Transanal submucosal endoscopic resection: a new endosurgical approach to the resection of giant rectal lesions.

a new endosurgical approach to the resection of giant rectal lesions Transanal surgical and advanced endoscopic resection procedures have the potential to provide complete and successful eradication of rectal lesions [1–3]. However, both approaches have limitations in terms of practicability and safety [3–5]. Transanal submucosal endoscopic resection (TASER) is a new endosurgical approach, which combines the advantages of both endoscopic therapy and transanal surgery. It utilizes a three-port channel platform (GelPoint Path; Applied Medical, Rancho Santa Margarita, California, USA), which allows simultaneous transanal passage of an endoscope and two laparoscopic instruments (●" Fig.1). We present a video clip demonstrating TASER, where an endoscopic knife is used as the primary cutting tool to resect a (9.4×7.6cm) circumferential (abutting the dentate line to the upper rectum), benign, nongranular, lateral spreading tumor (●" Fig.2). A 2-mm lateral resection margin around the lesion was maintained during circumferential mucosal incision. The GelPoint Path system was then mounted across the anal canal and a surgeon passed two laparoscopic forceps retractors (Johann Forceps 33cm; Karl Storz, Tuttlingen, Germany) into the rectum, working alongside the endoscopist who passed a gastroscope through the third port; both operators utilized the endoscopic view. Once a tissue flap had been created, the submucosal dissection was rapid, using long sweeping movements of the endoscopic knife (FlushKnife BT, 1.5mm; Fujifilm, Tokyo, Japan) parallel to the underlying muscle. Repeated injections expanded the submucosal plane and sustained a clear separation of the submucosal and muscle layers. The retractors could be repositioned multiple times and in any direction, providing the endoscopist with a continuous view of the submucosal plane (●" Video 1). The en bloc resection was completed in 182 minutes. Large vessels were coagulated and clipped to prevent delayed bleeding. After a 6-month interval, a check-up endoscopy showed a healed scar with no signs of recurrence or rectal stricture (●" Fig.3). Fig.1 Transanal passage of an endoscope and two laparoscopic retractors using the GelPoint Path platform (Applied Medical, Rancho Santa Margarita, California, USA).