Rectal pneumatosis close to a colorectal anastomosis unmasked by cystic spaces in a cold snare resection defect.

To the Editor: A 59-year-old male patient was referred by a collaborating endoscopist for a second opinion concerning questionable polypoid lesions in the rectum just below a colorectal anastomosis with essentially normal mucosal biopsies. Of note, history included subtotal colectomy due to colon cancer and multiple advanced polyps in the setting of MYH-associated polyposis (MAP). Recent colonoscopy revealed some subepithelial lesions in the upper rectum with firm consistency on forceps palpation (Fig. 1A). Meticulous endoscopic assessment indicated smooth surface with normal mucosal and vessel pattern. (Fig. 1B—not shown ancillary linked color imaging and blue laser imaging characterization) To unequivocally clarify the nature of the lesions, cold snare resection (or, in the case of a truly solid subepithelial lesion, “decaptation” to allow for deep biopsies) was performed without complications. Intriguingly, visualization of the resection bed, apparently enough reaching the submucosal space, demonstrated multiple intramural cystic