Endoscopic full-thickness resection using a novel over-the-scope device

Combined endoscopic mucosal resection and full-thickness resection for large colorectal polyps: a systematic review and meta-analysis

BACKGROUND AND AIMS

Combined endoscopic mucosal resection (EMR) with endoscopic Full thickness resection (EFTR) is an emerging technique that has been developed to target colorectal polyps larger than 2 cm. We performed a systematic review and meta-analysis to evaluate this technique for the resection of large colorectal lesions.

METHODS

We conducted a comprehensive search of multiple electronic databases from inception through August 2023, to identify studies that reported on hybrid FTR. A random-effects model was employed to calculate the overall pooled technical success, macroscopic complete resection, free vertical margins resection rate, adverse events, and recurrence on follow up.

RESULTS

A total of 8 Study arms with 244 patients (30% women) were included in the analysis. The pooled technical success rate was 97% (95% CI 88%-100%, I2 = 79.93%). The pooled rate of macroscopic complete resection was achieved in 95% (95% CI 90%-99%, I2 = 49.98) with a free vertical margins resection rate 88% (95% CI, 78%-96%, I2 = 63.32). The overall adverse events rate was 2% (95% CI 0%-5%, I2 = 11.64) and recurrence rate of 6% (95% CI 2%-12%, I2=20.32).

CONCLUSION

Combined EMR with EFTR is effective and safe for resecting large, and complex colorectal adenomas, offering a good alternative for high surgical risk patients. Regional heterogeneity was observed, indicating that outcomes may be impacted by differences in operator expertise and industry training certification across regions. Comparative studies that directly compare combined EMR with EFTR against alternative methods such as ESD and surgical resection are needed.

Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study

BACKGROUND AND AIMS

Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center.

METHODS

From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes.

RESULTS

R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1).

CONCLUSION

eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.

Long-term oncological outcomes of endoscopic full-thickness resection after previous incomplete resection of low-risk T1 CRC (LOCAL-study): study protocol of a national prospective cohort study

BACKGROUND

T1 colorectal cancer (CRC) without histological high-risk factors for lymph node metastasis (LNM) can potentially be cured by endoscopic resection, which is associated with significantly lower morbidity, mortality and costs compared to radical surgery. An important prerequisite for endoscopic resection as definite treatment is the histological confirmation of tumour-free resection margins. Incomplete resection with involved (R1) or indeterminate (Rx) margins is considered a strong risk factor for residual disease and local recurrence. Therefore, international guidelines recommend additional surgery in case of R1/Rx resection, even in absence of high-risk factors for LNM. Endoscopic full-thickness resection (eFTR) is a relatively new technique that allows transmural resection of colorectal lesions. Local scar excision after prior R1/Rx resection of low-risk T1 CRC could offer an attractive minimal invasive strategy to achieve confirmation about radicality of the previous resection or a second attempt for radical resection of residual luminal cancer. However, oncologic safety has not been established and long-term data are lacking. Besides, surveillance varies widely and requires standardization.

METHODS/DESIGN

In this nationwide, multicenter, prospective cohort study we aim to assess feasibility and oncological safety of completion eFTR following incomplete resection of low-risk T1 CRC. The primary endpoint is to assess the 2 and 5 year luminal local tumor recurrence rate. Secondary study endpoints are to assess feasibility, percentage of curative eFTR-resections, presence of scar tissue and/or complete scar excision at histopathology, safety of eFTR compared to surgery, 2 and 5 year nodal and/or distant tumor recurrence rate and 5-year disease-specific and overall-survival rate.

DISCUSSION

Since the implementation of CRC screening programs, the diagnostic rate of T1 CRC is steadily increasing. A significant proportion is not recognized as cancer before endoscopic resection and is therefore resected through conventional techniques primarily reserved for benign polyps. As such, precise histological assessment is often hampered due to cauterization and fragmentation and frequently leads to treatment dilemmas. This first prospective trial will potentially demonstrate the effectiveness and oncological safety of completion eFTR for patients who have undergone a previous incomplete T1 CRC resection. Hereby, substantial surgical overtreatment may be avoided, leading to treatment optimization and organ preservation. Trial registration Nederlands Trial Register, NL 7879, 16 July 2019 ( https://trialregister.nl/trial/7879 ).

Correlation between endoscopic resection outcomes and endosonographic findings in gastric tumors with muscularis propria origin

Endoscopic resection is an effective treatment for subepithelial tumors arising from the muscularis propria layer of the stomach. However, the invasion pattern revealed by the pathological examination of tumor specimens is often not consistent with the findings of preprocedural endoscopic ultrasounds (EUS). We compared the real growing patterns of tumors, as evaluated on histopathological examination, with their EUS images, and analyzed the outcomes of endoscopic resections in relation to the EUS findings. From January 2006 to June 2015, 32 patients underwent endoscopic resection for gastric tumors originating from the muscularis propria at our hospital. We divided the patients into 3 groups according to the location of the tumor as diagnosed using pre procedural EUS: submucosa (group I, n = 5), muscularis propria (group II, n = 14), and tumors extending into the outer cavity (group III, n = 13). Histopathological examination revealed 15 patients with gastrointestinal stromal tumors (GISTs), 14 with leiomyomas, and 3 with schwannomas. Accuracy of EUS in evaluating tumor invasion was 56%. Some tumors in groups I and II was removed by endoscopic submucosal dissection only. Muscular dissection was needed in 10 patients (71%) in group II and 9 patients (69%) in group III. Four patients (31%) in group III were found to have subserosal tumors. The complete resection rate was 88% (23 patients) among patients who underwent endoscopic submucosal dissection and endoscopic muscular dissection, and 67% (4 patients) among patients who underwent endoscopic subserosal dissection (ESSD). The tumor was completely removed in 12 patients (86%) in group II and 10 patients (77%) in group III. EUS accurately predicts the layer of the subepithelial tumor in the stomach; however, the pattern of invasion of surrounding structures is difficult to evaluate using EUS.

Colon Sparing Endoscopic Full-Thickness Resection for Advanced Colorectal Lesions: Is It Time for Global Adoption?

The majority of colon lesions are <10 mm in size and are easily resected by endoscopists with appropriate basic training. Lesions ≥10 mm in size are difficult to remove technically and are associated with higher rates of incomplete resection. Currently, the main endoscopic approaches include endoscopic mucosal resection (EMR) for lesions without submucosal invasion, and endoscopic submucosal dissection (ESD) for relatively larger lesions involving the superficial submucosal layer. Both of these approaches have limitations, EMR cannot reliably ensure complete resection for larger tumors and recurrence is a key limitation. ESD reliably provides complete resection and an accurate pathological diagnosis but is associated with risk such as perforation or bleeding. In addition, both EMR and ESD may be ineffective in treating subepithelial lesions that extend beyond the submucosa. Endoscopic full-thickness resection (EFTR) is an emerging innovative endoscopic therapy which was developed to overcome the limitations of EMR and ESD. Advantages include enabling a transmural resection, complete resection of complex colorectal lesions involving the mucosa to the muscularis propria. Recent studies comparing EFTR with current resection techniques and radical surgery for relatively complicated and larger lesion have provided promising results. If the current trajectory of research and development is maintained, EFTR will likely to become a strong contender as an alternative standard of care for advanced colonic lesions. In the current study we aimed to address this need, and highlighted the areas of future research, while stressing the need for multinational collaboration provide the steppingstone(s) needed to bring EFTR to the mainstream.

Colon Polypectomy with Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection has become the gold standard for the management of most of the large colorectal polyps. Various endoscopic resection techniques include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). ESD is a minimally invasive method for the resection of advanced lesions in the gastrointestinal (GI) tract to achieve en-bloc resection. While, EFTR is more commonly used in lesions with suspected deeper submucosal invasion, lesions originating from muscularis propria, or those with advanced fibrosis. This article reviews the indications, technique, and adverse events for use of ESD and EFTR in the colon.

Endoscopic management of difficult laterally spreading tumors in colorectum

Due to the advent of the screening programs for colorectal cancer and the era of quality assurance colonoscopy the number the polyps that can be considered difficult, including large (> 20 mm) laterally spreading tumors (LSTs), has increased in the last decade. All LSTs should be assessed carefully, looking for suspicious areas of submucosal invasion (SMI), such as nodules or depressed areas, describing the morphology according to the Paris classification, the pit pattern, and vascular pattern. The simplest, most appropriate and safest endoscopic treatment with curative intent should be selected. For LST-granular homogeneous type, piecemeal endoscopic mucosal resection should be the first option due to its biological low risk of SMI. LST-nongranular pseudodepressed type has an increased risk of SMI, and en bloc resection should be mandatory. Underwater endoscopic mucosal resection is useful in situations where submucosal injection alters the operative field, e.g., for the resection of scar lesions, with no lifting, adjacent tattoo, incomplete resection attempts, lesions into a colonic diverticulum, in ileocecal valve and lesions with intra-appendicular involvement. Endoscopic full thickness resection is very useful for the treatment of difficult to resect lesions of less than 20 up to 25 mm. Among the indications, we highlight the treatment of polyps with suspected malignancy because the acquired tissue allows an exact histologic risk stratification to assign patients individually to the best treatment and avoid surgery for low-risk lesions. Endoscopic submucosal dissection is the only endoscopic procedure that allows completes en bloc resection regardless of the size of the lesion. It should therefore be indicated in the treatment of lesions with risk of SMI.

Risk and Time Pattern of Recurrences After Local Endoscopic Resection of T1 Colorectal Cancer: A Meta-analysis

BACKGROUND & AIMS

Growing numbers of patients with T1 CRC are being treated with local endoscopic resection only and as a result, the need for optimization of surveillance strategies for these patients also increases. We aimed to estimate the cumulative incidence and time pattern of CRC recurrences for endoscopically treated patients with T1 CRC.

METHODS

Using a systematic literature search in PubMed, EMBASE, Web of Science and Cochrane Library (from inception till 15 May 2020), we identified and extracted data from studies describing the cumulative incidence of local or distant CRC recurrence for patients with T1 CRC treated with local endoscopic resection only. Pooled estimates were calculated using mixed-effect logistic regression models.

RESULTS

Seventy-one studies with 5167 unique, endoscopically treated patients with T1 CRC were included. The pooled cumulative incidence of any CRC recurrence was 3.3% (209 events; 95% CI, 2.6%-4.3%; I² = 54.9%), with local and distant recurrences being found at comparable rates (pooled incidences 1.9% and 1.6%, respectively). CRC-related mortality was observed in 42 out of 2519 patients (35 studies; pooled incidence 1.7%, 95% CI, 1.2%-2.2%; I² = 0%), and the CRC-related mortality rate among patients with recurrence was 40.8% (42/103 patients). The vast majority of recurrences (95.6%) occurred within 72 months of follow-up. Pooled incidences of any CRC recurrence were 7.0% for high-risk T1 CRCs (28 studies; 95% CI, 4.9%-9.9%; I² = 48.1%) and 0.7% (36 studies; 95% CI, 0.4%-1.2%; I² = 0%) for low-risk T1 CRCs.

CONCLUSIONS

Our meta-analysis provides quantitative outcome measures which are relevant to guidelines on surveillance after local endoscopic resection of T1 CRC.

[Colorectal carcinoma: from prevention to endoscopic diagnosis and therapy]

In recent decades, significant progress has been made in the diagnosis and treatment of colorectal carcinomas. Prevention and early detection with endoscopic therapy are of central importance. With the introduction of national screening programs, the early detection of adenomas and small tumors during colonoscopy has been significantly improved, thus reducing the incidence of colorectal carcinoma. In Germany, for example, this has been reduced by 17-26 % since its introduction in 2002. Thus, primary and secondary prevention are of considerable importance, although the annual uptake in Germany for screening Kolonoscopy is still only between 1.9 and 4.4 % and for stool test use between 8.6 and 27.1 %. We present here the importance of primary and secondary prevention based on pathogenesis, risk factors and diagnostic and therapeutic endoscopic options.

Current Endoscopic Resection Techniques for Gastrointestinal Lesions: Endoscopic Mucosal Resection, Submucosal Dissection, and Full-Thickness Resection

Background

Endoscopic resection of dysplastic lesions in early stages of cancer reduces mortality rates and is recommended by many national guidelines throughout the world. Snare polypectomy and endoscopic mucosal resection (EMR) are established techniques of polyp removal. The advantages of these methods are their relatively short procedure times and acceptable complication rates. The latter include delayed bleeding in 0.9% and a perforation risk of 0.4-1.3%, depending on the size and location of the resected lesion. EMR is a recent modification of endoscopic resection. A limited number of studies suggest that larger lesions can be removed en bloc with low complication rates and short procedure times. Novel techniques such as endoscopic submucosal dissection (ESD) are used to enhance en bloc resection rates for larger, flat, or sessile lesions. Endoscopic full-thickness resection (EFTR) is employed for non-lifting lesions or those not easily amenable to resection. Procedures such as ESD or EFTR are emerging standards for lesions inaccessible to EMR techniques.

Summary

Endoscopic treatment is now regarded as first-line therapy for benign lesions.

Key Message

Endoscopic resection of dysplastic lesions or early stages of cancer is recommended. A plethora of different techniques can be used dependent on the lesions.

Efficacy and safety of endoscopic resection in treatment of small gastric stromal tumors: A state-of-the-art review

Gastrointestinal stromal tumors can occur in any part of the gastrointestinal tract, but gastric stromal tumors (GSTs) are the most common. All GSTs have the potential to become malignant, and these can be divided into four different grades by risk from low to high: Very low risk, low risk, medium risk, and high risk. Current guidelines all recommend early complete excision of GSTs larger than 2 cm in diameter. However, it is not clear whether small GSTs (sGSTs, i.e., those smaller than 2 cm in diameter) should be treated as early as possible. The National Comprehensive Cancer Network recommends that endoscopic ultrasonography-guided (EUS-guided) fine-needle aspiration biopsy and imaging (computed tomography or magnetic-resonance imaging) be used to assess cancer risk for sGSTs detected by gastroscopy to determine treatment. When EUS indicates a higher risk of tumor, surgical resection is recommended. There are some questions on whether sGSTs also require early treatment. Many studies have shown that endoscopic treatment of GSTs with diameters of 2-5 cm is very effective. We here address whether endoscopic therapy is also suitable for sGSTs. In this paper, we try to explain three questions: (1) Does sGST require treatment? (2) Is digestive endoscopy a safe and effective means of treating sGST? and (3) When sGSTs are at different sites and depths, which endoscopic treatment method is more suitable?

Efficacy and Safety of Endoscopic Full-Thickness Resection in the Colorectum: Results From the German Colonic FTRD Registry

INTRODUCTION

Endoscopic full-thickness resection (EFTR) is a powerful option for resection of colorectal lesions not amenable to conventional endoscopic resection. The full-thickness resection device (FTRD) allows clip-assisted EFTR with a single-step technique. We report on results of a large nationwide FTRD registry.

METHODS

The "German colonic FTRD registry" was created to further assess efficacy and safety of the FTRD System after approval in Europe. Data were analyzed retrospectively.

RESULTS

Sixty-five centers contributed 1,178 colorectal FTRD procedures. Indications for EFTR were difficult adenomas (67.1%), early carcinomas (18.4%), subepithelial tumors (6.8%), and diagnostic EFTR (1.3%). Mean lesion size was 15 × 15 mm and most lesions were pretreated endoscopically (54.1%). Technical success was 88.2% and R0 resection was achieved in 80.0%. R0 resection was significantly higher for subepithelial tumor compared with that for other lesions. No difference in R0 resection was found for smaller vs larger lesions or for colonic vs rectal procedures. Adverse events occurred in 12.1% (3.1% major events and 2.0% required surgical treatment). Endoscopic follow-up was available in 58.0% and showed residual/recurrent lesions in 13.5%, which could be managed endoscopically in most cases (77.2%).

DISCUSSION

To date, this is the largest study of colorectal EFTR using the FTRD System. The study demonstrated favorable efficacy and safety for "difficult-to-resect" colorectal lesions and confirms results of previous studies in a large "real-world" setting. Further studies are needed to compare EFTR with other advanced resection techniques and evaluate long-term outcome.

Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry

BACKGROUND

Endoscopic full-thickness resection (eFTR) is a minimally invasive resection technique that allows definite diagnosis and treatment for complex colorectal lesions ≤ 30 mm unsuitable for conventional endoscopic resection. This study reports clinical outcomes from the Dutch colorectal eFTR registry.

METHODS

Consecutive patients undergoing eFTR in 20 hospitals were prospectively included. The primary outcome was technical success, defined as macroscopic complete en bloc resection. Secondary outcomes were: clinical success, defined as tumor-free resection margins (R0 resection); full-thickness resection rate; and adverse events. RESULTS : Between July 2015 and October 2018, 367 procedures were included. Indications were difficult polyps (non-lifting sign and/or difficult location; n = 133), primary resection of suspected T1 colorectal cancer (CRC; n = 71), re-resection after incomplete resection of T1 CRC (n = 150), and subepithelial tumors (n = 13). Technical success was achieved in 308 procedures (83.9 %). In 21 procedures (5.7 %), eFTR was not performed because the lesion could not be reached or retracted into the cap. In the remaining 346 procedures, R0 resection was achieved in 285 (82.4 %) and full-thickness resection in 288 (83.2 %). The median diameter of resected specimens was 23 mm. Overall adverse event rate was 9.3 % (n = 34/367): 10 patients (2.7 %) required emergency surgery for five delayed and two immediate perforations and three cases of appendicitis. CONCLUSION : eFTR is an effective and relatively safe en bloc resection technique for complex colorectal lesions with the potential to avoid surgery. Further studies assessing the role of eFTR in early CRC treatment with long-term outcomes are needed.

Devices and techniques for endoscopic treatment of residual and fibrotic colorectal polyps (with videos)

BACKGROUND AND AIMS

Residual neoplasia after macroscopically complete EMR of large colon polyps has been reported in 10% to 32% of resections. Often, residual polyps at the site of prior polypectomy are fibrotic and nonlifting, making additional resection challenging.

METHODS

This document reviews devices and methods for the endoscopic treatment of fibrotic and/or residual polyps. In addition, techniques reported to reduce the incidence of residual neoplasia after endoscopic resection are discussed.

RESULTS

Descriptions of technologies and available outcomes data are summarized for argon plasma coagulation ablation, snare-tip coagulation, avulsion techniques, grasp-and-snare technique, EndoRotor endoscopic resection system, endoscopic full-thickness resection device, and salvage endoscopic submucosal dissection.

CONCLUSIONS

Several technologies and techniques discussed in this document may aid in the prevention and/or resection of fibrotic and nonlifting polyps.

Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels

Introduction

Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR.

Material and methods

In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications.

Results

Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4–88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8–83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1–93.7%). Of the resectates obtained (n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation.

Discussion

In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07772-5) contains supplementary material, which is available to authorized users.

Future of Endoscopy: Brief review of current and future endoscopic resection techniques for colorectal lesions

Endoscopic treatment of colorectal lesions has seen major developments in the last decade. It is now considered curative for intramucosal and superficial submucosal cancers. Endoscopic Mucosal Resection in expert hands has very good outcomes with low complication rates but recurrence and inadequate treatment of early cancers remain an issue. This has led to a technical evolution that can lead to one piece resection of neoplasia. This includes a range of techniques from knife assisted snare resection (KAR), endoscopic submucosal dissection (ESD) to full thickness resections. This article reviews all the resection techniques and the evidence base behind them.

Mucosectomy device-assisted endoscopic resection of gastric subepithelial lesions

OBJECTIVE

Some gastrointestinal subepithelial tumors (SETs) have malignant potential and complete resection may be required. However, endoscopic submucosal dissection (ESD) can be a tedious procedure and requires a long and extensive training to master. Devices for endoscopic full-thickness resection (EFTR) are limited and are not widely available. We report here a simpler endoscopic method to resect small SETs using a commercially available endoscopic mucosal resection (EMR) kit and enucleation technique.

METHODS

All patients with SET who underwent device-assisted resection at our tertiary care hospital from April 2015 to November 2016 were enrolled in this retrospective study. All procedures were performed by a single expert endoscopist with an advanced endoscopy trainee. A mucosectomy and a limited dissection under mucosa were performed to preserve the mucosa before a device-assisted enucleation of the tumor to facilitate endoscopic closure of the defect closure in all cases.

RESULTS

A total of 12 patients aged 38-70 y, of whom six were males, were included. Most of the tumors originated from the muscularis propria and were located at the proximal gastric body. The mean procedural duration was 53 minutes (range 23-91 min). The average size of the lesions was 13 mm (range 9-21 mm). The mean duration of hospitalization was 1.3 days. Bleeding and intentional perforation were all successfully managed during the procedure and did not result in any clinically significant adverse event.

CONCLUSION

A device-assisted EFTR using a commercially available EMR kit is a safe and feasible method for the endoscopic resection of small gastric extrovert SETs.

Efficacy and safety of endoscopic full-thickness resection in the colon and rectum using an over-the-scope device: a meta-analysis

OBJECTIVE

Relevant publications were identified by searching PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science before December 1, 2019. Studies in which ≥ 10 cases of colorectal lesions were resected with endoscopic full-thickness resection (EFTR) were included. Rates of efficacy (technical success (en bloc), full-thickness resection and R0 resection), rates of safety (bleeding, perforation and postpolypectomy syndrome) and rates of follow-up (residual/recurrent adenoma, fate of over-the-scope clip and surgery for any reason) were pooled and analyzed. Forest plots were graphed based on random effects models. Subgroup analyses and sensitivity analyses were also performed if significant heterogeneity existed.

RESULTS

A total of 469 patients across 9 studies were eligible for analysis. The pooled rates of technical success, full-thickness resection and R0 resection were 94.0% (95% CI 89.8-97.3%), 89.5% (83.9-94.2%) and 84.9% (75.1-92.8%), respectively. The pooled estimates of bleeding, perforation and postpolypectomy syndrome were 2.2% (95% CI 0.4-4.9%), 0.19% (95% CI 0.00-1.25%) and 2.3% (95% CI 0.1-6.3%), respectively. Finally, the pooled rates of residual/recurrent adenoma, fate of OTSC and surgery for any reason were 8.5% (95% CI 4.1-14.0%), 80.3% (95% CI 67.5-90.8%) and 6.3% (2.4-11.7%), respectively.

CONCLUSIONS

EFTR for nonlifting, invasive lesions in the colon and rectum appears to be effective and safe. However, future studies are necessary to explore the role of EFTR in large colorectal lesions and specify its indications.

Pediatric Endoscopy, Update 2020

Optimal management of pediatric endoscopy requires a multidisciplinary approach. In most hospitals, endoscopy in pediatric patients is performed by conventional gastroenterologists and only a few centers have specialized pediatric gastroenterologists. This is due to the fact that the number of pediatric gastroenterologists is limited and not all of them are experienced in endoscopic techniques. However, there are also some pediatric centers offering a high-quality and high-volume endoscopy service provided by very experienced pediatric gastroenterologists. Up to now, the literature on pediatric endoscopy is rather sparse. In this article, we describe current knowledge and practice of endoscopic procedures in pediatric patients, which should be relevant for both the adult and pediatric gastroenterologists.

Comparison of two methods for endoscopic full-thickness resection of gastrointestinal lesions using OTSC

Background and aims: The aim of this study was to compare and analyze the feasibility and safety of two methods of endoscopic full-thickness resection (EFTR) for the management of challenging epithelial and subepithelial neoplasms that are not amenable to resection techniques.Material and methods: This was a retrospective case series study of patients who underwent one of two methods of EFTR, resection using ESD knives and post-resection closure with OTSC (Group 1), or closure with OTSC and secondary EFTR with snare (Group 2).Results: Of 11 patients, six were in Group 1 and five in Group 2. The mean time of the EFTR procedure was 76.83 ± 34.97 min in Group 1 which is significantly longer than that of Group 2 (p = .0128). The mean time of OSTC closure and length of hospital stay of Group 1 were also longer compared to Group 2, but the difference was not significant. Complete resection (R0) and technical success rates of Group 1 and Group 2 were 83.3% and 100% (p = .338), respectively. VAS scores of Group 1 immediately after the operation and after 24 h are significantly higher than those of Group 2 (p = .047 and p = .009, respectively). In Group 1, one patient had delayed perforation which led to fever and pneumoperitoneum, and one patient developed abdominal pain. No complications associated with the endoscopic procedure were observed in Group 2.Conclusion: EFTR of pre-resection closure are potentially faster compared with the concept of applying closure after EFTR. Larger prospective controlled studies comparing these two techniques are warranted in the future.

Colo-rectal endoscopic full-thickness resection (EFTR) with the over-the-scope device (FTRD®): A multicenter Italian experience

BACKGROUND AND AIM

Endoscopic full-thickness resection(EFTR) with FTRD^® in colo-rectum may be useful for several indications.The aim was to assess its efficacy and safety.

MATERIAL AND METHODS

In this retrospective multicenter study 114 patients were screened; 110 (61M/49F, mean age 68 ± 11 years, range 20-90) underwent EFTR using FTRD^®. Indications were:residual/recurrent adenoma (39), incomplete resection at histology (R1 resection) (26), non-lifting lesion (12), adenoma involving the appendix (2) or diverticulum (2), subepithelial lesions(10), suspected T1 carcinoma (16), diagnostic resection (3). Technical success (TS: lesion reached and resected), R0 resection (negative lateral and deep margins),EFTR rate(all layers documented in the specimen) and safety have been evaluated.

RESULTS

TS was achieved in 94.4% of cases. EFTR was achieved in 91% with lateral and deep R0 resection in 90% and 92%. Mean size of specimens was 20 mm (range 6-42). In residual/recurrent adenomas, final analysis revealed: low-risk T1 (11), adenoma with low-grade dysplasia (LGD) (24) and high-grade dysplasia (HGD) (3), scar tissue (1). Histology reports of R1 resections were: adenoma with LGD (6), with HGD (1), low-risk (6) and high-risk (1) T1, scar tissue (12). Non-lifting lesions were diagnosed as: adenoma with HGD (3), low-risk (7) and high risk (2) T1. Adverse clinical events occurred in 12 patients (11%),while adverse technical events in11%. Three-months follow-up was available in 100 cases and residual disease was evident in only seven patients.

CONCLUSIONS

EFTR using FTRD^® seems to be a feasible, effective and safe technique for treating selected colo-rectal lesions. Comparative prospective studies are needed to confirm these promising results.

Endoscopic Full-Thickness Resection of Colorectal Lesions with the New FTRD System: Single-Center Experience

Background and Aims

Endoscopic full-thickness resection (EFTR) is an emerging technique for the treatment of various conditions for which classic endoscopic resection techniques have failed or were considered to be at high risk for perforation. The full-thickness resection device (FTRD) is an over-the-scope system which allows a single-step EFTR. The aim of our study is to describe our experience in EFTR of colorectal lesions using the FTRD.

Methods

Nine patients (10 colorectal lesions) were proposed for EFTR. Safety, R0 resection and endoscopic treatment success were evaluated.

Results

Reasons for referral included nonlifting adenomas (n = 4), nonlifting adenoma recurrence (n = 5), and submucosal lesion (n = 1). EFTR was technically successful in all patients. The mean duration of the procedure was 55 min. R0 resection was obtained in all patients. No major complications were detected. All lesions were successfully treated by the endoscopic technique and no patient was referred for surgery. In patients with available follow-up (n = 6), no recurrence was detected.

Conclusions

EFTR is a feasible, reasonable time-consuming, safe, and promising endoscopic resection technique.

Key Messages

FTRD is an additional tool for difficult-to-treat colorectal lesions.

Purse-string sutures using novel endoloops and repositionable clips for the closure of large iatrogenic duodenal perforations with single-channel endoscope: a multicenter study

BACKGROUND

Serious complications due to perforation restrict the development of duodenal endoscopic treatment. The key stage for remediation is the successful endoscopic closure to prevent peritonitis and the need for surgical intervention. This report aimed to present a new simple method for the closure of large iatrogenic duodenal perforations with purse-string sutures using the novel endoloops and repositionable clips through a single-channel endoscope.

METHODS

A total of 23 patients with iatrogenic duodenal perforations ≥ 1 cm were retrospectively studied who were presently treated by purse-string sutures using the novel endoloops and the repositionable hemostasis clips with the single-channel endoscope at four institutes. During and after the procedure, a 20-gauge needle was used to relieve the pneumoperitoneum or subcutaneous emphysema. Finally, a gastroduodenal decompression tube was placed.

RESULTS

The median maximum diameter of iatrogenic duodenal perforations was 1.65 cm (range 1.0-3.0 cm). Complete endoscopic closure of all 23 perforations was achieved. No patient had severe complications such as peritonitis. The wounds were healed and no obvious duodenal stricture was observed in all cases after 3 months.

CONCLUSION

Purse-string sutures using the novel endoloops and repositionable endoclips through single-channel endoscope were feasible, effective and easy methods for the closure of large duodenal iatrogenic perforations.

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study

Background and study aims  Colorectal polyps involving the appendiceal orifice (AO) are difficult to resect with conventional polypectomy techniques and therefore often require surgical intervention. These appendiceal polyps could potentially be removed with endoscopic full-thickness resection (eFTR) performed with a full-thickness resection device (FTRD). The aim of this prospective observational case study was to evaluate feasibility, technical success and safety of eFTR procedures involving the AO. Patients and methods  This study was performed between November 2016 and December 2017 in a tertiary referral center by two experienced endoscopists. All patients referred for eFTR with a polyp involving the AO that could not be resected by EMR due to more than 50 % circumferential involvement of the AO or deep extension into the AO were included. The only exclusion criterion was lesion diameter > 20 mm. Results  Seven patients underwent eFTR for a polyp involving the AO. All target lesions could be reached with the FTRD and retracted into the device. Technical success with an endoscopic radical en-bloc and full-thickness resection was achieved in all cases. Histopathological R0 resection was achieved in 85.7 % of patients (6/7). One patient who previously underwent an appendectomy developed a small abscess adjacent to the resection site, which was treated conservatively. Another patient developed secondary appendicitis followed by a laparoscopic appendectomy. Conclusion  This small exploratory study suggests that eFTR of appendiceal polyps is feasible and can offer a minimally invasive approach for radical resection of these lesions. However, more safety and long-term follow-up data are needed to evaluate this evolving technique.

Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications

OBJECTIVE

Endoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device.

DESIGN

181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection.

RESULTS

EFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%.

CONCLUSION

EFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions.

TRIAL REGISTRATION NUMBER

NCT02362126; Results.

Endoscopic full-thickness resection for gastrointestinal submucosal tumors

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

Endoscopic muscle biopsy sampling of the duodenum and rectum: a pilot survival study in a porcine model to detect myenteric neurons

BACKGROUND AND AIMS

Small bowel and colorectal muscle biopsy sampling requires a surgical approach. Advancing our understanding of the pathophysiology of motility disorders, such as functional bowel disorders, intestinal pseudo-obstruction, and slow-transit constipation, is hindered by our inability to noninvasively obtain muscularis propria (MP) for evaluation of multiple cell types, including myenteric neurons. The aims of this study were to determine (1) technical feasibility, reproducibility, and safety of performing duodenal endoscopic muscle biopsy sampling (dEMB) and rectal endoscopic muscle biopsy sampling (rEMB) using a clip-assist technique and (2) the presence of myenteric neurons in tissue samples.

METHODS

Five 40-kg pigs were studied. Each animal underwent a dEMB and rEMB procedure. dEMB was performed using a single resection clip-assist technique. An over-the-scope clip was advanced to the duodenum. Tissue was suctioned into the cap and the clip deployed. The pseudopolyp of the duodenal wall created was then resected using snare electrocautery. rEMB was performed using a double resection clip-assist technique. EMR was initially performed to uncover the underlying MP using a band ligation technique. An over-the-scope clip was then advanced to the exposed MP. The MP was retracted and suctioned into the cap and the clip deployed. The pseudopolyp of the MP was resected using snare electrocautery. An antibody to protein gene product 9.5 was used to determine the presence of myenteric neurons in the samples. Animals were kept alive for 2 weeks, at which time an upper endoscopy and necropsy were performed.

RESULTS

dEMB and rEMB were successfully performed in all animals with no procedural adverse events using this "no hole" (close then cut) approach. Mean procedure times for dEMB and rEMB were 23.7 ± 2.5 minutes and 13.25 ± 2.8 minutes, respectively. Mean length of resected full-thickness duodenal wall was 13.25 ± 4.3 mm and rectal MP was 12.5 ± 1.7 mm. Hematoxylin and eosin stain and antibody to protein gene product 9.5 confirmed the presence of MP with inner circular, outer longitudinal, and intermuscular layers, including myenteric neurons, in all samples. Clinical course was uneventful in all animals. Repeat upper endoscopy at 2 weeks showed well-healed dEMB sites. Necropsy in all animals showed no perforation, fluid collection, or abscess at the dEMB and rEMB sites.

CONCLUSIONS

Based on this preclinical study, dEMB and rEMB appear to be technically feasible, reproducible, and safe. Sufficient MP tissue was obtained to identify myenteric neurons. These promising results are a step toward successful and safe implementation of these techniques into clinical practice for tissue diagnosis of muscle-based pathologies.

Full-Thickness Resection Device for Complex Colorectal Lesions in High-Risk Patients as a Last-Resort Endoscopic Treatment: Initial Clinical Experience and Review of the Current Literature

The full-thickness resection device (FTRD) is a novel endoscopic device approved for the resection of colorectal lesions. This case-series describes the device and its use in high-risk patients with colorectal lesions and provides an overview of the potential indications in recently published data.

Between December 2014 and September 2015, 3 patients underwent endoscopic full thickness resection using the FTRD for colorectal lesions: 1 case for a T1 adenocarcinoma in the region of a surgical anastomosis after recto-sigmoidectomy, 1 case for a non-lifting colonic adenoma with low-grade dysplasia in an 89-year old patient and 1 for a recurrent adenoma with high-grade dysplasia in a young patient with ulcerative rectocolitis who was under immunosuppression after renal transplantation. Both technical and clinical success rates were achieved in all cases. The size of removed lesions ranged from 9 to 30 mm.

Overall, the most frequent indication in the literature has been for lifting or non-lifting adenoma, submucosal tumors, neuroendocrin tumors, incomplete endoscopic resection (R1) or T1 carcinoma.

Colorectal FTRD is a feasible technique for the treatment of colorectal lesions and represents a minimally invasive alternative for either surgical or conventional endoscopic resection strategies.

Endoscopic full-thickness resection with an over-the-scope clip device (FTRD) in the colorectum: results from a university tertiary referral center

BACKGROUND AND STUDY AIMS

 The full-thickness resection device (FTRD) represents a novel endoscopic treatment method for lesions unresectable with conventional endoscopic techniques. The overall aim of this study was to evaluate technical success and in toto resection rates, recurrence rates, as well as immediate or late complications in patients who underwent polyp removal with the FTRD.

PATIENTS AND METHODS

 Data from a prospectively collected database of 12 patients who underwent 13 over-the-scope clip-based full-thickness resections between June 2015 and June 2017 were analyzed. Follow-up endoscopy was performed in 11 out of 12 patients.

RESULTS

 13 full-thickness resections were performed in 7 males and 5 females (mean age 64.3 ± 6.3 years). Mean size of the lesions removed with FTRD was 17 ± 4 mm. Location was rectum (n = 6), cecum (n = 2), ascending colon (n = 2), left flexure (n = 1) and right flexure (n = 2). Mean procedure time was 68 ± 35 minutes and mean hospital stay was 2.5 ± 1.2 days. 2 patients developed post-polypectomy syndrome, which resolved after conservative treatment. No perforations and no immediate surgical revision were needed. Histology of the 13 lesions removed with FTRD showed 5 adenomas with low grade intraepithelial neoplasia (IEN), 4 high grade IEN, 1 fibrosis, 1 fibrosis without dysplasia and 2 adenocarcinomas. Technical success was achieved in all procedures (13/13, 100 %). R0 resection was achieved in 10/12 patients (83.3 %). 2 patients underwent surgery because of recurrence or not evaluable margins. In 1 patient no residual malignancy was proven in histological examination, in the other patient residual low grade IEN adenoma.

CONCLUSION

 FTRD is a minimally invasive approach with good success rate of complete resection and minimal side effects.

Endoscopic full-thickness resection for T1 early rectal cancer: a case series and video report

BACKGROUND AND STUDY AIMS

 Endoscopic treatment of malignant colorectal polyps is often challenging, especially for early rectal cancer (ERC) localized close to the dentate line. Conversely, the surgical approach may result in temporary or definitive stoma and in frequent post-surgical complications. The Full-Thickness Resection Device (FTRD ^® ) System (Ovesco Endoscopy, Tübingen, Germany) is a novel system that, besides having other indications, appears to be promising for wall-thickness excision of intestinal T1 carcinoma following incomplete endoscopic resection. However, follow-up data on patients treated with this device are scarce, particularly for ERC.

PATIENTS AND METHODS

 Six consecutive patients with incomplete endoscopic resection of T1-ERC were treated with the FTRD and their long-term outcomes were evaluated based on a detailed clinical and instrumental assessment.

RESULTS

 The endoscopic en bloc full-thickness resection was technically feasible in all patients. The histopathologic analysis showed a complete endoscopic resection in all cases, and a full-thickness excision in four. Neither complications, nor disease recurrence were observed during the 1-year follow-up period.

CONCLUSIONS

 The FTRD System is a promising tool for treating ERC featuring a residual risk of disease recurrence after incomplete endoscopic mucosal resection in patients unfit for surgery or refusing a surgical approach.

Endoscopic management of colorectal adenomas

Colorectal adenomas are well known precursors of invasive adenocarcinoma. Colonoscopy is the gold standard for adenoma detection. Colonoscopy is far more than a diagnostic tool, as it allows effective treatment of colorectal adenomas. Endoscopic resection of colorectal adenomas has been shown to reduce the incidence and mortality of colorectal cancer. Difficult resection techniques are available, such as endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic full-thickness resection. This review aims to provide an overview of the different endoscopic resection techniques and their indications, and summarizes the current recommendations in the recently published guideline of the European Society of Gastrointestinal Endoscopy.

Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland

Background

Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD) has recently been introduced as a method to allow resection of certain lesions such as adenomatous polyps that would not be resectable by standard polypectomy techniques. We report our clinical experience with FTRD procedures, assessing technical success, completeness of resection (R0 status), rate of histologically proven FTR and safety.

Patients and methods

We conducted a retrospective analysis of 33 consecutive patients with colonic polyps treated with FTRD from May 2015 to November 2016.

Results

Indications mainly were adenoma recurrence or residual adenoma with nonlifting sign after previous polypectomy. In the 31 cases amenable to EFTR, resection was en bloc and histologically complete (R0) in 87.9% (29/33) of patients. Histologically confirmed complete full thickness resection (FTR) was achieved in 80.6% (25/31). Three post-procedure bleedings and one perforation were seen.

Conclusion

FTRD offers an additional endoscopic approach to treat nonlifting colorectal lesions. EFTR by FTRD appears to be feasible and efficacious in the resection of benign neoplasms of up to 30 mm in diameter and may be an alternative to surgery in selected patients. Given a significant rate of complications, safety is a concern and needs to be assessed in larger prospective studies.

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.

Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions

BACKGROUND AND AIMS

Endoscopic full-thickness resection (EFTR) allows for definitive diagnosis and treatment of select subepithelial and epithelial lesions unsuitable to conventional resection techniques. Our aim was to evaluate the efficacy and safety of over-the-scope (OTS) clip-assisted EFTR for these lesions.

METHODS

Patients who underwent OTS clip-assisted EFTR between June 2014 and October 2015 were analyzed. The procedure involved (1) thermal marking of the periphery of the lesion; (2) lesion suction into the cap of either an OTSC (Ovesco Endoscopy AG, Tübingen, Germany) or Padlock clip (Aponos Medical Corp, Kingston, NH, USA) with or without triprong anchor retraction of the lesion; (3) clip deployment; and (4) en bloc resection of the lesion above the clip using an electrosurgical snare and/or knife. Data were abstracted for demographics, lesion features, histopathologic diagnoses, R0 resection (negative margins) status, and adverse events.

RESULTS

Nine patients (7 men) with a mean age of 63 ± 9.6 years were identified. The endoscopic findings included subepithelial lesions in the duodenum (n = 4), rectosigmoid colon (n = 2), stomach (n = 1), and postappendectomy appendiceal orifice polyps (n = 2). The mean lesion size was 8 ± 3 mm and the mean procedure time 53 ± 21 minutes. R0 resection was confirmed in all cases. The histopathologic diagnoses included neuroendocrine tumors (n = 6), sessile serrated adenomas (n = 2), and pancreatic heterotopia (n = 1). No adverse events were noted.

CONCLUSIONS

OTS clip-assisted EFTR is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional resection techniques.

Hybrid endoscopic mucosal resection and full-thickness resection: a new approach for resection of large non-lifting colorectal adenomas (with video)

BACKGROUND

Clip-assisted endoscopic full-thickness resection (EFTR) with an over-the-scope device has been recently described to be feasible and effective for the resection of non-lifting adenomas in the lower gastrointestinal tract. However, tumor size is the major limitation of that technique. We describe a hybrid technique using endoscopic mucosal resection (EMR) in ten patients with large non-lifting colorectal adenomas to reduce tumor size and facilitate clip-assisted EFTR.

METHODS

Data of ten consecutive patients (median age 72.5 years, SD 8.86) who underwent combined EMR and EFTR in the colon were analyzed retrospectively. The main outcome measures were technical success, histological confirmation of full-thickness resection, and adverse events.

RESULTS

All lesions (median size 35.5 mm, SD 5.99) could be resected successfully. No immediate or delayed adverse events were observed. Histology confirmed full-thickness resection in all cases. Three-month follow-up showed no residual or recurrent adenomas.

CONCLUSIONS

Hybrid EMR-EFTR in the colon seems to be an effective approach for large non-lifting lesions with positive lateral lifting signs. Prospective studies are needed to further evaluate efficacy, safety, rate of recurrence, and long-term outcome of this technique.

[Full thickness resection device (FTRD). Experience and outcome for benign neoplasms of the rectum and colon]

BACKGROUND

The diagnostic validity of a full-thickness resection is higher compared to endoscopic mucosal resection (EMR) or endoscopic mucosal dissection (ESD). Whereas transanal endoscopic microsurgery techniques (TEM, TAMIS) are established therapeutic procedures in the rectum no established and safe minimally invasive or endoscopic procedure exists in the colon.

AIM

In this study the novel endoscopic full thickness resection device (FTRD, Ovesco, Germany) was investigated concerning success rates with histologically proven full thickness resections, R0 status as well as patient and device safety for the rectum and colon.

METHOD

In the period from November 2014 to June 2015 full thickness resections in the rectum and colon were performed with the FTRD in 20 patients. Data on technical success, R0 resection rate and histologically confirmed full thickness resections were retrospectively analyzed.

RESULTS

The following indications were treated in the rectum (n = 11) and colon (n = 9): T1 carcinoma (n = 6) and neuroendocrine tumors (n = 2), untreated and nonlifting adenomas (n = 3) and incomplete resection of adenomas with low and high grade dysplasia (n = 9). The technical success rate was 75 %, 3 technical failures made a conventional polypectomy necessary in 2 patients and in 1 patient an operative resection of the duplicated intestinal wall had to be performed. The median endoscopic follow-up time was 61.5 days (n = 10) and in 7 patients the clip had dislodged at the first follow-up. A thermal perforation in one case of conventional polypectomy gave rise to indications for a partial resection of the colon. In one patient the lesion in the cecum could be reached but not treated for technical reasons. The histological R0 rate was 80 %, whereas the full thickness resection rate was 60 % (85.7 % in the colon and 54.6 % in the rectum). In two patients with carcinoma and incomplete FTRD, surgical treatment was performed. The median size of the resection specimen was 5  cm(2) (range 1.6-12.9  cm(2)).

CONCLUSION

The results show that FTRD is a safe and effective instrument for use in the lower gastrointestinal tract. Limitations of the FTRD system concerning full thickness resection are scarring, fibrosis and thickness of the intestinal wall, especially in the lower rectum; therefore, it is suggested that a simulation with a tube similar in size to the FTRD should be performed during the screening colonoscopy in order to establish whether an endoscopic resection with FTRD is possible.

Management of a large mucosal defect after duodenal endoscopic resection

Duodenal endoscopic resection is the most difficult type of endoscopic treatment in the gastrointestinal tract (GI) and is technically challenging because of anatomical specificities. In addition to these technical difficulties, this procedure is associated with a significantly higher rate of complication than endoscopic treatment in other parts of the GI tract. Postoperative delayed perforation and bleeding are hazardous complications, and emergency surgical intervention is sometimes required. Therefore, it is urgently necessary to establish a management protocol for preventing serious complications. For instance, the prophylactic closure of large mucosal defects after endoscopic resection may reduce the risk of hazardous complications. However, the size of mucosal defects after endoscopic submucosal dissection (ESD) is relatively large compared with the size after endoscopic mucosal resection, making it impossible to achieve complete closure using only conventional clips. The over-the-scope clip and polyglycolic acid sheets with fibrin gel make it possible to close large mucosal defects after duodenal ESD. In addition to the combination of laparoscopic surgery and endoscopic resection, endoscopic full-thickness resection holds therapeutic potential for difficult duodenal lesions and may overcome the disadvantages of endoscopic resection in the near future. This review aims to summarize the complications and closure techniques of large mucosal defects and to highlight some directions for management after duodenal endoscopic treatment.

Application of novel endoloops to close the defects resulted from endoscopic full-thickness resection with single-channel gastroscope: a multicenter study

BACKGROUND

The key step of the endoscopic full-thickness resection (EFTR) procedure is the successful closure of any gastric wall defect which ultimately avoids surgical intervention. This report presents a new method of closing large gastric defects left after EFTR, using metallic clips and novel endoloops by means of single-channel endoscope.

METHODS

We retrospectively analyzed 68 patients who were treated for gastric fundus gastrointestinal stromal tumors originating from the muscularis propria layer at four institutes between April 2014 and February 2015 and consequently underwent EFTR. The large gastric post-EFTR defects were completely closed with metallic clips and novel endoloops using single-channel endoscope, and all the patients were discharged with subsequent endoscopic and clinical follow-up. Patient characteristics, tumor size, en bloc resection rate, closure operation time, and postoperative adverse events were evaluated.

RESULTS

EFTR was successfully performed on 68 patients [41 male (60 %), 27 female (40 %); median age 61 years, range 38-73], and the en bloc resection rate was 100 %. Complete closure of all the gastric post-EFTR defects was achieved (success rate 100 %). The mean closure operation time was 13 min (range 9-21 min). The mean maximum size of the lesions was 2.6 cm (range 2.0-3.5 cm). One Mallory-Weiss syndrome and one delayed bleeding were resolved with nonsurgical treatment. The wounds were healed in all cases 1 month after the procedure.

CONCLUSIONS

The use of metallic clips and novel endoloops with single-channel endoscope is a relatively safe, easy, and feasible method for repairing large gastric post-EFTR defects.

[Endoscopic full-thickness resection]

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are powerful tools for the treatment of gastrointestinal (GI) neoplasms. However, those techniques are limited to the superficial layers of the GI wall (mucosa and submucosa). Lesions without lifting sign (usually arising from deeper layers) or lesions in difficult anatomic positions (appendix, diverticulum) are difficult - if not impossible - to resect using conventional techniques, due to the increased risk of complications. For larger lesions (>2 cm), ESD appears to be superior to the conventional techniques because of the en bloc resection, but the procedure is technically challenging, time consuming, and associated with complications even in experienced hands. Since the development of the over-the-scope clips (OTSC), complications like bleeding or perforation can be endoscopically better managed. In recent years, different endoscopic full-thickness resection techniques came to the focus of interventional endoscopy. Since September 2014, the full-thickness resection device (FTRD) has the CE marking in Europe for full-thickness resection in the lower GI tract. Technically the device is based on the OTSC system and combines OTSC application and snare polypectomy in one step. This study shows all full-thickness resection techniques currently available, but clearly focuses on the experience with the FTRD in the lower GI tract.

Non-Exposure, Device-Assisted Endoscopic Full-thickness Resection

Recent developments have expanded the frontier of interventional endoscopy toward more extended resections following surgical principles. This article presents two new device-assisted techniques for endoscopic full-thickness resection in the upper and lower gastrointestinal tract. Both methods are nonexposure techniques avoiding exposure of gastrointestinal contents to the peritoneal cavity by a "close first-cut later" principle. The full-thickness resection device is a novel over-the-scope device designed for clip-assisted full-thickness resection of colorectal lesions. Endoscopic full-thickness resection of gastric subepithelial tumors can be performed after placing transmural sutures underneath the tumor with a suturing device originally designed for endoscopic antireflux therapy.

Endoscopic Full-thickness Resection (EFTR) for Gastrointestinal Subepithelial Tumors

There has been booming interest in the endoscopic full-thickness resection (EFTR) technique since it was first described. With the advent of improved and more secure endoscopic closure techniques and devices, such as endoscopic suturing devices, endoscopists are empowered to perform more aggressive procedures than ever. This article focuses on the procedural technique and clinical outcomes of EFTR for gastrointestinal subepithelial tumors.

Endoscopic resection of colorectal lesions: The narrowing divide between East and West

Colonic polypectomy is an effective way of reducing colon cancer mortality. Multiple techniques now exist for the resection of polyps, and the endoscopist must decide on the appropriate resection approach for individual patients and lesions. This decision should maximize efficacy, safety and cost-effectiveness and provide optimal oncological outcomes while minimizing unnecessary surgical treatment. Advances in endoscopic imaging technology are improving the accuracy of endoscopic diagnosis and allowing more precise risk assessment of colonic lesions. Resection technique can be tailored to the endoscopic findings. Diminutive (≤5 mm) and small polyps (≤9 mm) are best resected primarily by snare techniques. Cold snare polypectomy has proven safety, but efficacy and technique require further study. There is variation in techniques used for polyps 6-20 mm in size and incomplete resection rates for conventional polypectomy may be considerable. Endoscopic mucosal resection (EMR) is well established, safe and effective for lesions without submucosal invasion (SMI); however, recurrence is a key limitation. Endoscopic submucosal dissection (ESD) is well established in the East; however, it is resource intensive and its role in lesions with a low risk of SMI is questionable. ESD in the West remains incompletely defined and is associated with high adverse event rates, but it is becoming increasingly available and successful as experience grows. Emerging full-thickness resection technologies are still in their infancy and remain experimental as a result of the absence of reliable closure devices and techniques. Patient-focused outcomes should guide technique selection.