A treatment option for rectal gastrointestinal stromal tumor: endoscopic submucosal dissection combined with endoscopic hand-suturing

Rectal gastrointestinal stromal tumors (GISTs) are very rare, accounting for about 5% of all GISTs [1]. Treatment for a rectal GIST should be carefully selected to avoid postoperative complications and impairment of anal sphincter function [2] [3]. Recently, several cases of endoscopic resection for rectal GISTs have been reported, but there is a lack of reports on strategies for defect closure [4] [5]. We report a novel method for treating a rectal GIST via a combination of endoscopic hand-suturing (EHS) with endoscopic submucosal dissection (ESD).

A 64-year-old man presented to our center with a rectal mass located 3 cm from the anal verge. Magnetic resonance imaging (MRI) and endoscopic ultrasound (EUS) identified a submucosal tumor measuring 1.2 × 1.0 cm in the lower rectum ([Fig. 1]). After a multidisciplinary discussion, the tumor was considered to be a rectal GIST. Subsequently, having been fully informed of the condition and its associated risks, the patient chose to undergo ESD to treat the lesion and clarify the diagnosis.

Fig. 1 The preoperative examination findings were: a on colonoscopy, a submucosal tumor (arrow) located 3 cm from the anal verge; b on magnetic resonance imaging, the tumor was found to be situated in the lower rectum without invasion of adjacent organs; c on endoscopic ultrasound, the tumor (arrow) was hypoechoic and measured 1.2 × 1.0 cm.

The steps of ESD were performed strictly according to protocols and the tumor was removed en bloc ([Fig. 2] a, b). After resection, a significant depression was observed in the artificial ulcer, accompanied by damage to the muscularis propria layer ([Fig. 2] c). To prevent postoperative perforation, we performed endoscopic hand-suturing to close the defect and secured the suture tail with a clip after removing the needle ([Fig. 3]; [Video 1]). The ESD and endoscopic hand-suturing times were 51 and 53 minutes, respectively. The patient was discharged on postoperative day 4, without any adverse events having occurred. Histology confirmed that the tumor was a very low risk GIST and had been completely resected. Colonoscopy during the third postoperative month showed a healed scar without any signs of recurrence ([Fig. 4]).

Fig. 2 Endoscopic images during resection of a rectal gastrointestinal stromal tumor (GIST) by endoscopic submucosal dissection (ESD) showing: a dissection of the submucosa; b the tumor completely removed with the capsule remaining intact; c the defect after ESD, with accompanying damage to the muscularis propria layer.

Fig. 3 Endoscopic images after the endoscopic submucosal dissection of the rectal lesion showing: a closure of the defect using an absorbable barbed suture with needle (VLOCL0803; Covidien, Mansfield, Massachusetts, USA) and a needle holder originally designed by our team (entrusted manufacturer: Vedkang, Jiangsu, China); b the suture tail secured with a clip after closure of the defect; c the appearance 3 days after closure of the defect by endoscopic hand-suturing.

Fig. 4 Follow-up colonoscopic image 3 months after the procedure showing a well-healed defect with fibrotic scar formation.

Closure of the defect, which showed muscularis propria damage, after complete removal of a rectal gastrointestinal stromal tumor by endoscopic submucosal dissection using endoscopic hand-suturing.Video 1

The use of ESD combined with endoscopic hand-suturing for treatment of a rectal GIST has not been previously reported. The application of endoscopic hand-suturing in this case successfully avoided postoperative adverse events, demonstrating the safety and feasibility of this novel method for treating rectal GISTs.

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• References

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