Post written by Sukit Pattarajierapan, MD, from the Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Our video presents a challenging case of difficult polypectomy in the nondistensible rectum from severe fecal incontinence. An 89-year-old woman with ischemic heart disease and hypertension underwent laparoscopic sigmoidectomy for stage II sigmoid cancer 1 year ago. After the colectomy, she had severe fecal incontinence. She could not hold gas and sometimes had leakage of liquid stool.

We performed a surveillance colonoscopy. We used a magnifying colonoscope (CF-HQ290ZI; Olympus Medical Systems, Tokyo, Japan) and found a 10-mm sessile polyp at the upper rectum. Magnifying narrow-band-imaging (NBI) showed a type 2B polyp of the Japanese NBI Expert Team classification. At first, we tried to perform conventional endoscopic mucosal resection (EMR). After submucosal injection with indigo carmine mixed saline solution, it was still difficult to snare the polyp en bloc due to poor rectal distension. Occluding the anus with gauze did not help. We injected hyoscine butylbromide to decrease the peristalsis, but it was not helpful. Finally, we decided to perform underwater EMR. Water was infused until we achieved complete filling of the lumen. Her rectum was well distended with minimal anal leakage. We got better exposure and performed successful polypectomy using a SnareMaster (10 mm; Olympus Medical Systems, Tokyo, Japan). The mucosal defect was closed by endoscopic clips. There were no adverse events. The pathology report showed tubular adenoma with high-grade dysplasia with a clear resection margin.

In a patient with severe fecal incontinence, polypectomy of rectal adenomas may be difficult if the patient cannot retain the gas in the rectum. Existing literature does not include reports of the optimal polypectomy technique in these patients. We demonstrated the advantage of underwater EMR in a challenging case with severe fecal incontinence.

Stool consistency has a crucial role in fecal incontinence. In theory, the liquid is easier than the gas to be retained in the rectum in the patients with fecal incontinence. For this reason, underwater EMR is suitable in this rare situation when the adenoma is located in the nondistensible rectum from severe fecal incontinence.

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