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19 Transanal Local Excisions andEndoluminal Approaches
Fig. 19.2 Perforations. (a) Muscular defect. (b) Full-thickness perforation
191
Therefore, these should be quickly identied,
evaluated, and treated. One common reason for
delayed perforations is the overuse of electrocauterization during the procedure, leading to insufcient blood supply and eventual perforation.
Even if any perforation is detected and closed
during the procedure, delayed perforation can
occur afterward. Another condition that can cause
delayed perforation is the development of an
abscess due to partial perforation of the colon
wall. Fecal contamination causes inammation
and abscess in the muscular defect. Inammation
and abscess can lead to delayed perforations after
the procedure.
Several perforation rates were previously
reported after local excisions and endoluminal
procedures, ranging from 2.5% to 18% [5–9].
Generally, ESD has a higher perforation rate
Studies show that the perforation rate is higher in
lesions with submucosal brosis [11, 13].
Submucosal brosis can occur in patients with
recurrence, so they should be treated more carefully during procedures.
Post-polypectomy syndrome, rst described
in 1986, is another complication of conventional
and advanced polypectomy techniques [14]. It
may initially present as perforation and show
fever, abdominal pain, and leukocytosis symptoms. However, peritonitis is generally localized
in post-polypectomy, and there is no perforation
in the bowel wall. Excessive electrocautery use,
which is a signicant risk factor for postpolypectomy syndrome, can cause burning in the
muscular layer. Other risk factors include lesions
larger than 3cm, prolonged procedure time, and
rectosigmoid lesions [15].
than EMR [10]; however, with increasing experience and completion of the learning curve, perforation rates could be improved. A lesion’s
Prevention
location, size, and histopathological morphology
can all be risk factors for perforation. It is known
that excision of rectum lesions leads to less perforation than that of colon lesions [11, 12].
Perforations are more common in lesions larger
than 2cm [12]. Submucosal brosis is also a risk
factor for perforation in transanal and endoluminal approaches. A muscle-like structure in the
submucosal plane, inadequate lifting, and a
white web are all signs of submucosal brosis.
Preoperative patient positioning is a factor that
facilitates proper dissection. The position can be
changed during procedures depending on the
location of the lesion. In addition, the scope can
be rotated 180° to position the target area at the
6 o’clock position during endoluminal
procedures. TAMIS port placement and instrument choice should be made according to the
location of the lesions.
192
K. Erozkan and E. Gorgun
Injection of the lifting solution into the submucosal area is the critical step for all transanal
local excisions and endoluminal approaches.
Submucosal injection is widely utilized in ESD
and EMR. However, its application in TAMIS
remains understudied and less commonly
employed. As the authors of this chapter, we
rmly believe that incorporating submucosal
injection into TAMIS procedures not only facilitates dissection but also serves as a preventive
measure for achieving superior outcomes.
Nonetheless, challenges do exist when attempting a submucosal injection during TAMIS. To
overcome these challenges, we employ throughthe- scope (TTS) endoscopy injection needles.
These needles are placed through the shaft of a
laparoscopic instrument’s metal sheet and subsequently directed into the target area (Fig.19.3).
Sufcient injection into the submucosal area
is essential to prevent perforations or other complications since injecting solutions under the
muscle layer, or insufcient injections, can cause
difculties during dissection and excision. In
case of unsuccessful injections, proper cushioning might not be created and the muscular layer
can be trapped in the snare while snaring or dissection cannot be continued in a proper plane. If
the patient is not under anesthesia, biting the
muscular layer can result in abdominal pain. In
the event of non-lifting, reapplication of the lifting solution should be preferred, even if it is
time-consuming. If proper lifting cannot be
achieved with reapplication, piecemeal removal
might be considered to prevent perforation. Two
Fig. 19.3 Submucosal injection in TAMIS
types of solutions are available for lifting during
transanal local excisions and endoluminal procedures. The Food and Drug Administration (FDA)approved premixed solutions are LiftUp®
(Ovesco Endoscopy AG, Tübingen, Germany),
Blue Eye™ (The Standard Co., Ltd., Gunpo-si,
Korea), Blue Beacon™ (Micro-Tech Co., Ltd.,
Nanjing, China), EverLift™ Submucosal Lifting
Agent (Gi Supply, Inc.), Eleview® (SIC 8000)
(Cosmo Technologies, Ltd., Dublin, Ireland), and
EndoClot® solution (EndoClot Plus Co., Ltd.,
Santa Clara, CA, USA). These solutions remain
in the submucosal plane for long durations,
reducing the procedure time by eliminating preparation steps and repeat injections. In addition to
premixed solutions, diluted adrenaline (1mL of
0.1% adrenaline) and hydroxyethyl starch solution mixed with methylene blue or other dyes can
also be used. Saline is not a preferred solution as
it stays in the tissue only for a limited time and
dissipates quickly.
Traction can also be applied to lesions for dissection and complication prevention. There are
various traction techniques in anal procedures.
Clips can be attached to the mucosa proximal or
opposite to the lesion if a sufcient submucosal
opening is not created during dissection.
Alternatively, externally placed exible endoscopic graspers can be used for distal lesions.
Other traction methods, such as balloon-assisted
overtube, thin-type endoscopy, or string clip traction devices, could improve the traction for
colorectal ESD, especially in large lesions with
submucosal brosis.
Special techniques can be considered to prevent perforation. Underwater EMR (UEMR),
described by Binmoeller et al. [16], lls the
bowel lumen with water so that the bowel maintains the circular shape of the muscle layer while
the mucosa and submucosa oat on water. This
technique allows for proper excision without
using an injection. Moreover, studies have shown
that UEMR reduces complications such as perforation and delayed bleeding [16, 17]. Another
technique is an adaptive customized approach, as
shown in Video 19.1. In this video, we demonstrate how different approaches can be utilized if
one technique does not work. For example, con-
19 Transanal Local Excisions andEndoluminal Approaches
193
version to TAMIS to treat lesions that cannot be
adequately accessed by transanal local excision
or for which resection cannot be completed with
techniques such as EMR and ESD is a customized approach. We believe that this can facilitate
dissection and reduce the risk of complications.
In case of minor perforation or mucosal defect
closure, endoscopic clips can close the defect
area and prevent major perforation and later
abscess development (Fig. 19.4). Through-thescope (TTS) endoscopic clips are Resolution™
Clip (Boston Scientic, Marlborough, MA,
USA), SureClip® (Micro-Tech Endoscopy, Ann
Arbor, MI, USA), QuickClip Pro™ (Olympus
America, Center Valley, PA, USA), EZ Clip™
(Olympus America, Center Valley, PA, USA),
Tomel Clip™ (Century Medica, Inc., Tokyo,
Japan), and ZEOCLIP™ (Zeon Medical Inc.,
Tokyo, Japan). These clips have higher rotation
and repositioning ability [18]. Mucosal defect
closure involves using a clip to grasp the edges of
the defect. It is important to degas the intestinal
lumen before clipping to grasp the mucosal
defect edge. Several techniques have been
described for closing large defects with clips. If
the defect is wider than a clip, a mucosal incision
method may be used, where a clip is hooked onto
a small hole on one side of the mucosa [19].
Another method, the endoscopic mucosa–submucosa clip closure, uses a single clip to grasp
the defect edge and the submucosa above the
muscularis layer, reducing the size of the mucosal defect [20]. The clip-on-clip closure method
involves placing one clip over another and using
the gap between clips as an anchor (zipping technique) [21]. To close the defects in thin gastrointestinal sections such as the rectosigmoid colon,
the mucosal and muscular layers can be softened
by submerging them in water during clipping
[22]. Various mucosal defect closure methods
have been proposed using clips and special
devices such as sutures, rings, endoloops, and
double-channel endoscopes [23]. Additionally,
TTS clips should not be used alone when inamed
or indurated tissue surrounds the defect or when
anatomical variations prevent clip placement
[24]. Clip-and-snare, clip-and-endoloop techniques, and band-assisted closure are more successful in such cases. Closed layer levels of these
techniques are generally limited to the mucosa
and submucosa. Endoscopic procedures such as
over-the-scope clip (OTSC) or endoscopic suturing, described in the “Management” section,
could be also an alternative option.
In TAMIS, exible endoscopic clips or laparoscopic clips can be used via the transanal access
platforms. Flexible endoscopic clips are suitable
to pass along through trocars and placed with the
assistance of TAMIS instruments. Primary
suturing is an option for defect closure during
Fig. 19.4 Endoscopic clip placement for closure after a full-thickness perforation
194
K. Erozkan and E. Gorgun
TAMIS and TAE. Using exible robotic platforms for transanal procedures facilitates the closure of defects with improved dexterity.
Endoscopic clips can be used to prevent postpolypectomy syndrome and bleeding.
Prophylactic antibiotics can be administered to
reduce the risk of post-polypectomy syndrome
[25]. Endoscopic clips are also an option for preventing post-polypectomy syndrome.
Recognition
Early recognition and treatment of complications
are crucial for reducing morbidity and mortality
risks. Perforation and bleeding can be identied
early by carefully observing the resection site
during the procedure. Patients undergoing transanal local excisions and endoluminal approaches
are typically observed for 3–4h after the procedure, and those with complicated or larger lesions
may stay overnight.
Perianal and pelvic abscesses can be seen in
lower rectum lesions. Perforations after rectosigmoid and anteriorly located mid- and upper rectum lesion resections can be connected with the
intraabdominal cavity. Surgeons should stay alert
for perforation signs and symptoms, which
include fever, leukocytosis, abdominal pain, distention, and rebound tenderness. Delayed complications can lead to more severe clinical
presentations. In rare cases, the patient may
develop pelvic sepsis and septic shock, which can
be life-threatening. If perforation is suspected,
the patient should undergo thorough physical
examination, laboratory tests, or imaging studies.
Laboratory tests such as a complete blood count
(CBC) and C-reactive protein (CRP) can help
identify the presence of inammation and infection. Digital rectal examination and exible sigmoidoscopy can help diagnose lesions at the
distal level. Abdominal X-rays can verify free
air’s presence after suspicious procedures. In
addition, computed tomography (CT) scanning,
or in some cases magnetic resonance imaging
(MRI), can provide more detailed information on
the extent of the perforation and the presence of
any associated abscess or bleeding.
Management
The management of perforation and bleeding
depends on the timing of diagnosis and the
patient’s condition. Intraprocedural recognition
and diagnosis of perforation are crucial for
prompt management and to prevent further severe
complications. Intraoperative detection and clipping can be performed to manage perforations
and bleeding, preventing additional surgical procedures [26]. However, delayed complications
may require more severe medical attention if perforation is detected later.
General strategies such as oral intake restriction, intravenous uid resuscitation, and intravenous antibiotic therapy are commonly employed
against perforation. Endoscopic and transanal
methods are often the preferred initial treatment
for early or delayed perforations in patients with
stable vital signs and good overall health.
Endoscopic procedures may be performed for
delayed perforations, such as closure with TTS
clips, OTSC, or endoscopic suturing. The OTSC®
system (Ovesco Endoscopy AG, Tübingen,
Germany) is generally used for tightly grasping
large defects. It is recommended to create a
slightly larger dissection area around the perforation and hook one side of the clip around the nonneoplastic mucosa to prevent the excision bed or
muscle layer from tearing during clipping [27,
28]. Lumen occlusion is one of the worst and
most unknown complications of OTSC application [29]. Endoscopists should check wall integrity and lumen patency each time after an OTSC
clip placement. Closure of major perforations is
feasible with an endoscopic suturing device.
Overstitch™ (Apollo Endosurgerry Inc., Austin,
TX, USA) is the only FDA-approved device for
endoscopic suturing. This system comprises a
cap attached to a scope, a hand lever-controlled
needle driver, and an anchor exchange component. It enables the application of full-thickness
sutures using different suturing patterns and
comes with accessories such as scissors and
grasping forceps that aid in targeting and tissue
release.
Another defect closure technique can be
applied using TAMIS.When a peritoneal breach
19 Transanal Local Excisions andEndoluminal Approaches
195
occurs during TAMIS, immediate placement of a
corner suture before completing the rectal mass
removal provides control of the peritoneal defect
site. Early suture placement can prevent losing
control of the defect site and loss of pneumorectum. TAMIS can be a valuable option to repair
the defect, especially for anteriorly located midand upper rectum lesions. A corner suture also
prevents enlargement of the peritoneal breach,
which could result in an uncontrollable pneumoperitoneum. After the dissection is completed,
defect closure can be resumed (Video 19.2). This
technical approach prompts successful TAMIS
completion and reduces the risk of conversion to
laparoscopy or laparotomy.
Sometimes in lesions with brosis, TAMIS
can lead to full-thickness excision, which might
lead to almost complete loss of the rectal domain.
These challenging cases can be prone to potential
complications, such as formation of mesorectal
abscesses or the complete disruption of anatomy.
To reinforce this issue, we believe that a sleeve
advancement can be applied (Video 19.3).
In cases of diffuse peritonitis when endoscopic and transanal management is not feasible,
alternative interventional options and abdominal
surgical procedures can be considered. The
choice of surgical approach depends on the extent
and severity of the perforation as well as the surgeon’s experience and preference. The management of delayed complications requires close
monitoring and may require a multidisciplinary
approach.
Bleeding
Background
Bleeding is one of the most common complications encountered during transanal local excisions and endoluminal approaches (Fig.19.5). It
develops as a result of vascular injury in the submucosal area. Studies have reported bleeding
rates ranging from 2% to 13% [8, 9]. Delayed
bleeding may also occur postoperatively, and it
has been reported in 2% of colorectal ESD
patients [30]. Although most bleeding is minor
and managed conservatively, severe bleeding can
sometimes occur. Risk factors for bleeding
include using anticoagulant and antiplatelet
drugs, previous ESD procedures, male gender,
and lesions larger than 2cm [8]. Hypertension
and using hot biopsy forceps are additional risk
factors for delayed bleeding [31]. Rectal lesions
are specically an independent risk factor for
bleeding. Bleeding may occur due to injury to the
hemorrhoidal venous plexus during lower rectal
lesion excision. Hemorrhoidal bleeding comes
from an easily accessible area and can be stopped
with sutures.
Prevention
Before the procedure, it is crucial to evaluate the
patient’s risk of bleeding and discontinue any
anticoagulant or antiplatelet therapy if possible.
Fig. 19.5 Bleeding during ESD and endo-robotic submucosal dissection (ERSD)
196
K. Erozkan and E. Gorgun
Adequate submucosal injection, slow dissection
pace, a stepwise approach, and preventive coagulation of visible blood vessels before the dissection are methods to prevent bleeding during
the procedure [32]. Adding adrenaline to the
injection solutions might also be considered in
high- risk patients. Many methods and techniques
for preventing and managing perforations can
also be used for early or delayed bleeding.
(Please refer to the perforation prevention and
management section for submucosal injection,
endoscopic clipping, UEMR, etc.). Endoscopic
clips, cautery, or sutures can be used during the
procedure to control bleeding, but, even if we
use these techniques, delayed bleeding can
occur. A multicentric study showed that prophylactic clipping could reduce the risk of delayed
bleeding in high- risk groups with no complications such as perforation [33]; however, conicting data also exist [34]. Using electrocautery for
prophylactic coagulation is also a debated
method to stop bleeding. A randomized controlled study showed that prophylactic coagulation of non-bleeding visible vessels is ineffective
[35], but some studies claim the opposite [36].
We believe electrocautery use is a valuable
option to prevent delayed bleeding with the
proper device and technique (Please refer to the
bleeding management section).
Recognition
Patients with bleeding may present with hematochezia, hypotension, tachycardia, low hemoglobin levels, or even hypovolemic shock. Melena is
rarely seen after excisions at the pelvic level.
Physical examination, CBC, and colonoscopy
can be used for diagnosis. CT is the preferred
imaging method for bleeding suspicions.
Angiography can be used for both diagnosis and
treatment in resilient patients with bleeding.
Scintigraphy is theoretically an alternative option
for the diagnosis of bleeding but is not common
in practice.
Management
In case of minor bleeding, careful observation
and cessation of anticoagulant therapy may be
sufcient for management. If bleeding is continuous, endoscopic treatment methods, which are
also options for managing perforation, such as
clips or sutures, can be used to control bleeding.
Conventional retractors can be used for identifying and managing bleeding. If it is not possible to
identify a bleeding spot or continue dissection
because of blood pooling, changing the patient’s
position by taking advantage of gravity can
improve the view. Endoscopic coagulation of visible vessels can also be performed to stop bleeding, but excessive electrocautery should be
avoided as it may lead to late perforation. Using
proper coagulation devices and generators is
essential, especially for endoluminal procedures.
The most utilized energy towers are VIO®3 (Erbe
USA, Inc., Marietta, GA, USA) and Geradores
THUNDERBEAT (ESG-400 e USG-400)
(Olympus America Inc., Center Valley, PA,
USA). These generators are designed for endoluminal procedures providing different energy
modalities, including swift, forced, and spray
coagulation. In their cutting mode, blended
energy can be applied that can be combined in the
cutting mode with a blend of coagulation period.
Additionally, incremental a coagulation modality
can be added for patients with specic hematological issues to minimize bleeding even in the
cutting or blend mode. The other advantage of
these generators is that in the blend cutting mode,
application of pulsatile energy is enabled, which
allows physicians to make a clear cut at supercial levels that can expose deeper vessels more
clearly. Subsequently, prophylactic coagulation
can be performed in forced and spray coagulation
modes. Additionally, topical agents, band ligation, and sclerosing agent injections can be preferred instead for bleeding treatment.
Angiography or abdominal surgical approaches
may be necessary in severe hypovolemic conditions unresponsive to intravenous resuscitation.
19 Transanal Local Excisions andEndoluminal Approaches
197
Abscesses
Background
Infections and abscesses are inammatory complications of transanal local excisions and endoluminal approaches. Surgical site infections are
the most common hospital-acquired infections
after colorectal surgery, increasing morbidity,
mortality, and hospital costs. However, these
techniques are performed in the third space.
Infections are generally related to perforation
and usually result in abscesses. An abscess is a
frequent complication of transanal local excisions and endoluminal approaches, often resulting from delayed perforations. However, minor
perforations can also cause an abscess due to
fecal obstruction of the muscularis propria defect
and bacterial colonization. Insufcient blood
supply, and inammation secondary to bacterial
colonization, may result in a full- thickness perforation. Abscesses can be localized within the
abdominal cavity or cause diffuse peritonitis
after rectosigmoid and anterior upper and midrectum procedures [37]. Lower rectum perforations generally result in perianal and pelvic
abscesses, although delayed cases may develop
Fournier’s gangrene.
be considered in cases of perforation and large
lesion resections [40]. Prophylactic antibiotics
are not recommended for the excision of lesions
smaller than 20mm [41]. However, our prospective project, which is the implementation of the
surgical site infection prevention bundle at our
center, substantially declined surgical site infection rates in our department for all colorectal procedures [42]. We believe that prophylactic
pre- and perioperative antibiotic use can reduce
infections and abscess development after local
anal operations and endoluminal approaches. In
particular, we believe that it is effective in case of
perforation and minimizes the contamination that
may be caused by ow and blow.
Prevention and early management of perforations also prevent possible abscess development.
The excision bed should be carefully evaluated for
perforations at the end of the procedure. Endoscopic
clips, sutures, and other techniques can be used as
described in the “Perforation” section for early
management of perforations (please refer to the perforation prevention and management section). Even
within the mesorectum full- thickness defect, we
prefer to close them using endoscopic clips or possibly suture closing. As discussed earlier, excessive
use of electrocautery should be avoided to prevent
disruption of blood ow, which might cause delayed
perforations and abscesses.
Prevention
Bowel preparation reduces contamination due to
minor leakage and can effectively prevent abscess
development [38]. Additionally, it provides a better operation view and facilitates dissection,
which is important for preventing other complications. Position change can also reduce contamination in the peritoneal cavity in case of
perforation [38].
Even though prophylactic antibiotics can
reduce the incidence of clinical adverse events,
including abdominal pain, diarrhea, hematochezia, and fever [39], their preoperative use is not
recommended for preventing infections and
abscess development [40, 41]. Antibiotic use can
Recognition
Abscess diagnosis is based on clinical symptoms
and imaging methods. The diagnostic criteria for
perianal abscesses include redness, warmth, tenderness, digital rectal fullness, and uctuation.
Digital rectal examination helps identify perianal
and pelvic abscesses. Patients with a pelvic
abscess, which is more common than an abdominal abscess after transanal excisions and endoluminal approaches, might present with sacral pain,
pain when sitting, and tailbone pain. Patients may
have abdominal abscesses in case of a peritoneal
breach. These patients may have abdominal pain,
tenderness, fever, nausea, and vomiting. CBC,
198
K. Erozkan and E. Gorgun
possible emergency visits, and CT are recommended for these patients.
Management
The primary treatment of an abscess is surgical
drainage. Once a perianal or perirectal abscess is
diagnosed, it is crucial to promptly drain it,
regardless of the presence of uctuance. Delaying
treatment can lead to the abscess expanding into
nearby spaces and potentially causing a systemic
infection. Depending on the localization, perianal
abscesses can be drained via the endoluminal or
perianal route. Perianal and ischiorectal abscesses
can be drained by incision through the perineum.
It is important to make the skin incisions as close
to the anal verge as possible. This approach helps
minimize the potential length of a stula that may
develop while still ensuring adequate drainage of
the abscess. Following the incision and drainage
procedure, wound packing is a common practice.
However, it is worth stating that there is no
proven benet to this approach [43]. Although
supra levator abscesses are generally rare, their
incidence may increase after endoluminal
approaches. They occur in case of perforation in
the rectum wall. These abscesses should be
drained into the rectum through an incision in the
resection bed to avoid creating an extrasphincteric stula.
If CT ndings reveal presacral or abdominal
uid collections larger than 2cm, possible drainage is highly recommended, especially for symptomatic patients. For collections smaller than
2 cm, a course of antibiotics might be trailed;
however, even if the patients are symptomatic
with smaller lesions, possible drainage and at
least aspiration under CT guidance may be recommended. Typically, these drains are placed in
the transgluteal area to collect a larger amount of
liquids from the pelvis. This can be painful, and
the access route should be explained to patients,
as the insertion points for trans-gluteal drains can
cause varying amounts of pain. These drains
should be monitored daily until drainage is
required. When using drains with negative pressure application, monitoring should continue
until the amount of drainage becomes minimal.
Especially in pelvic drains, daily irrigation is
strongly advised to prevent clogging.
After the incision and drainage of an abscess,
it is suggested to administer empiric antibiotics
to all patients. This practice has been shown to
potentially reduce the rate of stula formation,
according to available evidence. The duration of
antibiotic coverage is based on extrapolating
from studies focusing on intraabdominal infection following source control. A systematic
review and meta-analysis of two randomized trials and one retrospective study provided the
strongest evidence supporting the use of routine
empiric antibiotics after drainage [44–46]. The
analysis showed that the rate of stula formation
was lower in patients who received antibiotics
compared to those who did not. The American
Society of Colon and Rectal Surgeons (ASCRS)
recommends empiric antibiotics after abscess
drainage only for patients with extensive perianal/perineal cellulitis, signs of systemic infection, diabetes, valvular heart disease, or
immunosuppression [47]. All these publications
are based on perianal and pelvic abscesses and
are not specic for abscesses after transanal local
excisions and endoluminal procedures.
If interventional and antibiotic treatments are
unsuccessful, abdominal surgical procedures can be
an option for abscess treatment. Endoscopic ultrasound-guided (EUS-guided) drainage is feasible for
localized abdominal and pelvic abscesses [48].
Strictures
Background
Strictures after colorectal local excisions are not
as commonly seen as in esophageal and gastric
antral lesions after tissue resections [49].
Preventive approaches enhance epithelialization
and mucosal healing after colorectal lesions;
however, strictures may occur, especially after
circumferential resection, with reported rates of
50–70% [50–52]. We have found the rates to be
lower in our practice, particularly if dissection is
at a higher level in the rectum, farther from the
ab
cd
19 Transanal Local Excisions andEndoluminal Approaches
199
anal canal. Rectal lesions with more than threequarters of the luminal circumference carry a
higher risk of post-ESD strictures, especially if
they are large or have long longitudinal lengths or
if mucosal defects cover more than 90% of the
luminal circumference [51] (Fig.19.6). Total circumferential resection possesses a high risk and
requires close postoperative follow-up [38].
Prevention
Close monitoring of patients after circumferential excision is essential to prevent stricture formation. Prophylactic bougie or balloon dilation
can be performed in the follow-up period. Steroid
treatment to prevent stricture formation is controversial in colorectal lesions. Even though con-
icting studies exist in the literature [50],
prophylactic usage of steroids may be effective
[51]. Steroid treatment has been reported to cause
necrosis to prevent esophageal strictures, but
there is no data for colorectal lesions [53]. Fullthickness resection and primary sleeve advancement with TAMIS can be an option to prevent
strictures in cases of circumferential lesions [54].
Recognition
Strictures may present with constipation and
develop over an extended period. The diagnosis
is usually conrmed by exible sigmoidoscopy
and digital rectal examination. Imaging studies
may show dilatation of the bowel loops.
Fig. 19.6 Stricture development and treatment. (a) Circumferential lesion. (b) Resection bed. (c) Specimen. (d)
Stricture
200
K. Erozkan and E. Gorgun
Management
Strictures that generally develop in distal lesions
can be prevented and treated with bougie and
balloon dilation [52]. In addition, dilation can be
achieved by endoscopic knife escharotomy.
Alternatively, a re-resection can be performed to
manage strictures [49]. Triamcinolone–acetonide injection and rectal suppository hydrocortisone acetate may be adjuncts in healing and
prevention [49, 50]. Fixing endoscopic stents
with biomaterials, which can be used for esophageal lesions, are not preferred for colorectal
lesions due to possible stent migration [55].
Close follow- up is essential to monitor the effectiveness of treatment and prevent recurrence of
the stricture.
Fecal Incontinence
Background
Fecal incontinence is a distressing complication
that can happen especially following transanal
local excisions. The involuntary loss of fecal contents signicantly impairs the quality of life of
the affected patients. Postoperative fecal incontinence is observed in approximately 29% of
patients who undergo transanal endoscopic
microsurgery (TEM) with varying degrees of
severity [56]. The TEM device’s relatively large
diameter and rigidity contribute to this higher
incidence. Conventional retractors can cause
sphincter damage during TAE procedures probably with the same pathophysiology. However, the
diameter of the retractor in TAE is smaller than
that in TEM and operation times are shorter. The
expected fecal incontinence rate is lower than
that of the TEM procedure. The introduction of
TAMIS has helped mitigate fecal incontinence.
TAMIS utilizes a more exible platform, reducing the risk of sphincter damage and improving
functional outcomes. Moreover, fecal incontinence is not an expected complication in EMR
and ESD, which are more exible approaches.
Nevertheless, when these procedures are performed in the distal rectum, fecal incontinence
can still arise from sphincter damage. Injuries
that can occur during dissection or resection can
cause a loss of anal sphincter pressure. Fecal
incontinence may occur due to complications
arising after the procedure. For example, a perforation or an abscess, which might occur after
these procedures, can cause fecal incontinence.
The severity of fecal incontinence symptoms gets
worse after the procedure, especially in patients
who have undergone TEM. However, most
patients experience transient symptoms that
improve over time [57]. The procedure-specic
risk factors for the development of functional disorders after transanal excisions are the TEM procedure, prolonged operative time, tumor
localization at <3 cm from the anal verge, and
tumor size larger than 3cm [56].
Prevention
Preventing fecal incontinence following transanal local excisions and endoluminal approaches
requires a comprehensive approach. Surgeons
should employ surgical techniques to minimize
damage to the anal sphincter complex and surrounding structures. Careful dissection and preservation of the anal sphincter muscles, nerves,
and blood supply are crucial for reducing the risk
of fecal incontinence. Transitioning to more exible platforms like EMR, ESD, and TAMIS has
demonstrated a reduced incidence of sphincter
damage and subsequent fecal incontinence.
Flexible platforms should be considered for
larger lesions, especially in older patients.
Preoperative evaluation of anal sphincter function through anorectal manometry and endoanal
ultrasonography can help identify patients at a
higher risk. A trauma to the anal sphincters
caused by inserting operating devices or platforms and prolonged stretching of the anal canal
during surgery can impair continence [57].
Therefore, operative time should be kept to a
minimum.