A challenging endoscopic approach to an unexpected case of extraluminal recurrence after rectal surgery

Postsurgical anastomotic recurrences of colorectal cancer represent a specific type of local recurrence [1] and several theories exist regarding their pathogenesis, including positive margins, lymphatic dissemination, and implantation of tumor cells [2]. Here, we present an unusual case of anastomotic recurrence that developed in a para-anastomotic cavity and was approached endoscopically.

A 73-year-old man underwent a lower anterior resection of the rectum. Over time, he developed several nonmalignant anastomotic recurrences that were treated endoscopically and, 10 years after the surgical intervention, he was referred to our center for management of a further recurrence. Owing to the presence of fibrosis and the histology from fragments showing low/high grade adenomatous dysplasia, a piecemeal knife-assisted snare resection was performed. During the procedure however, a fistulous orifice communicating with a cavity that was endoscopically accessible was noticed ([Fig. 1 a]). Inside the cavity, a florid villous tissue growth was observed, so biopsies were taken ([Fig. 1 b]). An endoscopic ultrasound examination was performed to evaluate the cavity, which was 62 × 34 mm in size.

Fig. 1 Endoscopic images showing: a the access to the cavity through the fistulous orifice; b the villous tissue growing inside the cavity; c resection of the tissue being performed using a cold snare.

Pathological examination diagnosed a low grade adenoma, so an endoscopy session was scheduled to remove the intracavitary tissue recurrence. The procedure was performed using a standard gastroscope (EG-2990i; Pentax Medical, Japan) equipped with a cap. The “lifting sign” was not observed, so multiple tissue fragments were resected with cold and hot snares ([Fig. 1 c]). Avulsion of debris with a biopsy forceps led to complete resection of the tissue ([Video 1]). No complications occurred, and the patient was discharged on the subsequent day; however, the histology showed invasive adenocarcinoma, so the patient was ultimately referred to surgery.

Video 1 Endoscopic approach to an unusual postsurgical anastomotic recurrence of colorectal cancer.

This case demonstrates how malignant locoregional recurrences of colorectal cancer may occur, even in unusual locations and after a considerable time. Although endoscopic management did not prove curative in this case, it should be considered as the first treatment option for anastomotic recurrence, where the endoscopic appearance and histologic findings are nonmalignant, in order to avoid immediate surgical re-intervention.

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• References

• 1 Galandiuk S, Wieand HS, Moertel CG. et al. Patterns of recurrence after curative resection of carcinoma of the colon and rectum. Surg Gynecol Obstet 1992; 174: 27-32
• 2 Gopalan S, Bose JC, Periasamy S. Anastomotic recurrence of colon cancer-is it a local recurrence, a second primary, or a metastatic disease (local manifestation of systemic disease)?. Indian J Surg 2015; 77: 232-236