Endoscopic resection of a diverticulum-arisen colonic adenoma using a full-thickness resection device

Outcomes of endoscopic full thickness resection in the colon rectum at an Italian tertiary center

PURPOSE

Endoscopic full-thickness resection (EFTR) is an innovative technique for the treatment of colonic lesions not feasible by conventional endoscopic resection. Here, we aimed to evaluate the efficacy and safety of a Full-Thickness Resection Device (FTRD) for colonic lesions in a high-volume tertiary referral center.

METHODS

A review of a prospectively collected database on patients that underwent EFTR with FTRD for colonic lesions from June 2016 to January 2021 at our institution was performed. Data regarding the clinical history, previous endoscopic treatments, pathological examination, technical and histological success, and follow-up were evaluated.

RESULTS

Thirty-five patients (26 males, median age 69 years) underwent FTRD for colonic lesion. Eighteen lesions were in the left colon, three in the transverse, and 12 in the right colon. The median size of the lesions was 13 (range 10-40) mm. Resection was technically successful in 94% of patients. The mean hospital stay was 3.2 (SD ± 1.2) days. Adverse events were reported in four cases (11.4%). Histological complete resection (R0) was achieved in 93.9% of cases. Endoscopic follow-up was available in 96.8% of patients, at a median duration of 14.6 months (3-46 months). Recurrence was observed in 19.4% of cases at a median time of 3 months (3-7 months). Five patients had multiple FTRD performed, with R0 resection in three cases. In this subset, adverse events were observed in 40% of cases.

CONCLUSIONS

FTRD is safe and feasible for standard indication. The non-negligible rate of recurrence observed suggests the need for close endoscopic follow-up in these patients. Multiple EFTR could help achieve complete resection in selected cases; however, in this setting, a higher risk of adverse events was observed.

Endoscopic Full Thickness Resection: A Systematic Review

Background Endoscopic full thickness resection (EFTR) is an emerging therapeutic option for resecting subepithelial lesions (SELs) and epithelial neoplasms. We aimed to systematically review the techniques, applications, outcomes, and complications of EFTR.

Methods A systematic literature search was performed using PubMed. All relevant original research articles involving EFTR were included for the review along with case report/series describing novel/rare techniques from 2001 to February 2022.

Results After screening 7,739 citations, finally 141 references were included. Non-exposed EFTR has lower probability of peritoneal contamination or tumor seeding compared with exposed EFTR. Among exposed EFTR, tunneled variety is associated with lower risk of peritoneal seeding or contamination compared with non-tunneled approach. Closure techniques involve though the scope (TTS) clips, loop and clips, over the scope clips (OTSC), full thickness resection device (FTRD), and endoscopic suturing/plicating/stapling devices. The indications of EFTR range from esophagus to rectum and include SELs arising from muscularis propria (MP), non-lifting adenoma, recurrent adenoma, and even early gastric cancer (EGC) or superficial colorectal carcinoma. Other indications include difficult locations (involving appendicular orifice or diverticulum) and full thickness biopsy for motility disorders. The main limitation of FTRD is feasibility in smaller lesions (<20–25 mm), which can be circumvented by hybrid EFTR techniques. Oncologic resection with lymphadencetomy for superficial GI malignancy can be accomplished by hybrid natural orifice transluminal endoscopic surgery (NOTES) combining EFTR and NOTES. Bleeding, perforation, appendicitis, enterocolonic fistula, FTRD malfunction, peritoneal tumor seeding, and contamination are among various adverse events. Post OTSC artifacts need to be differentiated from recurrent/residual lesions to avoid re-FTRD/surgery.

Conclusion EFTR is safe and effective therapeutic option for SELs, recurrent and non-lifting adenomas, tumors in difficult locations and selected cases of superficial GI carcinoma.

From advanced diagnosis to advanced resection in early neoplastic colorectal lesions: Never-ending and trending topics in the 2020s

Colonoscopy represents the most widespread and effective tool for the prevention and treatment of early stage preneoplastic and neoplastic lesions in the panorama of cancer screening. In the world there are different approaches to the topic of colorectal cancer prevention and screening: different starting ages (45-50 years); different initial screening tools such as fecal occult blood with immunohistochemical or immune-enzymatic tests; recto-sigmoidoscopy; and colonoscopy. The key aspects of this scenario are composed of a proper bowel preparation that ensures a valid diagnostic examination, experienced endoscopist in detection of preneoplastic and early neoplastic lesions and open-minded to upcoming artificial intelligence-aided examination, knowledge in the field of resection of these lesions (from cold-snaring, through endoscopic mucosal resection and endoscopic submucosal dissection, up to advanced tools), and management of complications.

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.

Feasibility and safety of endoscopic submucosal dissection for lesions in proximity to a colonic diverticulum

Background/Aims

Endoscopic submucosal dissection (ESD) for diverticulum-associated colorectal lesions is generally contraindicated because of the high risk of perforation. Several studies on patients with such lesions treated with ESD have been reported recently. However, the feasibility and safety of ESD for lesions in proximity to a colonic diverticulum (D-ESD) have not been fully clarified. The aim of this study was to evaluate the feasibility and safety of D-ESD.

Methods

D-ESD was defined as ESD for lesions within approximately 3 mm of a diverticulum. Twenty-six consecutive patients who underwent D-ESD were included. Two strategic approaches were used depending on whether submucosal dissection of the diverticulum-related part was required (strategy B) or not (strategy A). Treatment outcomes and adverse events associated with each strategy were analyzed.

Results

The en bloc resection rate was 96.2%. The rates of R0 and curative resection in strategies A and B were 80.8%, 73.1%, 84.6%, and 70.6%, respectively. Two cases of intraoperative perforation and one case of delayed perforation occurred. The delayed perforation case required emergency surgery, but the other cases were managed conservatively.

Conclusions

D-ESD may be a feasible treatment option. However, it should be performed in a high-volume center by expert hands because it requires highly skilled endoscopic techniques.

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.

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.

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.

Fatal Outcome Consequent to an Endoscopic Full Thickness Resection of a Colonic Lateral Spreading Tumor: A Case Report

Patient: Male, 77-year-old

Final Diagnosis: Enterocolic fistula

Symptoms: Diarrhea • pain and guarding of the abdomen • weight loss

Medication:—

Clinical Procedure: Colonoscopy with colon biopsy

Specialty: Gastroenterology and Hepatology

Endoscopic Management of a Tubulovillous Adenoma Within a Diverticulum: Report of a Case and Review of Literature

Adenomas or adenocarcinomas located within a colonic diverticulum are considered a rare phenomenon that has been described in the literature. These lesions are technically difficult to manage endoscopically and usually require surgical intervention for removal. There is also an increased risk of perforation upon endoscopic resection owing to the lack of a muscular layer within the diverticulum. We report a case and include a literature review to evaluate different endoscopic techniques and propose the most effective for management of adenomas within a diverticulum. This technique is potentially comprised of employing a combined approach using a suction banding device, an over-the-scope clip (OTSC; Ovesco Endoscopy AG, Tübingen, Germany) , and hyperthemic snare to successfully remove the polyp, ensure tissue retrieval, and reduce risk of iatrogenic colonic perforation.

Comparison of underwater endoscopic mucosal resection and endoscopic submucosal dissection of rectal neuroendocrine tumors (with videos)

BACKGROUND AND AIMS

The first choice of treatment for rectal neuroendocrine tumors (NETs) ≤10 mm in size is endoscopic resection. However, because rectal NETs usually invade the submucosal layer, achieving R0 resection is difficult. Endoscopic submucosal dissection (ESD) has a high R0 resection rate, and underwater endoscopic mucosal resection (UEMR) was recently introduced to ensure a negative resection margin easily and safely. The aim of this study was to evaluate the efficacy and safety of UEMR versus ESD for rectal NETs ≤10 mm in size.

METHODS

This retrospective observational study enrolled 115 patients with rectal NETs ≤10 mm in size who underwent ESD or UEMR between January 2015 and July 2019 at the National Cancer Center, Korea. The differences in R0 resection rate, adverse event rate, and procedure time between the ESD and UEMR groups were evaluated.

RESULTS

Of the 115 patients, 36 underwent UEMR and 79 underwent ESD. The R0 resection rate was not different between the UEMR and ESD groups (UEMR vs ESD, 86.1% vs 86.1%, P = .996). The procedure time was significantly shorter with UEMR (UEMR vs ESD, 5.8 ± 2.9 vs 26.6 ±13.4 minutes, P < .001). Two patients (2.5%, 2/79) experienced adverse events in the ESD group and but there were no adverse events in the UEMR group; however, this difference was not statistically significant.

CONCLUSION

UEMR is a safe and effective technique that should be considered when removing small rectal NETs. Further studies are warranted to define its role compared with ESD.

Endoscopic submucosal dissection in management of colorectal tumors near or involving a diverticulum: a retrospective case series

Background and study aims  Surgery is the standard treatment for colon tumors associated with diverticulum. U se of endoscopic submucosal dissection (ESD) to treat such tumors is controversial. The aim of this study was to assess the safety and feasibility of ESD in treating superficial colorectal tumors situated near or involving diverticulum. Patients and methods  Consecutive patients from two referral centers who had colorectal tumors near or involving diverticulum treated by ESD were retrospectively studied. Clinicopathological characteristics and clinical outcomes were analyzed. Results  Of the 12 patients studied, six had tumors near diverticulum and six had tumors involving diverticulum. The overall en-bloc R0 resection rate, median tumor size and procedure time were 67 %, 26.5 mm (range, 15 - 80 mm) and 110 minutes (range, 50 - 220 minutes), respectively. For tumors near diverticulum group, the en-bloc R0 resection rate was 100 % and no adverse events (AEs) or residual/recurrent tumors were observed. In contrast, for intradiverticular tumors group, the en-bloc R0 resection rate was low at 33 %, and one AE (perforation) was observed. The diverticula were ≥ 6 mm in diameter in the patients with incomplete resection. However, all but one diverticulum was unrecognized before ESD. Two residual tumors were detected at the 12-month surveillance and one required surgery. Conclusions  This case series indicates that ESD is safe and feasible for treating colorectal tumors near a diverticulum and might be feasible for tumors involving a diverticulum smaller than 6 mm. Selection for smaller diverticulum size may contribute to higher en-bloc R0 resection rates.

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.

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.

Diagnostic use of endoscopic full-thickness wall resection (eFTR)-a novel minimally invasive technique for colonic tissue sampling in patients with severe gastrointestinal motility disorders

BACKGROUND

Complex gastrointestinal (GI) motility disorders such as chronic intestinal pseudo-obstruction (CIPO) or Hirschsprung's disease (HD) are challenging to diagnose and treat appropriately. Thorough assessment of patient history, radiographic exams, endoscopy, and motility measurements aid in diagnostic workup, yet underlying histology is the cornerstone to enable a more distinct diagnosis of neuromuscular GI disorders. Traditionally, surgical procedures have been performed to obtain specimen suitable for accurate histologic analysis.

METHODS

We performed endoscopic full-thickness resection (eFTR) using a full-thickness-resection device (FTRD) under moderate propofol sedation in four patients with suspected severe neuromuscular gut disorders including CIPO.

KEY RESULTS

The mean age of the four patients was 43 y (range 19-56 y). Technical and histological success providing large colonic full-thickness tissue samples of excellent quality was achieved in all four patients (success rate 100%). The mean procedure time was 12 min (range 5-20 min). The mean diameter of the resected specimen was 21 mm (range 20-22 mm). No adverse events connected to the procedure itself occurred. Histology ranged from aganglionosis such as Hirschsprung's disease (HD) to hypoganglionosis and eosinophilic leiomyositis combined with lymphocytic ganglionitis in a third patient. Histology was unspecific in one patient.

CONCLUSION AND INFERENCES

EFTR allows safe and minimal invasive harvesting of ample full-thickness tissue samples for accurate histological analysis in patients with suspicion of neuromuscular gut disorders.

Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: A single-centre study

BACKGROUND AND AIM

Endoscopic full-thickness resection (EFTR) provides complete en-bloc resection with a histopathological evaluation of submucosal, muscular, and serosal layers. The aim of this study was to investigate the efficacy and safety of a novel over-the-scope device for colorectal EFTR.

MATERIAL AND METHODS

In this retrospective, observational, open-label case study, a total of 20 patients with superficial colorectal neoplasms, underwent EFTR using a new endoscopic full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany). Endoscopic treatment outcomes (technical success, rate of EFTR, adverse events) and early follow-up at three months, were analyzed.

RESULTS

We reported a 100% of technical success, defined as full-thickness resection. Among the R1 resections, histology was negative for neoplasm. Non-lifting adenomas had histology positive for adenocarcinoma: seven T1/G1/sm1; one T1/G1/sm2; one, who underwent a surgical resection, T1/G1/sm3. Mean size of the resected lesions was 26mm, ranging from 10 to 42mm. One (5%) patient developed abdominal pain, fever and leukocytosis and was treated conservatively with medical therapy. In all specimens, histological complete resection was confirmed.

CONCLUSIONS

EFTR is a feasible and effective technique that could become a valid alternative to EMR and ESD in the management of recurrent adenomas, no-lifting lesions and scars of R1 resections. However, prospective studies are needed to further evaluate the device and technique.

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.

Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®)

BACKGROUND AND STUDY AIMS

Classic endoscopic resection techniques (EMR and ESD) are limited to mucosal lesions. In the case of deeper growth into the gut wall and anatomic sites prone to perforation, the novel full-thickness resection device (FTRD^®) opens a new dimension of possibilities for endoscopic resection.

PATIENTS AND METHODS

Sixty patients underwent endoscopic full-thickness resection (eFTR) at our institution. Safety, learning curve, R0 resection rate, and clinical outcome were studied.

RESULTS

In 97% (58/60) of the interventions, the FTRD^®-mounted endoscope reached the previously marked lesion and eFTR was performed (technical success). Full-thickness resection was achieved in 88% of the cases, with an R0 resection on histological examination in 79%. The clinical success rate based on follow-up histology was even higher (88%). Adverse events occurred in 7%. Appendicitis of the residual cecal appendix after eFTR of an adenoma arising in the appendix led to the only post-eFTR surgery (1/58, 2%). Minor bleeding at the eFTR site (2/58, 3%) and an eFTR performed accidently without proper prior deployment of the OTSC^® (1/58, 2%) were successfully treated endoscopically. There was no secondary perforation or eFTR-associated mortality.

CONCLUSIONS

After specific training, eFTR is a feasible, safe, and promising all-in-one endoscopic resection technique. Our data show that eFTR allows complete resection of lesions affecting layers of the gut wall beneath the mucosa with a low risk of adverse events. However, our preliminary results need to be confirmed in larger, controlled studies.

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.

Endoscopic Full-Thickness Resection of Synchronous Adenocarcinomas of the Distal Rectum

Endoscopic full-thickness resection (EFTR) with an innovative full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany) allows a safe and complete full-thickness resection of early colorectal cancer. We present the first case of two EFTR performed at the same time to treat synchronous rectal adenocarcinomas.

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.

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 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.

Duodenal endoscopic full-thickness resection (with video)

BACKGROUND AND AIMS

Endoscopic resection of duodenal non-lifting adenomas and subepithelial tumors is challenging and harbors a significant risk of adverse events. We report on a novel technique for duodenal endoscopic full-thickness resection (EFTR) by using an over-the-scope device.

METHODS

Data of 4 consecutive patients who underwent duodenal EFTR were analyzed retrospectively. Main outcome measures were technical success, R0 resection, histologic confirmation of full-thickness resection, and adverse events. Resections were done with a novel, over-the-scope device (full-thickness resection device, FTRD).

RESULTS

Four patients (median age 60 years) with non-lifting adenomas (2 patients) or subepithelial tumors (2 patients) underwent EFTR in the duodenum. All lesions could be resected successfully. Mean procedure time was 67.5 minutes (range 50-85 minutes). Minor bleeding was observed in 2 cases; blood transfusions were not required. There was no immediate or delayed perforation. Mean diameter of the resection specimen was 28.3 mm (range 22-40 mm). Histology confirmed complete (R0) full-thickness resection in 3 of 4 cases. To date, 2-month endoscopic follow-up has been obtained in 3 patients. In all cases, the over-the-scope clip was still in place and could be removed without adverse events; recurrences were not observed.

CONCLUSIONS

EFTR in the duodenum with the FTRD is a promising technique that has the potential to spare surgical resections. Modifications of the device should be made to facilitate introduction by mouth. Prospective studies are needed to further evaluate efficacy and safety for duodenal resections.

Endoscopic full-thickness resection: Current status

Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.