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High-Risk TEM: Large Anterior and Upper Rectal Lesion With Peritoneal Entry
Winta T. Mehtsun^*, Patricia Sylla

Surgery, Massachusetts General Hospital, Cambridge, MA

We describe TEM excision of a nearly 7 cm large pedunculated tubulovillous adenoma of the upper rectum. The patient is a 87 year-old female with extensive cardiac co-morbidities, who on diagnostic colonoscopy, was found to have multiple colonic adenomas that were removed, as well as a large and floppy villous lesion with a wide stalk located along the anterolateral rectal wall. Biopsies and staging CT scans were negative for malignancy despite a CEA being 5.5. In an effort to avoid radical resection, she was offered TEM full-thickness excision, which was performed in prone position, given the high risk for peritoneal entry during dissection. Transanal endoscopic resection was performed using a rigid TEM platform, and the lesion was located in the upper rectum, approximately 12 cm from the anal verge. The lesion was first scored circumferentially and the long stalk identified along the right lateral rectal wall. Full thickness rectal dissection of the lesion was performed circumferentially, which resulted in sizeable peritoneal entry with a wide defect along the right lateral rectal wall. The prone position significantly helped prevent excessive loss of pneumorectum into the abdomen, by tamponading the abdominal cavity against the operating room table. The lesion was entirely resected and extracted transanally, and the full-thickness defect through the rectal wall was closed using continuous and interrupted absorbable sutures. Following full-thickness closure of the large rectal wall defect, the rectal lumen remained patent and the transanal endoscopic platform was removed. The patient was discharged home on postoperative day 2, and pathology demonstrated a 6.5 cm tubulovillous adenoma with focal features of serrated adenoma but no evidence of dysplasia.

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