Introduction Endoscopic mucosal resection (EMR) is an excellent technique for removing large lesions. It can also be used as an adjunct to surgery. Be describe a case where EMR was used to partially remove a large rectal adenoma, enabling a less radical surgical approach to be taken.

Methods A 55-year-old woman with a previous history of an anterior resection for a sigmoid tumour was referred with a large 18-cm LST-G rectal adenoma, crossing the dentate line and involving the surgical anastomosis. It had been suggested that the only treatment option was an AP resection with permanent colostomy. On assessment of the lesion it was clear that a complete endoscopic resection was not possible due to the scar tissue from the previous surgery. However, it was decided that it would be possible to clear a 10-cm cuff to enable a low resection with primary anastomosis to be performed.

Results A 10-cm cuff was cleared by piecemeal resection of the lesion using a conventional EMR technique. The patient was followed up after 8 weeks where a joint assessment by gastroenterologist and rectal surgeon was performed. It was felt that a sufficient margin had been created for a resection and primary anastomosis to be performed in. She subsequently underwent a successful laparoscopic surgical resection.

Conclusion When a complete EMR is not viable it is important not to dismiss the potential benefit which can be gained by a combined endoscopic and laparoscopic surgical approach. This case illustrates how a permanent colostomy can be avoided in patients with low rectal lesions associated with scarring precluding a total endoscopic mucosal resection.