Robert Tamai, MD1, James Buxbaum, MD, MS2, Ara B. Sahakian, MD2; 1LAC+USC Medical Center, Los Angeles, CA; 2University of Southern California, Los Angeles, CA
Introduction: Endoscopic mucosal resection (EMR) is considered first-line therapy for benign laterally spreading lesions (LSLs) of the colon and rectum. The most common complication of endoscopic resection is delayed bleeding within 3 weeks post-procedure which occurs in up to 7% of cases. This video demonstrates band ligation and subsequent endoscopic ultrasound (EUS)-guided n-butyl cyanoacrylate (NBCA) glue injection and obliteration of rectal varices followed by piecemeal EMR of an LSL in the rectum.
Methods: 70-year-old male with a history of alcoholic liver cirrhosis complicated by large esophageal varices status post band ligation was found to have a 2.5 cm LSL in the rectum on screening colonoscopy. Biopsy demonstrated tubular adenoma with high grade dysplasia. A flexible sigmoidoscopy and rectal EUS were performed. Large varices were noted in the rectum, including a varix which appeared to course underneath the lesion. Under EUS, the polyp appeared limited to the mucosa with a varix with active doppler flow coursing beneath the mass. Band ligation of the varices distal to the lesion was performed. Three months later, repeat colonoscopy was performed. Persistent varices were again noted coursing under the lesion. EUS was used to identify the feeding vessel under the lesion and 0.5cc of NBCA glue was injected into the feeding varix. Active flow ceased under doppler examination. Band ligation of the remaining varices in the distal rectum was performed. Two months later, the patient returned for flexible sigmoidoscopy with EMR. The rectal varices were now decompressed. A 25-mm polypectomy stiff snare with cautery was used for resection of the lesion. En-bloc resection was attempted due to concern for underlying malignancy. However, a small piece of polypoid tissue remained after the initial attempt. Thus, the lesion was successfully resected in two pieces. The EMR mucosal defect was visualized with no perforation noted. Using the snare tip, the margins and multiple vessels in the resection bed were cauterized. The mucosal defect was then closed with endoclips. The post-procedural course was uneventful. Histopathological findings revealed a tubulovillous adenoma with focal high-grade dysplasia. Discussion: Endoscopic resection of LSLs of the colorectum with underlying varices is a high-risk procedure. Varices should be obliterated prior to resection. Band ligation and EUS-guided NBCA obliteration of varices may help mitigate risk of peri-procedural hemorrhage during EMR.
Disclosures: Robert Tamai indicated no relevant financial relationships. James Buxbaum: Boston Scientific – Consultant, Boston Scientific. Cook – Consultant. Olympus – Consultant, Grant/Research Support. Ara Sahakian: Boston Scientific – Consultant. Cook Medical – Consultant.