal ultrasound with gastrointestinal agent instillation for rectal adenoma and early-stage rectal cancer: comparison of conventional transrectal ultrasound techniques.

Despite being a major focus of medical research for decades, rectal cancer remains a major threat to human health. This study aimed to compare and analyze the diagnostic value of transrectal ultrasonography (TRUS) for rectal adenoma and early-stage rectal cancer before and after gastrointestinal agent instillation. In this prospective study, patients diagnosed with rectal adenomas and early-stage rectal cancer by ultrasound were randomly selected for inclusion. All patients underwent ultrasound examination at the Outpatient Department of the First Affiliated Hospital of China Medical University and underwent surgical treatment at the First Affiliated Hospital of China Medical University. Patients with a lesion located 13 cm or more from the edge of the anus, or history of surgery, and a history of radiation and chemotherapy were excluded. A gastrointestinal agent was directly instilled into the rectal cavity during conventional TRUS to compare and analyze the display of rectal lesions before and after such instillation and to evaluate the infiltration depth of rectal lesions. These findings were compared to the pathological findings to determine the diagnostic efficacy. Both the conventional TRUS and TRUS with gastrointestinal agent instillation were able to show the rectal wall structure and rectal lesions; the detection rate of rectal lesions of the former was 75.0%, and that of the latter was 97.1% (P<0.001). Of the 27 rectal adenomas, conventional TRUS detected 10, and TRUS with gastrointestinal agent instillation detected 25 lesions. The accuracy [90.54%; 95% confidence interval (CI): 81.48-96.11%; P=1.05E-08], specificity (87.88%; 95% CI: 71.80-96.60%; P=1.09E-05), and sensitivity (92.68%; 95% CI: 80.08-98.47%; P=1.05E-08) of TRUS in diagnosing early-stage rectal cancer were consistent with the pathological findings (P<0.001). The accuracy (95.95%, 95% CI: 88.61-99.16%; P=3.82E-11), specificity (93.94%, 95% CI: 79.77-99.26%; P=1.31E-07), and sensitivity (97.56%, 95% CI: 87.15-99.94%; P=3.82E-11) of TRUS after gastrointestinal agent infusion in diagnosing early-stage rectal cancer were consistent with the pathological findings (P<0.001). The specificity (87.88%; 95% CI: 71.80-96.60%; P=1.09E-05) of TRUS in diagnosing rectal adenomas was consistent with the pathological finding (P<0.001), but the accuracy (65%; 95% CI: 51.60-76.87%; P=0.25) and sensitivity (37.04%, 95% CI: 19.40-57.63%; P=0.25) were not (P>0.05). Meanwhile, the accuracy (93.33%; 95% CI: 83.80-98.15%; P=5.65E-06), specificity (93.94; 95% CI: 79.77-99.26%; P=1.31E-07), and sensitivity (92.59%; 95% CI: 75.71-99.09%; P=5.65E-06) of TRUS after gastrointestinal agent infusion in diagnosing rectal adenomas were consistent with the pathological findings (P<0.001). TRUS with gastrointestinal agent instillation had significantly improved accuracy in diagnosing early-stage rectal cancer and detecting intrarectal adenomatoid lesions.

Endoscopic ultrasonography-related diagnostic accuracy and clinical significance on small rectal neuroendocrine neoplasms.

This research aimed to examine the diagnostic accuracy and clinical significance of endoscopic ultrasonography (EUS) in the context of small rectal neuroendocrine neoplasms (NENs). A total of 108 patients with rectal subepithelial lesions (SELs) with a diameter of < 20 mm were included in the analysis. The diagnosis and depth assessment of EUS was compared to the histology findings. The prevalence of NENs in rectal SELs was 78.7% (85/108). The sensitivity of EUS in detecting rectal NENs was 98.9% (84/85), while the specificity was 52.2% (12/23). Overall, the diagnostic accuracy of EUS in identifying rectal NENs was 88.9% (96/108). The overall accuracy rate for EUS in assessing the depth of invasion in rectal NENs was 92.9% (78/84). Therefore, EUS demonstrates reasonable diagnostic accuracy in detecting small rectal NENs, with good sensitivity but inferior specificity. EUS may also assist physicians in assessing the depth of invasion in small rectal NENs before endoscopic excision.

Successful hemostasis with red dichromatic imaging for bleeding rectal dieulafoy's lesion.

Successful hemostasis with red dichromatic imaging for bleeding rectal dieulafoy's lesion.

Case report: atypical presentation of mpox with massive hematochezia and prolonged viral shedding despite tecovirimat treatment

BackgroundThe outbreak of mpox that occurred between 2022 and 2023 is primarily being transmitted through sexual contact. As of now, there is no consensus on the recommended duration of isolation to prevent sexual transmission of the virus. Moreover, this particular mpox outbreak has presented with distinct complications in comparison to previous occurrences. In this report, we present a case involving severe rectal bleeding from an ulcer in a mpox patient with a history of engaging in receptive sexual contact.Case presentationA 30-year-old Korean man presented at the hospital with complaints of fever, multiple skin lesions, and anal pain. Monkeypox virus polymerase chain reaction (PCR) results were positive for skin lesions on the penis and wrist. The patient received a 12-day course of tecovirimat due to anal symptoms and perianal skin lesions. Following isolation for 12 days and after all skin scabs had naturally fallen off, with no new skin lesions emerging for a consecutive 48 hours—conforming to the criteria of the Korean Disease Control and Prevention Agency—the patient was discharged. However, 1 day after discharge, the patient returned to the hospital due to hematochezia. His hemoglobin level had significantly dropped from 14.0 g/dL to 8.2 g/dL. Sigmoidoscopy unveiled a sizable rectal ulceration with exposed blood vessels, prompting the application of hemostasis through metal clipping. Subsequent monkeypox virus real-time PCR conducted on rectal tissue and swabs yielded positive results (with cycle threshold values of 28.48 and 31.23, respectively). An abdominal CT scan exposed a perirectal abscess, for which ampicillin-sulbactam was administered.ConclusionThis case underscores the importance of monitoring for bleeding complications and confirming the resolution of rectal lesions before discharging patients from isolation, particularly in cases where patients have a history of engaging in receptive sexual contact with men or are presenting with anal symptoms.

Prone Jack-Knife Transanal Minimally Invasive Surgery: A Safe and Effective Approach for Anterior Low Rectal GI Stromal Tumors.

Subepithelial rectal lesions, including gastrointestinal stromal tumours (GIST), leiomyomas, neuroendocrine tumours, lipomas, and schwannomas, are rare surgical conditions. 1 Surgical management in this region often entails radical surgical excisions with stoma creation. Radical surgical excisions with stoma creation are often required for surgical management in this region. In this video, we demonstrate a transanal minimally invasive surgery (TAMIS) approach to anterior low rectal GIST. Patient underwent neoadjuvant Imatinib Mesylate after multidisciplinary team discussion, and were evaluated preoperatively with colonoscopy, pelvis MRI, and endoscopic ultrasound-guided tissue biopsy. 2,3 The procedure was performed with the patient in the prone jack-knife position and using the GelPOINT® Path transanal access, providing an excellent surgical platform. 4 The access channel was chosen based on the lesion's location from the anal verge, and ports were placed in a triangular fashion onto the GelSeal Cap, including an apex 10 mm sleeve for the telescope connected to the insufflation stabilization bag, two lower 10 mm working ports, and an additional port if traction was necessary. The RapidVac TM smoke evacuator was used for smooth surgery without fluctuating the surgical field and to achieve optimal vision. Dissection was initiated over the lower margin of the mass into the subepithelial plane and then performed along and around the mass in the desired plane. This approach and positioning in prone jack-knife, allowed dissection under direct vision with excellent surgical ergonomics and avoided radical resection. Our video demonstrates the feasibility and safety of TAMIS for the management of anterior low rectal subepithelial lesion, providing an alternative to more radical surgical approaches. See Video Vignette.