Peranal endoscopic myectomy (PAEM) is a novel endoscopic technique for removing lesions
together with the inner circular muscle layer in patients with lower rectal tumors
with severe submucosal fibrosis [1]
[2]
[3]
[4]. In this procedure, the outer longitudinal muscle is exposed at the resection area
and its fragility poses a risk for perforation. As there are few reports on PAEM,
the thickness of the muscles in the lower rectum is not well known. In our experience,
the outer longitudinal muscle is usually dense and the extraluminal tissue is invisible
([Fig. 1]). Herein, we present the management of a patient with a sparse outer longitudinal
muscle layer ([Video 1]).
Fig. 1 Previous cases of peranal endoscopic myectomy showing the dense outer longitudinal
muscle layer at the resection margin (a–c).
Management of a sparse outer longitudinal muscle layer in peranal endoscopic myectomy.Video
1
A 52-year-old man underwent cold snare polypectomy for a small rectal lesion. Histological
examination of the resected specimen revealed a 5-mm neuroendocrine tumor, grade 1,
with a positive vertical margin. Additional surgery was recommended according to the
Japanese guidelines [5], and he was referred to our hospital.
No residual tumor was detected around the scar ([Fig. 2]). After discussions with surgeons regarding the patient’s desire to preserve anal
function, PAEM was performed. During the procedure, sparse and partially injured outer
longitudinal muscles were observed ([Fig. 3]). After en bloc resection, the muscle layer was roughly closed with endoclips, and
a self-assembling peptide gel (PuraStat; 3D-Matrix, Tokyo, Japan) was injected into
the gap ([Fig. 4]).
Fig. 2 The scar after endoscopic resection for a neuroendocrine tumor in the left wall of
the lower rectum.
Fig. 3 The sparse outer longitudinal muscle layer at the resection margin after peranal endoscopic
myectomy.
Fig. 4 Wound closure after resection. a The resection wound was closed with endoclips. b Self-assembling peptide gel was injected into the gap.
Antibiotics were administered prophylactically on postoperative days 0 and 1. Oral
intake was resumed on postoperative day 2, and the patient was discharged on postoperative
day 5 without adverse events. Histological examination of the resected specimen revealed
a 2-mm, grade 1 neuroendocrine tumor with a negative margin.
Injection of self-assembling peptide gel combined with endoscopic clips can be used
to easily reinforce wound closure.
Endoscopy_UCTN_Code_TTT_1AQ_2AD_3AZ
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
