Full-thickness Resection Device Research Articles

Hybrid endoscopic approaches for complex colorectal polyps with a non-lifting sign: the Greek experience.

Hybrid approaches combining endoscopic full-thickness resection (EFTR) with conventional techniques (endoscopic mucosal resection [EMR], endoscopic submucosal dissection [ESD]) have enabled the resection of difficult fibrotic colorectal adenomas exhibiting a "non-lifting" sign, and polyps in difficult positions. We present our cohort treated with either EMR+EFTR or ESD+EFTR as salvage hybrid endoscopic approaches for complex colorectal polyps not amenable to conventional techniques. Retrospective analysis included technical success, histological confirmation of margin-free resection, assessment of adverse events and follow up with histological assessment. All patients underwent follow-up endoscopy at least 6 and 12 months post-resection. Fourteen patients underwent hybrid EFTR procedures (11 EMR+EFTR and 3 ESD+EFTR). Technical success was achieved in all cases where the full-thickness resection device (FTRD) was advanced to the site of the resection (100%). In 2 cases, the FTRD system could not be passed through the sigmoid colon because of severe chronic diverticulitis, subsequent fibrosis and stiffness. The mean lesion size in the EMR+EFTR group (41.7 mm; range 20-50 mm) was larger than the ESD+EFTR group (31.7 mm; range 30-35 mm). Six patients (42.9%) were histologically diagnosed with T1 carcinoma. The mean duration of hospitalization was 1.4 days. Follow-up endoscopy was available in all patients and no recurrence was observed with histological confirmation during a mean follow-up period of 15.4 months. Hybrid procedures appear to be safe and effective treatments for complex colorectal lesions not amenable to EMR, ESD or EFTR alone, because of the lesion size, positive non-lifting sign, and difficult positions.

Safety and Efficacy of Endoscopic Full Thickness Resection of Upper Gastrointestinal Lesions Using a Full Thickness Resection Device: A Systematic Review and Meta-analysis.

Endoscopic full-thickness resection (EFTR) is a promising technique that allows for a minimally invasive resection of mucosal and submucosal lesions in the gastrointestinal (GI) tract. The data regarding the efficacy and safety of performing EFTR of upper GI lesions using a full-thickness resection device (FTRD) is limited. Hence, we performed a systematic review and meta-analysis of the studies that evaluated this technique. We performed a comprehensive systematic search of multiple electronic databases and conference proceedings that reported outcomes of EFTR using the FTRD system. The weighted pooled rates of technical success, complete (R0) resection, adverse events (AE), and residual or recurrent lesions were analyzed with 95% CI using the random effects model. Eight studies with a total of 139 patients who underwent EFTR of upper GI lesions were included in the study. The pooled, weighted rate of technical success was 88.2% (95% CI: 81.4-92.7%, I2 : 0). The R0 resection rate was 70.7% (95% CI: 62.5-77.8%, I2 : 0). Overall AE rates were 22.1% (95% CI: 15.8-30.1%, I2 : 0), however, most of the AEs were minor. Of the patients who had follow-up endoscopies, the residual and/or recurrent lesion rate was 6.1% (95% CI: 2.4-14.4%, I2 : 0). Heterogeneity in the analysis was low. EFTR using the FTRD seems to be effective and safe with acceptable R0 resection rates and low recurrence rates. Further prospective studies are required to validate our results and to compare various modalities of endoscopic resection with this single-step EFTR device.

Endoscopic transmural resection as an alternative to colorectal surgery after high-risk (non-curative) endoscopic resection.

Endoscopic full-thickness resection (eFTR) is an emerging technique that enables effective and safe management of complex colorectal lesions. The full-thickness resection device (FTRD®, Ovesco, Germany) has primarily been used for non-exposed transmural resection of challenging subepithelial or epithelial lesions, where conventional methods may be limited. This technique represents an alternative to surgery in selected patients, and its applications are rapidly expanding. In recent years, eFTR has been described as an alternative to surgery for scars aiming to exclude residual tumors after non-curative endoscopic resection. We present a case of a 41-year-old woman with Lynch syndrome (dMLH1) with rectal adenocarcinoma at the age of 20 underwent anterior resection of the rectum and adjuvant chemoradiotherapy. At the age of 39, during endoscopic surveillance, she presented with a suspicious lesion (Paris 0-Is+IIa, NICE2, JNET2B) measuring 16mm in the hepatic angle, and underwent en bloc endoscopic mucosal resection (EMR). Histopathological analysis revealed a low-grade invasive adenocarcinoma with lymphoid stroma with deep invasion of the submucosa and resection margin involvement (vertical R1). After a multidisciplinary team discussion, complementary surgery was proposed but the patient refused, opting for close endoscopic and imaging surveillance. Two subsequent colonoscopies plus computed tomography (CT) scans showed no signs of macro or microscopic residual or recurrent tumor, even after extensive biopsies of the colonic scar. However, a CT scan 20months post-resection showed a de novo 2cm thickening of the parietal wall in the hepatic angle, consistent with the location of the previous endoscopic resection. Suspecting deep parietal tumor recurrence without superficial endoscopic findings, a transmural endoscopic resection using FTRD® of the EMR scar was performed, whose histology revealed no transparietal tumor recurrence.

Clip Dislodgement After Full-Thickness Endoscopic Resection Device Removal of Scarred Gastric Subepithelial Lesion Leading to Delayed Perforation

ABSTRACT Endoscopic full-thickness resection using a full-thickness resection device is a newer technique for endoscopic removal of submucosal lesions not amenable to endoscopic mucosal resection or endoscopic submucosal dissection. There is a low rate of complications reported, although we report 2 cases of delayed perforation caused by dislodgement of a full-thickness resection device clip after removal of scarred gastric lesions. Both were managed endoscopically with good outcomes. However, special attention and consideration of alternative closure techniques should be considered with scarred gastric lesions and possible changes to the clip design could be considered.

S1238 Using an Endoscopic Full Thickness Resection Device to Obtain Histologically Complete Resection or Formal Staging in Patients With Previous Piecemeal Resection of Malignant Colon Polyps

S1238 Using an Endoscopic Full Thickness Resection Device to Obtain Histologically Complete Resection or Formal Staging in Patients With Previous Piecemeal Resection of Malignant Colon Polyps

Full-thickness resection device for management of lesions involving the appendiceal orifice: Systematic review and meta-analysis.

Background and study aims Endoscopic resection of lesions involving the appendiceal orifice is technically challenging and is commonly referred for surgical resection. However, post-resection appendicitis is a concern. Many studies have varying rates of post-procedure appendicitis. We aim to report the rate of post-resection appendicitis by performing a systematic review and meta-analysis. Methods Studies that involved the use of a full-thickness resection device (FTRD) for management of appendiceal polyps were included. The primary outcome was appendicitis after FTRD and a subgroup analysis was performed on studies that only included FTRD performed at the appendiceal orifice. Results Appendicitis was encountered in 15% (95%CI: [11-21]) of the patients with 61% (95% CI: [44-76]) requiring surgical management. Pooled rates of technical success, histologic FTR, and histologic R0 resection in this sub-group (n=123) were 92% (95% CI: [85-96]), 98% (95% CI: [93-100]), and 72% (95% CI: [64-84%]), respectively. Post-resection histopathological evaluation revealed a mean resected specimen size of 16.8 ± 5.4 mm, with non-neoplastic pathology in 9 (7%), adenomas in 103 (84%), adenomas + high-grade dysplasia (HGD) in nine (7%), and adenocarcinoma in two (2%). The pooled rate for non-appendicitis-related surgical management (technical failure and/or high-risk lesions) was 11 % (CI: 7-17). Conclusions FTRD appears to be an effective method for managing appendiceal lesions. However, appendicitis post-resection occurs in a non-trivial number of patients and the R0 resection rate in appendiceal lesions is only 72%. Therefore, caution should be employed in the use of this technique, considering the relative risks of surgical intervention in each patient.

Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas.

Endoscopic full-thickness resection (EFTR) with a full-thickness resection device (FTRD) has become the standard technique for selected nonlifting colorectal adenomas, but tumor size is the major limitation. However, large lesions might be approached in combination with EMR. Herein, we report the largest single-center experience to date of combined EMR and EFTR (hybrid EFTR) in patients with large (≥25mm) nonlifting colorectal adenomas not amenable to EMR or EFTR alone. This is a single-center retrospective analysis of consecutive patients who underwent hybrid EFTR of large (≥25mm) nonlifting colorectal adenomas. Outcomes of technical success (successful advancement of the FTRD with consecutive successful clip deployment and snare resection), macroscopic complete resection, adverse events, and endoscopic follow-up were evaluated. Seventy-five patients with nonlifting colorectal adenomas were included. Mean lesion size was 36.5mm (range, 25-60mm), and 66.6% were located in the right side of the colon. Technical success was 100% with macroscopic complete resection in 97.3%. Mean procedure time was 83.6 minutes. Adverse events occurred in 6.7%, leading to surgical therapy in 1.3%. Histology revealed T1 carcinoma in 16%. Endoscopic follow-up was available in 93.3% (mean follow-up time, 8.1 months; range, 3-36) and showed no signs of residual or recurrent adenoma in 88.6%. Recurrence (11.4%) was treated endoscopically. Hybrid EFTR is safe and effective for advanced colorectal adenoma that cannot be approached by EMR or EFTR alone. Hybrid EFTR expands the indication of EFTR substantially in selected patients.

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.

Endoscopic resection of upper gastrointestinal lesions using the colonic Ovesco full-thickness resection device: Retrospective observational case series of 22 cases

Background and study aims The endoscopic full-thickness resection (EFRT) device (FTRD) has been shown to have acceptable outcomes in regard to efficacy and safety in the resection of colorectal lesions. Data on its use in the upper gastrointestinal tract are limited to small case series. Patients and methods All consecutive patients undergoing endoscopic full-thickness resection of gastric or duodenal lesions at our institutions were analyzed retrospectively for a primary endpoint of technical success. Results A total of 22 patients with duodenal and gastric lesions underwent EFTR between June 2018 and February 2022. Technical success was achieved in 20 of 22 (91 %) of the procedures. Indications for EFTR were: subepithelial tumor (n = 14), mucosal lesion (n = 5), scar resection (n = 2), and EFTR of endoscopic submucosal dissection (ESD) resection base (n = 1). The FTRD could be advanced to the lesion in all 22 cases (100 %). No dilation of the upper esophageal sphincter (UES) or pylorus was required to pass the device. There were 14 cases of gastric lesions and eight duodenal. One subepithelial lesion was too big for the cap and one scar could not be sucked into the cap. One lesion (gastrointestinal stromal tumor) was removed at second procedure with the ESD technique, including over-the-scope clip. The R0 resection rate for deployed clips was 90 % (18 of 20). There were two superficial esophageal tears from FTRD insertion that required no therapy. No bleeding occurred during the postoperative period. Conclusions Upper gastrointestinal EFTR using the colonic Ovesco FTRD is feasible without pre-dilation of the upper esophageal sphincter or pylorus. This study further confirms acceptable efficacy and safety in upper gastrointestinal use.

Endoscopic full-thickness resection for upper gastrointestinal tract lesions: a systematic review and meta-analysis.

Endoscopic full-thickness resection (EFTR) is used to resect difficult superficial mucosal lesions and sub-epithelial lesions (SELs). We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EFTR for upper gastrointestinal tract (GIT) lesions. We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language that addressed outcomes of EFTR for upper GIT lesions through November 2021. The weighted pooled rates with the 95% confidence interval (CI) were calculated. Cochran Q test and I statistics were used to calculate heterogeneity. We identify 740 articles on the initial search and six studies met the inclusion criteria. 140 patients (45.7% females) with 142 lesions were analyzed. Four studies used the full-thickness resection device (FTRD®). EFTR was performed for 26 adenomas, 97 SELs, six adenocarcinomas, and ten full-thickness biopsies. The overall technical success rate was 86.9% (CI 79.8-94%, I 2 = 38.9%), R0 resection was 80% (CI 67.6-92.3%, I 2 = 75.6%), and the overall adverse events rate was 18.6% (9.8-27.2%, I 2 = 49.4%). Major adverse events includedsix episodes of major bleeding, three micro-perforations, one large duodenal perforation, and one case of mucosal damage from FTRD®. At 3-6months follow-up, there were only two cases of recurrence (R0 was not achieved in both). EFTR has a high technical and clinical success rate in managing upper GIT lesions with an acceptable safety profile. Large prospective studies comparing EFTR with conventional endoscopic resection techniques are needed.

Endoscopic resection of GI stromal tumor using full-thickness resection device: tips and tricks

Video 1R0 endoscopic resection of gastric GI stromal tumor using a dedicated gastroduodenal full-thickness resection device.

Adverse events of endoscopic full-thickness resection: results from the German and Dutch nationwide colorectal FTRD registry

Endoscopic full-thickness resection (eFTR) is emerging as a minimally invasive alternative to surgery for complex colorectal lesions. Previous studies have demonstrated favorable safety results; however, large studies representing a generalizable estimation of adverse events (AEs) are lacking. Our aim was to provide further insight in AEs after eFTR. Data from all registered eFTR procedures in the German and Dutch colorectal full-thickness resection device registries between July 2015 and March 2021 were collected. Safety outcomes included immediate and late AEs. Of 1892 procedures, the overall AE rate was 11.3% (213/1892). No AE-related mortality occurred. Perforations occurred in 2.5% (47/1892) of all AEs, 57.4% (27/47) of immediate AEs, and 42.6% (20/47) of delayed AEs. Successful endoscopic closure was achieved in 29.8% of cases (13 immediate and 1 delayed), and antibiotic treatment was sufficient in 4.3% (2 delayed). The appendicitis rate for appendiceal lesions was 9.9% (13/131), and 46.2% (6/13) could be treated conservatively. The severe AE rate requiring surgery was 2.2% (42/1892), including delayed perforations in .9% (17/1892) and immediate perforations in .7% (13/1892). Delayed perforations occurred between days 1 and 10 (median, 2) after eFTR, and 58.8% (10/17) were located on the left side. Other severe AEs were appendicitis (.4%, 7/1892), luminal stenosis (.1%, 2/1892), delayed bleeding (.1%, 1/1892), pain after eFTR close to the dentate line (.1%, 1/1892), and grasper entrapment in the clip (.1%, 1/1892). Colorectal eFTR is a safe procedure with a low risk for severe AEs in everyday practice and without AE-related mortality. These results further support the position of eFTR as an established minimally invasive technique for complex colorectal lesions.

Endoscopic full-thickness resection of gastric ulceration with persistent low-grade dysplasia using full-thickness resection device.

Video 1Endoscopic full-thickness resection of gastric ulceration with persistent low-grade dysplasia using full-thickness resection device.

Hybrid resection of GI stromal tumor with endoscopic submucosal dissection and the full-thickness resection device

Video 1Hybrid resection of gastric GI stromal tumor with endoscopic submucosal dissection and the Full-Thickness Resection Device.

S359 Endoscopic Full-Thickness Resection of Gastric Ulceration with Persistent Low-Grade Dysplasia Using the Full-Thickness Resection Device

Introduction: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are well-established treatment methods for resection of precancerous gastric lesions and early gastric cancers. Ulcerated or scarred gastric lesions are challenging to resect with EMR or ESD due to submucosal fibrosis and scarring, and hence, carry an increased risk for perforation. Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD) is rapidly gaining popularity for the treatment of upper gastrointestinal tract lesions. While it has been shown to be a safe and effective treatment modality for colorectal lesions not amenable to conventional resection methods, data regarding its use in the upper GI tract is evolving. Here, we describe a patient with an ulcerated gastric lesion with persistent low-grade dysplasia who underwent successful resection of the lesion using the FTRD. Case Description/Methods: A 75-year-old man with a history of diffuse gastric intestinal metaplasia was found to have a 1 cm ulcer in the gastric antrum (Figure A). Biopsies of the ulcer demonstrated low-grade dysplasia, while surrounding biopsies showed incomplete gastric intestinal metaplasia. He was started on a proton pump inhibitor with plan for repeat endoscopy for surveillance. Subsequent upper endoscopy 12 and 24 months later showed partial healing of the gastric ulcer (Figure B), however, biopsies showed persistent low-grade dysplasia. After a multidisciplinary discussion, the decision was made to pursue EFTR of the ulcerated lesion. An upper endoscopy was performed and the borders of the lesion were marked circumferentially with a marking probe. The FTRD was mounted on a modified therapeutic upper endoscope and the lesion was resected. The resection site was examined and demonstrated appropriate positioning of the clip and no evidence of bleeding (Figure C). Given the proximity of the lesion to the pylorus, the endoscope was advanced to the duodenum documenting luminal patency. The patient tolerated the procedure well and was discharged the same day. No adverse events were experienced within four weeks of the procedure. The final pathology report of the lesion confirmed focal low-grade dysplasia (Figure D) with negative resection margins (R0). Discussion: EFTR using the FTRD device can offer a safe and effective approach to treat ulcerated or scarred gastric lesions that are not typically amenable to conventional endoscopic resection techniques. Watch the video at https://tinyurl.com/ACGAbstractS359Figure 1.: A) Initial upper endoscopy with antral gastric ulcer. B) Subsequent upper endoscopy showing partial healing of the gastric ulcer. C) Endoscopic view of the resection site with overlying clip after EFTR. D) Pathology of resected lesion demonstrating focal low-grade dysplasia.

S2819 Endoscopic Full-Thickness Resection as a Means to Diagnose Hirschsprung Disease

Introduction: Hirschsprung Disease (HD) is the congenital absence of ganglionic cells in the rectum and often thought of as a disease of childhood. However, this disease may persist into adulthood and symptoms such as chronic constipation can negatively affect quality of life. Patients often require a multidisciplinary approach between geneticists, colorectal surgeons, endoscopists and gastrointestinal pathologists during initial evaluation. Confirming the diagnosis has historically required a suction or open rectal biopsy, which is considered the gold standard for diagnosis. This is an invasive procedure that is prone to complications. Potential biopsy modalities include open, punch, suction and endoscopic. Interestingly, endoscopic biopsy using an endoscopic full-thickness resection (EFTR) device is rarely reported. Case Description/Methods: Here we present a case of a 42-year-old female with a history of Hirschsprung disease diagnosed as a child. The patient had an extensive surgical history including colostomy, colostomy reversal, and closed loop obstruction. The patient had also been recently diagnosed with an enterocutaneous fistula. The patient was evaluated by a general surgeon who referred her to gastroenterology motility clinic. Gastrografin enema confirmed extensive stool burden without strictures. The patient underwent anorectal manometry, which found abnormal push, high sphincter pressure at rest, and absence in rectal inhibitory reflex, findings concerning for HD. A flexible sigmoidoscopy was performed to determine the extent of the disease. Full thickness endoscopic biopsy of the rectum using an EFTR device showed an absence of ganglionic cells. The patient underwent a takedown of enterocutaneous fistula as well with improvement in symptoms. (Figure) Discussion: Endoscopic biopsy of the rectum is a minimally invasive technique that can provide adequate tissue samples to confirm a diagnosis. There is a paucity of data regarding the comparison between endoscopic versus traditional techniques. Based on our experience, we suggest that endoscopic rectal biopsy may be a safe and effective method to diagnose Hirschsprung Disease in the adult population. EFTR devices are potentially able to resect the entire wall of the gastrointestinal tract. This technique could greatly simplify the diagnostic process in that it is safe and effective, and less invasive than surgical techniques. However, further studies are needed to better characterize the utility of this technique in this specific patient population.Figure 1.: A) H&E showing absence of myenteric ganglion cells B) Successful endoscopic full-thickness resection of tissue with Ovesco clip in place.

S1163 Endoscopic Full Thickness Resection of Gastrointestinal Neoplasia – Single Center Experience

Introduction: Endoscopic full-thickness resection (EFTR) is emerging therapeutic option for en-bloc treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. Study aim was to evaluate results at advanced endoscopy center. Methods: This was retrospective analysis of 18 EFTR cases from 01/2020 till 11/2021, that were performed in advanced endoscopy center with a dedicated full thickness resection device (FTRD®, Ovesco, Germany). We recorded the demographic, procedural and technical characteristics. Lesion pathology (surface size, type, location), timing of procedure, technical success (defined as reaching the lesion, deploying the clip, and performing an en bloc and macroscopically complete resection), clinical success (defined as R0 resection and histopathology evaluation compatible with adequate endoscopic treatment) and rate of procedure-related complications (bleeding, perforation, need for emergency surgery, infectious complications and cardio-pulmonary adverse events associated with sedation) were also recorded (Table). Results: Majority of lesions had previous failed attempts at removal (n=10, 55.5%). Other lesions (n=8, 44.4%) included appendiceal orifice (n=6, 33.3%) or neuroendocrine neoplasia (n=2, 11.1%). Mean age of patients was 67.4 years +/- (SD) 10.9 years. 8/18 (44.4%) patients were female. Procedures were performed with conscious sedation (midazolam) and analgesia (piritramide), with pulse oximetry monitoring. There were no cardiopulmonary adverse events. (Figure) One procedure was aborted due to postsurgical anatomy; the endoscope with the FTRD device could not be passed through. One patient developed post procedural appendicitis and a surgical appendectomy was performed, although the EFTR was technically successful. No other complications were recorded. Mean procedure time was 42.1 +/- (SD) 14.3 minutes. Technical success of the procedure was 94.4% (n=17/18), clinical success was achieved in 88.2% (n=15/17). One patient was referred to surgery due to insufficient safety margins of removed specimen and one patient due to presence of invasive adenocarcinoma (pT2). All but one (post-procedural appendicitis) patients were discharged after one day of observation. Conclusion: Our results confirm that EFTR is effective endoscopic technique. It is exceptionally useful in fibrotic lesions and neuroendocrine neoplasia. Technically less challenging than endoscopic submucosal dissection it can still pose technical difficulties especially in cases with postsurgical anatomy.Figure 1.: A) Pre-EFTR marks of a 20 mm sessile serrated lesion of the appendiceal orifice. B) Deployment of the EFTR device. C) Resection defect after EFTR. D) Mucosal side of the resected specimen. The pathology showed sessile serrated lesion. Table 1. - Demographics and Procedure Characteristics. SD - standard deviation. Timing of procedure (time of endoscopy and deployment of the device). Technical success (defined as reaching the lesion, deploying the clip, and performing an en bloc and macroscopically complete resection). Clinical success (defined as R0 resection and histopathology evaluation compatible with adequate endoscopic treatment). Other – hyperplastic polyps, fibrotic tissue and lipoma Sex (n=18) (n, %) Male 10 (55.6) Female 8 (44.4) Mean age +/- SD (years) 67.4 +/- 10.9 ASA classification, (n, %) II 12 (66.7) III 6 (33.3) Mean dose of midazolam +/- SD, mg 0.7 +/- 0.83 Mean dose of piritramide +/- SD, mg 4.5 +/- 5.1 Location of the lesion, n=18 (n, %) Rectum 8 (44.4) Transverse Colon 2 (11.1) Ascending Colon 1 (5.6) Appendiceal Orifice 6 (33.3) Body of Stomach 1 (5.6) Mean Procedure Time +/- SD, min 42.1 +/- 14.3 Technical success, n=18 (n, %) Yes 17 (94.4) No 1 (0.06) Clinical success, n=17 (n, %) Yes 15 (88.2) No 2 (12.8) Pathohistology of the Retrieved Specimen, n=17 (n, %) Adenoma with Low Grade Dysplasia 5 (29.4) Sessile Serrated Lesion 3 (17.6) Adenocarcinoma 3 (17.6) Neuroendocrine Neoplasia 2 (11.8) Other 4 (23.5)

S2827 Endoscopic Full Thickness Resection of a Sigmoid Colon GIST Diagnosed by EUS FNA

Introduction: Subepithelial lesions of colon are often encountered during colonoscopy with lipoma being a common etiology, with other etiologies such as neuroendocrine tumors, leiomyoma, schwannoma, and GIST being rare. While a lipoma can be diagnosed by endoscopic appearance, pillow sign, and fat on biopsy; a diagnostic dilemma is presented if these findings are not present. EUS can be used for lesions that are within reach of an echoendoscope, but the sonographic appearance may still not be diagnostic without tissue sampling. This is a case of a subepithelial lesion in the sigmoid colon noted on colonoscopy that was diagnosed as a gastrointestinal stromal tumor by EUS FNA. Case Description/Methods: A 67 year old man was noted to have a one centimeter smooth round lesion in his sigmoid colon on screening colonoscopy. The endoscopic appearance was consistent with a subepithelial lesion. A pillow sign was negative, showing a firm mobile mass. He was referred for endoscopic ultrasound. A radial echoendoscope was used to localize the lesion. It was round, well demarcated, hypoechoic, and originated in the fourth layer (muscularis propria). The radial scope was exchanged for a linear echoendoscope and FNA was performed using a 20 gauge biopsy needle. Pathology showed a spindle cell lesion that was positive for CD 117 staining consistent with a gastrointestinal stromal tumor. Multidiscipline discussion with colorectal surgery was had, and the decision to proceed with endoscopic resection using an over the scope clip to perform full thickness resection. Following the resection the patient had some post-procedure pain and was hospitalized for observation, treated with antibiotics, and serial imaging. No perforation was noted. Final pathology showed a 1.7cm low grade GIST with positive microscopic margins. Multidiscipline discussion at tumor board recommends continued surveillance for the low grade GIST. (Figure) Discussion: Colonic GISTs are rare lesions with variable clinical courses. Full thickness endoscopic resection is an option using either an over the scope clip or dedicated full thickness resection device, or surgery are available options for management. Size, location, and multidiscipline discussion are needed to determine the best management strategy.Figure 1.: 4th layer hypoechoic lesion, sigmoid colon.

Current status of endoscopic full-thickness resection with the full-thickness resection device.

Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD) is an integral part of diagnostic and therapeutic endoscopy. Since its market launch in Europe in 2014, its safety and effectiveness have been proven in numerous studies. Adaptations in design as well as new techniques, such as hybrid EFTR, expand the spectrum of the FTRD system. The following review is intended to provide an overview of the clinical application and current evidence of EFTR with the FTRD system.

Endoscopic Full Thickness Resection: A Systematic Review

Abstract 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.