Advanced mucosal neoplasia of the anorectal junction: endoscopic resection technique and outcomes (with videos)

Background: EMR at the anorectal junction (ARJ) is technically challenging. Issues of safety and procedural efficacy dictate that surgery is still performed as the primary management for noninvasive lesions in most centers. Modifications to the standard EMR technique may help to address the unique features and achieve safe and curative resection of most lesions. Objective: To describe an effective and safe, modified EMR technique to remove advanced mucosal neoplasia (AMN) of the ARJ. Design: Prospective, observational cohort study. Setting: Academic, tertiary care referral center. Patients: Patients undergoing EMR for AMN at the ARJ over 4.5 years, from June 2008 to December 2012. Interventions: Use of long-acting local anesthetic in the submucosal injectate, endoscopic resection over the dentate line and hemorrhoidal columns, prophylactic antibiotics for resection of lesions at high risk for bacteremia, and cap and gastroscope-assisted resection. Main Outcome Measurements: Procedural success and safety. Results: Twenty-six patients with lesions involving the ARJ were referred for EMR (males 53.8%, median age 63, median lesion size 40 mm). Two patients went directly to surgery because of an endoscopic diagnosis of adenocarcinoma. EMR was performed in 24 lesions with complete adenoma clearance achieved in 100%. Four patients were admitted to the hospital. Focal adenoma recurrence was seen in 4 of 18 patients (22%) at first surveillance colonoscopy and was managed by snare diathermy resection. No recurrences were found at the second follow-up colonoscopy. Procedural success, adenoma recurrence, and admission rates were similar between EMRs performed at the ARJ and proximal rectum on univariate analysis (all P > .05). Limitations: Single tertiary center, nonrandomized study. Conclusions: Simple modifications to the EMR technique allow safe and effective treatment of AMN at the ARJ on an outpatient basis and should be the first-line management when the risk of invasive disease is low.