Endoscopic full-thickness resection: Current status

Endoscopic full thickness resection: techniques, applications, outcomes

INTRODUCTION

Endoscopic full-thickness resection (EFTR) represents a pivotal advancement in the minimally invasive treatment of gastrointestinal lesions, offering a novel approach for the management of lesions previously deemed challenging or unreachable through conventional endoscopic techniques.

AREAS COVERED

This review discusses the development, methodologies, applications, and clinical outcomes associated with EFTR, including exposed and device-assisted EFTR, the integration of endoscopic mucosal resection with EFTR in hybrid techniques, and the collaborative approach between laparoscopic and endoscopic surgery (LECS). It encapsulates a comprehensive analysis of the various EFTR techniques tailored to specific lesion characteristics and anatomical locations, underscoring the significance of technique selection based on the lesion's nature and situational context.

EXPERT OPINION/COMMENTARY

The review underscores EFTR's transformative role in expanding therapeutic horizons for gastrointestinal tumors, emphasizing the importance of technique selection tailored to the unique attributes of each lesion. It highlights EFTR's capacity to facilitate organ-preserving interventions, thereby significantly enhancing patient outcomes and reducing procedural complications. EFTR is a cornerstone in the evolution of gastrointestinal surgery, marking a significant leap forward in the pursuit of precision, safety, and efficacy in tumor management.

Early Rectal Cancer and Local Excision: A Narrative Review

A rise in the incidence of early rectal cancer consequent to bowel-screening programs around the world and an increase in the incidence in young adults has led to a growing interest in organ-sparing treatment options. The rectum, being the most distal portion of the large intestine, is a fertile ground for local excision techniques performed with endoscopic or surgical techniques. Moreover, the advancement in endoscopic optical evaluation and the better definition of imaging techniques allow for a more precise local staging of early rectal cancer. Although the local treatment of early rectal cancer seems promising, in clinical practice, a significant number of patients who could benefit from local excision techniques undergo total mesorectal excision (TME) as the first approach. All relevant prospective clinical trials were identified through a computer-assisted search of the PubMed, EMBASE, and Medline databases until January 2024. This review is dedicated to endoscopic and surgical local excision in the treatment of early rectal cancer and highlights its possible role in current and future clinical practice, taking into account surgical completion techniques and chemoradiotherapy.

Facilitating endoscopic full-thickness resection for gastric submucosal tumors with a novel snare traction method (with video)

BACKGROUND AND AIM

Endoscopic full-thickness resection (EFTR) is a promising technique in treating gastric submucosal tumors originating from the muscularis propria (SMT-MPs). However, it is challenging without counter-traction.

METHODS

A snare was inserted through the forceps channel to grasp the part of the tumor or the mucosa connected to the tumor. The outer sheath and inner wire of snare in vitro were fixed by a pair of hemostatic forceps. The handle of snare was cut off, and the endoscope was pulled out without affecting the traction state of snare. Snare-assisted EFTR (EFTR-S) was then performed with counter-traction. One hundred and four patients with gastric SMT-MPs who received the procedure of EFTR with or without snare traction method were retrospectively analyzed using univariate and multiple regressions, and covariates were adjusted in the multiple analysis.

RESULTS

Compared with EFTR group (n = 36), EFTR-S group (n = 68) showed a higher operative success rate (95.6% vs 72.2%, P = 0.001), a lower incidence of intraoperative hemorrhage (4.4% vs 16.7%, P = 0.038) and shorter operative time among operative successes (53.6 ± 16.6 min vs 67.7 ± 33.4 min, P < 0.001). Univariate logistic analysis showed that snare traction represented a significant factor, which could improve operative successful rate (odds ratio, 8.3; 95% confidence interval, 2.1 to 32.7; P = 0.002). Postoperative outcomes and adverse events among operative successes were similar between the two groups.

CONCLUSIONS

This novel snare traction method may provide an effective counter-traction and reduce the difficulty of EFTR for gastric SMT-MPs.

Management after non-curative endoscopic resection of T1 rectal cancer

Since the introduction of population-based screening, increasing numbers of T1 rectal cancers are detected and removed by local endoscopic resection. Patients can be cured with endoscopic resection alone, but there is a possibility of residual tumor cells remaining after the initial resection. These can be located intraluminally at the resection site or extraluminally in the form of (lymph node) metastases. To decrease the risk of residual cells progressing towards more advanced disease, additional treatment is usually needed. However, with the currently available risk stratification models, it remains challenging to determine who should and should not be further treated after non-curative endoscopic resection. In this review, the different management strategies for patients with non-curatively treated T1 rectal cancers are discussed, along with the available evidence for each strategy and relevant considerations for clinical decision making. Furthermore, we provide practical guidance on the management and surveillance following non-curative endoscopic resection of T1 rectal cancer.

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.

Therapeutic Challenges for Gastric Neuroendocrine Neoplasms: Take It or Leave It?

Background and Objectives: Gastric neuroendocrine neoplasms (gNENs) represent rare but increasingly recognized tumors. They are distinguished into three main clinical types (type-1, type-2, and type-3) according to gastrin level and at histological evaluation in well-differentiated G1, G2, or G3 lesions, as well as poorly-differentiated lesions. Small type-1 and type-2 neoplasms with low proliferation indices demonstrated excellent survival without progression during an extended follow-up period, and for these reasons, active endoscopic observation or endoscopic resection are feasible options. On the other hand, surgery is the treatment of choice for more aggressive type-3, G3, or infiltrating neoplasms. The present study aims to comprehensively review and compare the available therapeutic strategies for gNENs. Materials and Methods: A computerized literature search was performed using relevant keywords to identify all of the pertinent articles with particular attention to gNEN endoscopic treatment. Results: In recent years, different endoscopic resective techniques (such as endoscopic mucosal dissection, modified endoscopic mucosal resection, and endoscopic full-thickness resection) have been developed, showing a high rate of complete resection for advanced and more aggressive lesions. Conclusions: Overall, gNENs represent a heterogeneous group of lesions with varying behavior which require personalized management. The non-operative approach for small type-1 gNENs seems to be feasible and should be promoted. A step-up approach with minimally invasive endoscopic therapies might be proposed, particularly for type-1 gNEN. On the other hand, it is important to recognize the negative prognostic factors in order to identify those rare cases requiring more aggressive approaches. A possible therapeutic algorithm for localized gNEN management is provided.

Recent advances and current challenges in endoscopic resection with the full-thickness resection device

Endoscopic full-thickness resection (EFTR) has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract (GIT) not amenable to conventional therapeutic approaches. While various devices and techniques have been described for EFTR, a single, combined full-thickness resection and closure device (full-thickness resection device, FTRD system, Ovesco Endoscopy AG, Tuebingen, Germany) has become commercially available in recent years. Initially, the FTRD system was limited to use in the colorectum only. Recently, a modified version of the FTRD has been released for EFTR in the upper GIT as well. This review provides a broad summary of the FTRD, highlighting recent advances and current challenges.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER)

Subepithelial lesions are often detected incidentally in patients undergoing an endoscopy. They are common tumors of the gastrointestinal (GI) tract which can originate from different layers of the GI tract wall. These lesions can be further classified based on GI layer of origin and unique histochemical staining. While most are benign and asymptomatic, some of these lesions have malignant potential with distant metastases. However, current diagnostic modalities including endoscopy with biopsy or endoscopic ultrasound with fine needle aspiration are not always reliable. In addition, management of these lesions has historically involved surgical resection via open or laparoscopic approaches. In recent years, with advancement in endoscopic techniques and improvement in endoscopists' skills, less invasive procedures such as endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) have been developed and now are being used by endoscopists worldwide. Upon reviewing the literature, multiple studies have shown the advantages of these endoscopic techniques when compared with surgical treatment. As a result, there has been a dramatic shift towards minimally invasive endoscopic procedures for the management of these subepithelial lesions. In this review article, we will discuss these endoscopic resection techniques in detail, their safety and efficacy, as well as comparison studies to other therapeutic modalities.

Smart surgical sutures using soft artificial muscles

Wound closure with surgical sutures is a critical challenge for flexible endoscopic surgeries. Substantial efforts have been introduced to develop functional and smart surgical sutures to either monitor wound conditions or ease the complexity of knot tying. Although research interests in smart sutures by soft robotic technologies have emerged for years, it is challenging to develop a soft robotic structure that possesses a similar physical structure as conventional sutures while offering a self-tightening knot or anchor to close the wound. This paper introduces a new concept of smart sutures that can be programmed to achieve desired and uniform tension distribution while offering self-tightening knots or automatically deploying secured anchors. The core technology is a soft hydraulic artificial muscle that can be elongated and contracted under applied fluid pressure. Each suture is equipped with a pressure locking mechanism to hold its temporary elongated state and to induce self-shrinking ability. The puncturing and holding force for the smart sutures with anchors are examined. Ex-vivo experiments on fresh porcine stomach and colon demonstrate the usefulness of the new smart sutures. The new approaches are expected to pave the way for the further development of smart sutures that will benefit research, training, and commercialization in the surgical field.

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.

Systematic review and meta-analysis on effectiveness and safety of the full-thickness resection device (FTRD) in the colon

BACKGROUND

 Endoscopic full-thickness resection (EFTR) has expanded the possibilities of endoscopic resection. The full-thickness resection device (FTRD, Ovesco Endoscopy, Tübingen, Germany) combines a clip-based defect closure and snare resection in a single device.

METHODS

 Systematic review and meta-analysis on effectiveness and safety of the FTRD in the colon.

RESULTS

 A total of 26 studies (12 published as full-text articles and 14 conference papers) with 1538 FTRD procedures were included. The pooled estimate for reaching the target lesion was 96.1 % (95 % confidence interval [95 % CI]: 94.6-97.1) and 90.0 % (95 % CI: 87.0-92.3) for technically successful resection. Pooled estimate of histologically complete resection was 77.8 % (95 % CI: 74.7-80.6). Adverse events occurred at a pooled estimate rate of 8.0 % (95 % CI: 5.8-10.4). Pooled estimates for bleeding and perforation were 1.5 % (95 % CI: 0.3-3.3) and 0.3 % (95 % CI: 0.0-0.9), respectively. The rate for need of emergency surgery after FTRD was 1.0 % (95 % CI: 0.4-1.8).

CONCLUSION

 The use of the FTRD in the colon shows very high rates of technical success and complete resection (R0) as well as a low risk of adverse events. Emergency surgery after colonic FTRD resection is necessary in single cases only.

Outcomes of a hybrid technique using EMR and endoscopic full-thickness resection for polyps not amenable to standard techniques (with video)

BACKGROUND AND AIMS

The full-thickness resection device (FTRD) offers a safe and effective approach for resection of complex colorectal lesions but is limited to lesions <2 cm in size. A hybrid approach-combining EMR with the FTRD-significantly expands the pool of lesions amenable to this technique; however, its safety and efficacy has not been well established.

METHODS

We report a single-center retrospective study of consecutive patients who underwent full-thickness resection (FTR) of colorectal lesions, either with a standalone FTRD or a hybrid (EMR + FTRD) approach. Outcomes of technical success, clinical success (macroscopically complete resection), R0 resection, and adverse events (AEs) were evaluated.

RESULTS

Sixty-nine FTR procedures (38 standalone FTR and 31 hybrid EMR + FTR) were performed on 65 patients. The most common indications were nonlifting polyp (43%) or suspected high-grade dysplasia or carcinoma (38%). Hybrid EMR + FTR permitted resection of significantly larger lesions (mean, 39 mm; range, 15-70 mm) compared with standalone FTR (mean, 17 mm; range, 7-25 mm; P < .01). Clinical success (91%), technical success (83%), and R0 resection (81%) rates did not differ between standalone and hybrid groups. Most patients (96%) were discharged home on the day of the procedure. Three AEs occurred, including 2 patients who developed acute appendicitis.

CONCLUSIONS

A hybrid approach combining EMR and FTRD maintains safety and efficacy while permitting resection of significantly larger lesions than FTRD alone.

Endoscopic full-thickness resection versus endoscopic submucosal dissection in the treatment of colonic neoplastic lesions ≤ 30 mm-a single-center experience

Endoscopic full-thickness resection (FTR) is a novel technique of endoscopic treatment of colorectal neoplastic lesions not suitable for endoscopic polypectomy or mucosal resection. FTR appears to be a reasonable alternative to technically demanding endoscopic submucosal dissection (ESD) for lesions ≤ 30 mm. However, comparison between FTR and ESD has not been published yet and their mutual positioning in the treatment algorithm is still unclear. The purpose of the analysis was to evaluate efficacy and safety of FTR in the treatment of colorectal lesions ≤ 30 mm by comparing prospectively followed FTR cohort to retrospective ESD cohort in the setting of single tertiary endoscopy center. Primary outcomes were technical success rate, R0 resection and curative resection rate, and complication rate. A total of 52 patients in FTR and 50 patients in ESD group were treated between 2015 and 2018. Technical success rate was significantly higher in FTR group (92 vs. 74%, P = 0.01) as well as R0 resection rate (85 vs. 62%, P = 0.01) and curative resection rate (75 vs. 56%, P = 0.01). Complications occurred more frequently in ESD group (40 vs. 13%, P = 0.002), mainly due to high incidence of electrocoagulation syndrome (24 vs. 0%). Total procedure time was substantially shorter in FTR group (26.4 ± 11.0 min vs. estimated 90-240 min). Local residual neoplastic lesions were detected numerically more often in FTR group (12 vs. 5%, P = 0.12). No patient died during follow-up. Compared to ESD, FTR proved significantly higher technical success rate, higher R0 and curative resection rate, and shorter procedure time. In the FTR group, there were significantly less complications but higher incidence of local residual neoplasia. Further research including randomized trials is needed to compare both resection techniques.

A Review of Endoscopic Full-thickness Resection, Submucosal Tunneling Endoscopic Resection, and Endoscopic Submucosal Dissection for Resection of Subepithelial Lesions

Gastrointestinal subepithelial tumors (SETs) are often found while performing routine endoscopy. Recently, there has been the development of new endoscopic techniques such as endoscopic submucosal dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection, all minimally invasive approaches which have made it possible to resect SETs that were previously resected with surgery. This review discusses the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, procedure-related complications, and advantages and disadvantages of these endoscopic techniques.

Gastrointestinal exposed endoscopic full-thickness resection in the era of endoscopic suturing: a retrospective single-center case series

Introduction

Exposed endoscopic full thickness resection (EFTR) is a minimally invasive technique that has shown promising efficacy and safety in the removal of both gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable for conventional resection techniques. Given the chance of realizing endosurgical full-thickness suturing, the Endoscopic Suturing System (ESS) can be used to close wall defects in this setting. However, data concerning its use in EFTR are still limited.

Aim

This study was conducted to evaluate the safety and efficacy of exposed EFTR with defect closure using the ESS for the removal of both GI SMTs and select ETs unsuitable for conventional resection techniques.

Material and methods

This was a retrospective, single-center, observational cohort study of patients who underwent GI exposed EFTR.

Results

Seven patients (M : F 6 : 1) with a mean age of 56 ±14.5 years were identified. The indications were MP-originating SMTs of the stomach (n = 2) and duodenum (n = 2), and from submucosa of the rectum (n = 1), and 2 ETs of the rectum. Exposed EFTR and defect closure were successfully performed in 6/7 patients. One case was converted to laparoscopic gastric wedge resection due to technical unfeasibility. We performed an R0 resection in all cases, with the exception of 1 case of rectal EFTR. No macroscopic recurrence was detected at 6-month endoscopic follow-up.

Conclusions

GI exposed EFTR with defect closure by the ESS appears to be feasible, effective, and safe in referral centers. Further studies are necessary to clarify the role of the ESS for post-EFTR wall defect closure.

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.

Comparison among different techniques for en-bloc resection of rectal lesions: transanal endoscopic surgery vs. endoscopic submucosal dissection vs. full-thickness resection device with Over-The-Scope Clip® System

BACKGROUND

The aim of our retrospective study is to compare the efficacy and indications of transanal endoscopic microsurgery (TEM), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection device (FTRD) with Over-The-Scope Clip (OTSC^®) System for en-bloc resection of rectal lesions.

METHODS

This study collected 76 cases of rectal neoplasms from a single hospital institution. Primary endpoints were complete en-bloc resection, intraprocedural adverse events, R0 en-bloc resection and an early discharge of the patient. Secondary endpoints included procedure-related adverse events.

RESULTS

Mean tumor sizes were statistically significant smaller among patients treated with FTRD rather than TEM and ESD. TEO and FTRD treated patients experienced a higher en-bloc resection rate, with a shorter procedure time and hospital stay. No significant difference concerning the R0 resection was found. TEO and FTRD recorded lower perforation rates as compared to ESD, whereas no difference emerged concerning the bleeding rate and the post-polypectomy syndrome rate.

CONCLUSIONS

Our study showed that each technique has specific features, so that each one offers advantages and disadvantages. Nevertheless, all of them ensure high en-bloc resection rates, whereas no difference exists for R0 resection rate. TEO provides the possibility to remove low rectal large lesions as compared to ESD and FTRD.

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.

ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

Endoscopic full thickness resection versus submucosal tunneling endoscopic resection for removal of submucosal tumors: a review article

Submucosal tumors (SMT) are protuberant lesions with intact mucosa that have a wide differential. These lesions may be removed by standard polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgically. However, in lesions that arise from the muscularis propria, full thickness resection is recommended. This can be completed using either endoscopic full thickness resection (EFTR) or submucosal tunneling endoscopic resection (STER). EFTR can be accomplished by completing a full thickness resection followed by defect closure or by securing gastrointestinal wall patency before resection. STER is an option that first creates a mucosal dissection proximal to the lesion to allow a submucosal tunnel to be created. Using this tunnel, the lesion may be resected. When comparing STER to EFTR, there was no significant difference when evaluating tumor size, operation time, rate of complications, or en bloc resection rate. However, suture time, amount of clips used, and overall hospital stay were decreased in STER. With these differences, EFTR may be more efficacious in certain parts of the gastrointestinal tract where a submucosal tunnel is harder to accomplish.

Gut disease in systemic sclerosis - new approaches to common problems

Purpose of review

The goal of this manuscript is to discuss the new diagnostic and potential treatment options for gut disease in systemic sclerosis (SSc). The concepts of quantification of gut perfusion and motility is reviewed. The risks of empiric therapeutics and challenges of studying the microbiome in SSc is discussed.

Recent findings

There are diagnostics that can provide information on gut perfusion and function that are of value in SSc. Easily implemented diagnostic tests are critical to avoid complications of empiric therapy. The role of the microbiome and drugs that target dysmotility are areas of active research.

Summary

SSc-related gastrointestinal tract involvement can be heterogeneous in clinical presentation and disease course. Noninvasive gastrointestinal measurement techniques that quantify neural communications with microvasculature in SSc can potentially guide the proper addition and discontinuation of therapeutics. The role of the microbiome and the role of nitric oxide on gut function are important areas of research for understanding gut dysfunction in SSc.

Usefulness of the thread-traction method in endoscopic full-thickness resection for gastric submucosal tumor: a comparative study

BACKGROUND

Endoscopic full-thickness resection (EFTR) has shown great prospects in treating gastric submucosal tumors (SMTs) from the muscularis propria. However, it is very difficult sometimes to ideally expose the tumor and gain adequate visualization for the dissection site. In the present study, we applied the thread-traction (TT) method to assist EFTR in treating gastric SMTs and investigated the feasibility and effectiveness of this strategy.

METHODS

A total of 28 patients were involved in the study. 13 patients were treated by TT-assisted EFTR (TT group) and the others by non-assisted EFTR (NA group). Data on clinical characteristics and therapeutic outcomes were collected for analysis.

RESULTS

The average tumor size was 1.6 ± 0.4 cm. En bloc resection rate was 92.9%. Histopathological evaluation indicated that 22 tumors were gastrointestinal stromal tumors (78.6%), all at low- or very low-risk, and 6 tumors were leiomyomas (21.4%). The total complication rate was 32.1%. All complications were managed intra-operatively or conservatively. Both the total procedure time and the perforation time were significantly shorter in patients of TT group than those of NA group (71.9 ± 30.5 vs. 107.5 ± 35.8 min, P = 0.010; 38.3 ± 22.0 vs. 68.6 ± 24.2 min, P = 0.002). The pain score evaluated by visual analogue system after operation was significantly lower in patients of TT group than those of NA group (4.5 ± 1.1 vs. 5.8 ± 1.4, P = 0.014). Although complication rate was lower in patients of TT group than those of NA group, the difference was not statistically significant (15.4% vs. 46.7%, P = 0.114). No residual or recurrent tumors were observed during a mean follow-up period of 17.9 ± 4.4 months.

CONCLUSIONS

The TT method could effectively assist EFTR to shorten operation time and decrease the risk of complications.

A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors

AIM

Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective methods for gastric fundus submucosal tumors (SMTs). However, there is little data that compares the two methods. The aim of this study was to compare the safety and efficacy of STER and EFTR for the treatment of SMTs in the gastric fundus.

METHODS

Clinical data was retrospectively collected from patients with gastric fundus SMTs who underwent STER or EFTR at our hospital from April 2011 to May 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, postoperative hospital stay, cost and follow-up data were compared.

RESULTS

A total of 43 patients were enrolled: 15 underwent STER and the remaining 28 cases underwent EFTR. There were no significant differences between the two groups with regard to gender, age, tumor size, en bloc resection rate, operation time, pathohistological results and cost (p > 0.05). However, patients who underwent EFTR had a longer suture time, required a larger number of clips for closure and a prolonged postoperative hospital stay (p < 0.05). No recurrence was noted in either the STER or the EFTR group during a mean follow-up of 12.1 and 22.8 months, respectively.

CONCLUSIONS

The treatment efficacy of STER and EFTR for the treatment of gastric fundus SMTs was comparable. However, STER has some advantages over EFTR in terms of suture time, the number of clips required for closure and postoperative hospital stay.

Endoscopic full-thickness resection in the colorectum: a single-center case series evaluating indication, efficacy and safety

Background and study aims  Endoscopic full-thickness resection (eFTR) allows en-bloc and transmural resection of colorectal lesions for which other advanced endoscopic techniques are unsuitable. We present our experience with a novel "clip first, cut later" eFTR-device and evaluate its indications, efficacy and safety. Patients and methods  From July 2015 through October 2017, 51 eFTR-procedures were performed in 48 patients. Technical success and R0-resection rates were prospectively recorded and retrospectively analyzed. Results  Indications for eFTR were non-lifting adenoma (n = 19), primary resection of malignant lesion (n = 2), resection of scar tissue after incomplete endoscopic resection of low-risk T1 colorectal carcinoma (n = 26), adenoma involving a diverticulum (n = 2) and neuroendocrine tumor (n = 2). Two lesions were treated by combining endoscopic mucosal resection and eFTR. Technical success was achieved in 45 of 51 procedures (88 %). Histopathology confirmed full-thickness resection in 43 of 50 specimens (86 %) and radical resection (R0) in 40 procedures (80 %). eFTR-specimens, obtained for indeterminate previous T1 colorectal carcinoma resection, were free of residual carcinoma in 25 of 26 cases (96 %). In six patients (13 %) a total of eight adverse events occurred within 30 days after eFTR. One perforation occurred, which was corrected endoscopically. No emergency surgery was necessary. Conclusion  In this study eFTR appears to be safe and effective for the resection of colorectal lesions. Technical success, R0-resection and major adverse events rate were reasonable and comparable with eFTR data reported elsewhere. Mean specimen diameter (23 mm) limits its use to relatively small lesions. A clinical algorithm for eFTR case selection is proposed. eFTR ensured local radical excision where other endoscopic techniques did not suffice and reduced the need for surgery in selected cases.

Tumor rupture of gastric gastrointestinal stromal tumors during endoscopic resection: a risk factor for peritoneal metastasis?

BACKGROUND AND STUDY AIMS

 Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract. Up to the present time, complete surgical excision has been the standard treatment for primary GISTs greater than 2 cm. It is well known that tumor rupture during surgery is an independent risk factor for peritoneal metastasis; however, it is not known whether the risk of peritoneal metastasis increases in cases where the tumor is ruptured during endoscopic resection.

PATIENTS AND METHODS

 A total of 195 patients treated for GIST between January 2014 and December 2016 in our hospital were enrolled in this study. They were divided into two groups according to whether the tumor was ruptured during endoscopic resection. The rate of peritoneal metastasis in patients in the two groups who also suffered perforation was investigated from the follow-up results.

RESULTS

 Approximately 55.4 % of all patients were female and the average age of the study group was 59.0 ± 10.3 years. Of the 195 patients, the tumors in 27 were ruptured and the remaining 168 patients underwent en bloc resection. There was no statistically significant difference in gender or age between the two groups. The median tumor size (maximum diameter) in all patients was 1.5 cm (0.3 - 5.0 cm): 2.5 cm (0.8 - 5.0 cm) and 1.4 cm (0.3 - 4.0 cm) in the tumor rupture group and en bloc resection group, respectively ( P  < 0.001). Most of the tumors were located in the gastric fundus. At a median follow-up of 18.7 ± 10.2 months, neither tumor recurrence (liver metastasis, peritoneal metastasis, local recurrence) nor mortality related to GISTs were detected.

CONCLUSIONS

 Tumor rupture during endoscopic resection of gastric GISTs may not be a risk factor for peritoneal metastasis.

Endoscopic Full Thickness Resection

Recent advances in minimally invasive endoscopic approaches have pushed the boundaries of well-established resection techniques for therapeutic and diagnostic applications. Endoscopic full thickness resection techniques are a key development in the management of challenging epithelial and subepithelial lesions that are not amenable to conventional endoscopic resection methods and previously required a surgical approach. Endoscopic full thickness biopsy represents a paradigm shift in tissue acquisition and will enhance our understanding of the pathophysiology, and guide therapy, of gastrointestinal neuromuscular diseases, as well as other inflammatory and neoplastic conditions. This review highlights current tools and techniques available for endoscopic full thickness resection and biopsy, as well as outcomes from such interventions.

Current status and future perspectives of endoscopic full-thickness resection

Flexible endoscopy has developed from a diagnostic tool for tissue biopsy sampling to a treatment tool for endoscopic resection of neoplasms in the digestive tract. In the near future, one of the advanced endoscopic techniques, endoscopic full-thickness resection (EFTR), is expected to be a feasible endoscopic procedure. In the present review, systematic review of conventional exposed EFTR was carried out. Search queries were (endoscopic full-thickness resection or EFTR) (over-the-scope clip or OTSC) (Overstitch System) from 2015 to 2017. Four retrospective, single-center studies with regard to conventional EFTR were identified. With regard to indication for conventional exposed EFTR, gastrointestinal stromal tumor was a good indication for EFTR. Mean tumor size of all four studies was 20.71 mm. In two studies, endoclips were used to close the resected opening without any complications, but the other two studies reported complications such as delayed perforation even using OTSC. Procedure times were reported from a minimum of 40 min to a maximum of 105 min. We also refer to introduction of a newly developed procedure of EFTR (non-exposed EFTR), and development of a new suturing device in Japan.

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 versus Laparoscopic Full-Thickness Biopsy in the Pathological Evaluation of the Enteric Nervous System

A full-thickness biopsy of the bowel wall is required to evaluate the enteric nervous system. A patient with aggravating gastrointestinal symptoms underwent a laparoscopic full-thickness biopsy of the ileum and, 1 year later, an endoscopic full-thickness biopsy of the sigmoid colon. Both samples showed enteric neuropathy characterized by vacuolated and enlarged neurons. The length of the myenteric plexus was greater in the endoscopic (23 mm) compared to the laparoscopic (11 mm) biopsy, with fewer tissue artefacts in the laparoscopic approach. Clinical deterioration was paralleled by enteric neuropathy with an increase in the percentage of vacuolated and enlarged enteric neurons from 24 to 35%.

Endoscopic treatment of early colorectal cancer - just a competition with surgery?

The endoscopic treatment of cancerous and precancerous lesions in the gastrointestinal (GI) tract has experienced major breakthroughs in the past years. Endoscopic mucosal resection (EMR) is a simple and efficient method for the treatment of most benign lesions in the GI tract. However, with the introduction of endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR), the scope of lesions eligible for endoscopic treatment has been widened significantly even in the colon. These methods are now being used routinely not just for the treatment of benign lesions but also in the curative en bloc resection of early colorectal cancers. The quick, efficient, and noninvasive character of these endoscopic procedures make them not just an alternative to surgery but, in many cases, the methods of choice for the treatment of most early colon cancers and some rectal cancers.

Management of complex polyps of the colon and rectum

PUPRPOSE

Benign polyps that are technically challenging and unsafe to remove via polypectomy are known as complex polyps. Concerns regarding safety and completeness of resection dictate they undergo advanced endoscopic techniques, such as endoscopic mucosal resection or surgery. We provide a comprehensive overview of complex polyps and current treatment options.

METHODS

A review of the English literature was conducted to identifyarticles describing the management of complex polyps of the colon and rectum.

RESULTS

Endoscopic mucosal resection is the standard of care for the majority of complex polyps. Only polyps that fail endoscopic mucosal resection or are highly suspicious of invasive cancer but which cannot be removed endoscopically warrant surgery.

CONCLUSION

Several factors influence the treatment of a complex polyp; therefore, there cannot be a "one-size-fitsall" approach. Treatment should be tailored to the lesion's characteristics, the risk of adverse events, and the resources available to the treating physician.

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 resection of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, and about 60% of them are found in the stomach. With the widespread application of endoscopy and endoscopic ultrasonography (EUS), more and more gastric GISTs are being found in an early stage (with a relative small diameter and no metastasis), giving the chance of complete resection. Endoscopic resection such as endoscopic band ligation (EBL), endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER), is a minimally invasive method compared with the conventional surgical approaches (open or laparoscopic), and has been demonstrated to be safe and effective for treating gastric GISTs. This review summarizes the recent advances on endoscopic resection of gastric GISTs, aiming to provide a rational management strategy for gastric GISTs.

Endoscopic full-thickness biopsy, a novel method in the work up of complicated abdominal symptoms

Gastrointestinal complaints without obvious organic causes confirmed by clinical laboratory analyses, endoscopy or radiology are often referred to functional entities. Irritable bowel syndrome (IBS) is the most common functional disorder in the gut. Careful examination of these patients may reveal other diagnoses of defined etiologies, e.g., enteric neuropathy, microscopic colitis, and primary Sjögre's syndrome. The present case describes a young patient with incapacitating gastrointestinal symptoms presumed to be IBS, who underwent endoscopic full-thickness biopsy in sigmoid colon. Histopathological examination revealed degenerative enteric neuropathy, possibly secondary to chronic ischemia.

Current standards and new developments of colorectal polyp management and resection techniques

Colonoscopy and endoscopic removal of precancerous polyps play an important role in colorectal cancer (CRC) prevention. Improved endoscopes and quality standards have led to an increasing polyp and adenoma detection rate. Optimal polyp resection techniques and management strategies are key for an effective colonoscopy practice. Areas covered: Strategies for how to improve diminutive polyp (polyps up to 5 mm in size) management are discussed because of their high prevalence. Systematic removal of diminutive polyps leads to increasing costs of colonoscopy practice, while the effect on colorectal cancer prevention might be negligible. Furthermore, polypectomy recommendations for mid-size and large polyps are provided. For all larger polyps larger, complete and safe resection is mandatory to avoid post colonoscopy cancers. The focus for managing such larger polyps is to use new techniques (i.e. cold snares) and to attempt complete removal and to reduce post-polypectomy complications. Expert commentary: The resect-and-discard strategy is a promising management strategy for diminutive polyps. However, modification of this approach might be required in order to make widespread adoption feasible. Cold snare polypectomy is a promising new approach for small polyp resection. For resection of large polyps adequate treatment recommendations with regard to endoscopic mucosal resection and complication prevention are provided.

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.

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.

Current Status of Exposed Endoscopic Full-Thickness Resection and Further Development of Non-Exposed Endoscopic Full-Thickness Resection

Endoscopic full-thickness resection (EFTR) is a procedure that makes it possible to access the lesions that are on the wall of the digestive tract via the shortest distance through the mouth. Because of the ultra-minimal invasive nature of the treatment, pure EFTR is a highly promising surgical procedure that allows the radical excision of full-thickness layers of digestive tract tumors using only a flexible endoscope. There are 2 types of EFTR methods: exposed and non-exposed. Considering the risks of contracting infection and intraperitoneal dissemination of tumor cells, non-exposed EFTR is an ideal method. However, a number of issues remain unresolved, including the method for performing a full-thickness suture under endoscopic view and the challenge of securing the operating field in the case of gastrointestinal tract collapse. Moreover, advances in the development of equipment such as full-thickness suturing devices would be helpful to make this therapeutic procedure the most minimally invasive endoscopic surgery ever.

Flexible Gastro-intestinal Endoscopy - Clinical Challenges and Technical Achievements

Flexible gastro-intestinal (GI) endoscopy is an integral diagnostic and therapeutic tool in clinical gastroenterology. High quality standards for safety, patients' comfort, and efficiency have already been achieved. Clinical challenges and technical approaches are discussed in this short review.

Image enhanced endoscopy for further characterization of mucosal and vascular patterns includes dye-spray or virtual chromoendoscopy. For confocal laser endoscopy, endocytoscopy, and autofluorescence clinical value has not yet been finally evaluated. An extended viewing field provided by additional cameras in new endoscopes can augment detection of polyps behind folds. Attachable caps, flaps, or balloons can be used to flatten colonic folds for better visualization and stable position.

Variable stiffness endoscopes, radiation-free visualization of endoscope position, and different overtube devices help reducing painful loop formation in clinical routine. Computer assisted and super flexible self-propelled colonoscopes for painless sedation-free endoscopy need further research. Single-use devices might minimize the risk of infection transmission in the future.

Various exchangeable accessories are available for resection, dissection, tunneling, hemostasis, treatment of stenosis and closure of defects, including dedicated suturing devices. Multiple arm flexible devices controlled via robotic platforms for complex intraluminal and transmural endoscopic procedures require further improvement.

Endoscopic ultrasound-guided puncture suture device versus metal clip for gastric defect closure after endoscopic full-thickness resection: A randomized, comparative, porcine study

Objective:

The secure closure of the wall defect is a critical stage of endoscopic full-thickness resection (EFTR). The aim of this study was to compare the closure of post-EFTR defects using an endoscopic ultrasound-guided puncture suture device (PSD) with the metal clip (MC) technique in a randomized, comparative, porcine study.

Methods:

We performed a randomized comparative survival study that included 18 pigs. The circular EFTR defects with a diameter of approximately 20 mm were closed with either a PSD or MC. Serum levels of interleukin-6 (IL-6) were determined preoperatively and on a postoperative day (POD) 1, 3, and 7. Three animals from each group were sacrificed at the end of the 7^th, 14^th, and 30^th POD. Tissue samples retrieved from the closure sites were examined macroscopically and microscopically.

Results:

Resection and closure were performed in 18 pigs (100%) without major perioperative complications. The mean closure time was significantly longer in the MC group than in the PSD group (25.00 ± 3.16 min vs. 1.56 ± 0.39 min; P < 0.05). Preoperative and POD 7 serum levels of IL-6 did not differ between the two groups. However, on POD 1, the IL-6 levels were observed to be significantly greater in the MC group than in the PSD group (P < 0.005). No significant differences between the PSD and MC groups were observed at necropsy.

Conclusion:

In this in vivo porcine model, PSD is a feasible device that achieves post-EFTR defect closure with a much shorter closure time and with less immunological responses than the MC technique.