TRANS-ANAL ENDOSCOPIC MICROSURGERY WITH THE SB-KNIFE FOR EARLY RECTAL CANCER

Endoscopic treatment of malignant colorectal lesions is challenging, especially for early rectal cancer (ERC) localized close to the dentate line. Conversely, the surgical approach may result in temporary or definitive stoma and in frequent post-surgical complications.

We report the case of a 85-years-old man with a history of atrial fibrillation who underwent high-dose pelvic radiotherapy for ERC after having refused abdominoperineal resection. Three-years later, a follow-up colonoscopy revealed a 1 cm non-polypoid (Paris0-IIA) rectal lesion, located 2-cm from anal verge along the inferior wall. Based on histopathology, CT-scan end endoscopic-ultrasonography (EUS) the diagnosis of residual adenocarcinoma with deep submucosal invasion (sm3, N0, M0) was made. An endoscopic full-thickness resection (FTR) with the FTR device (Ovesco Endoscopy, Tübingen, Germany) was attempted to achieve a complete treatment and avoid surgery [1]. However, the tissue stiffness and the limited distance from anus resulted in an incomplete suction of the neoplasia into the FTR device. We therefore adopted the SB-Knife Jr (Subimoto Bakelite, SUMIUS, Tokyo, Japan) to perform the FTR during the same procedure. This device is a through-the-scope grasping forceps for colorectal endoscopic submucosal dissection with 360 ° rotation and electrosurgical capability. The en bloc dissection achieved the perirectal fat and was performed in 90 minutes without complications. Patient was discharged home the following day under antibiotic prophylaxis. Histopathology confirmed the R0-resection, while the subsequent oncologic work-up revealed no recurrence at 6 and 12-month follow-up.

This case is interesting for several reasons. First, we report for the first time on feasibility and efficacy of Trans-anal Endoscopic Microsurgery with the novel SB-knife. Secondly, we first described an endoscopic rescue therapy for patients who experienced a failure with the FTR device. Our report adds to the growing literature on endoscopic approaches alternative to aggressive surgical strategies burdened by considerable risks and functional consequences in patients with ERC.