Combined endoscopic submucosal dissection and transanal minimally invasive surgery for the management of lower rectal adenoma extending above the dentate line: A case report

RATIONALE: Minimally invasive surgery is used to treat early colorectal tumors. Endoscopic submucosal dissection (ESD) for resection of tumors extending above the dentate line (particularly those with concomitant hemorrhoids) is technically difficult. We present a case of a patient with a lower rectal adenoma extending above the dentate line, which underwent combined ESD and transanal minimally invasive surgery (TAMIS) to achieve accurate excision and prevent complications. PATIENT CONCERNS: A 68-year-old man with a history of blood in stool over 2 to 3 years underwent colonoscopy, which revealed an adenoma measuring 3 cm in size in the lower rectum extending above the dentate line. The part extending above the dentate line was a type Is lesion and that of oral side was a type IIa lesion. Histopathologically, the lesion was diagnosed as a low-grade intramucosal tubulovillous adenoma. DIAGNOSIS: Intramucosal low-grade adenoma with sessile polyp (type Is). INTERVENTIONS: The cranial portion of the lesion was dissected via ESD and the anal portion via TAMIS with minimal bleeding. En bloc resection of the tumor was performed. OUTCOMES: His postoperative period was uneventful, and he was discharged and regularly followed-up. LESSONS: Combined ESD and TAMIS is effective in patients with benign and early neoplastic lesions of the anorectum extending above the dentate line with concomitant hemorrhoids and can prevent complications.