Going All the Way: Endoscopic Full-thickness Resection (EFTR) of a Rectal Mass

Abstract

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal lesions, such as early cancer or submucosal tumor. We present a case of young female with early rectal cancer treated successfully with EFTR of a rectal mass with clear margins on pathologic review. A 46-year-old female presents for initial screening colonoscopy. The patient had no GI complaints, and but her family history was significant for colorectal cancer in her father prior to the age of 50, but she had been delayed in obtaining a colonoscopy. An index screening colonoscopy was performed which a 3 cm semi-sessile mass was seen in the rectum about 1.5 cm from the anal verge. The mass was non circumferential and located at the posterior bowel wall. Biopsies of the rectal polyp revealed adenocarcinoma without lympho-vascular invasion. The large rectal mass was referred to our institution for resection, as the patient did not wish to undergo surgery. The periphery of the mass was injected submucosally with a solution of hyaluronic acid, hypertonic saline and methylene blue in order to raise the lesion and obtain an appropriate resection cushion. After a proper lift had been obtained, submucosal dissection was started. The dissection of the lesion began in the periphery moving towards the center. The 1.5 dual knife was used to create the initial mucosal incision and then dissect the submucosa with swift coagulation and endocut modes as deemed necessary. After the periphery of the lesion had been dissected, the center of the lesion was injected further with hyaluronic acid, hypertonic saline and methylene blue in order to raise the lesion. However, the center of the lesion did not raise well and it was difficult to separate the lesion from the muscularis. It was necessary to dissect through the muscularis to remove the lesion. The dissection was carried on until the whole lesion was resected completely. There was a 2 cm defect in the rectal wall afterwards. Apollo overstitch was used to close the defect using 4 running sutures. Pathology revealed moderately differentiated adenocarcinoma with clear mucosal margins. The patient did well after the procedure and has had no further complications. EFTR as a technique can achieve a full-thickness tumor resection with reliable closure of the bowel wall, but further refinements of the technique and device are necessary in order to reliably resect submucosal lesions, especially larger ones.