Full-thickness Resection Research Articles

Robotic Platforms for Therapeutic Flexible Endoscopy: A Literature Review.

Flexible endoscopy, initially developed for diagnosis and tissue sampling, has been adapted for therapeutic interventions, leading to the emergence of natural orifice transluminal endoscopic surgery (NOTES) in the 2000s. The need for a triangulation function to enhance the intuitiveness and safety of NOTES has prompted the development of dual-arm, flexible endoscopic robotic platforms. Although the global interest in NOTES has decreased in the last decade, no-scar surgery concepts are still being applied to other complex endoluminal interventions, such as endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR), with ongoing research and development. The application of robotics in flexible endoscopy may facilitate the standardization of these procedures and expedite their global spread. Various robotic platforms have been developed and tested in the preclinical and clinical settings to demonstrate their efficacy and safety. In this article, we review the publications on technology and elucidate their advantages and existing challenges.

Removal of an embedded gastric fishbone by traction-assisted endoscopic full-thickness resection.

Removal of an embedded gastric fishbone by traction-assisted endoscopic full-thickness resection.

Multiple snares-assisted endoscopic full-thickness resection of a giant submucosal tumor at the esophagogastric junction.

Multiple snares-assisted endoscopic full-thickness resection of a giant submucosal tumor at the esophagogastric junction.

Double-nylon purse-string suture in closing postoperative wounds following endoscopic resection of large (≥ 3 cm) gastric submucosal tumors.

Endoscopic full-thickness resection (EFTR) of gastric submucosal tumors (SMTs) is safe and effective; however, postoperative wound management is equally important. Literature on suturing following EFTR for large (≥ 3 cm) SMTs is scarce and limited. To evaluate the efficacy and clinical value of double-nylon purse-string suture in closing postoperative wounds following EFTR of large (≥ 3 cm) SMTs. We retrospectively analyzed the data of 85 patients with gastric SMTs in the fundus of the stomach or in the lesser curvature of the gastric body whose wounds were treated with double-nylon purse-string sutures after successful tumor resection at the Endoscopy Center of Renmin Hospital of Wuhan University. The operative, postoperative, and follow-up conditions of the patients were evaluated. All tumors were completely resected using EFTR. 36 (42.35%) patients had tumors located in the fundus of the stomach, and 49 (57.65%) had tumors located in the body of the stomach. All patients underwent suturing with double-nylon sutures after EFTR without laparoscopic assistance or further surgical treatment. Postoperative fever and stomach pain were reported in 13 (15.29%) and 14 (16.47%) patients, respectively. No serious adverse events occurred during the intraoperative or postoperative periods. A postoperative review of all patients revealed no residual or recurrent lesions. Double-nylon purse-string sutures can be used to successfully close wounds that cannot be completely closed with a single nylon suture, especially for large (≥ 3 cm) EFTR wounds in SMTs.

Advanced Diagnostic and Therapeutic Endoscopy for Early Gastric Cancer.

Endoscopy is mandatory to detect early gastric cancer (EGC). When considering the cost-effectiveness of the endoscopic screening of EGC, risk stratification by combining serum pepsinogen values and anti-H. pylori IgG antibody values is very promising. After the detection of suspicious lesions of EGC, a detailed observation using magnifying endoscopy with band-limited light is necessary, which reveals an irregular microsurface and/or an irregular microvascular pattern with demarcation lines in the case of cancerous lesions. Endocytoscopy enables us to make an in vivo histological diagnosis. In terms of the indications for endoscopic resection, the likelihood of lymph node metastasis and technical difficulties in en bloc resection is considered, and they are divided into absolute, expanded, and relative indications. Endoscopic mucosal resection and endoscopic submucosal dissection are the main treatment modalities nowadays. After endoscopic resection, curability is evaluated histologically as endoscopic curability (eCura) A, B, and C (C-1 and C-2). Recent evidence suggests that the outcomes of endoscopic resection for many EGCs are comparable to those of gastrectomy and that endoscopic resection is the gold standard for node-negative early gastric cancers. Personalized medicine is also being developed to overcome the unmet needs in treatments of EGC, for example the further expansion of indications and newer resection techniques, such as full-thickness resection.

Endoscopic resection for calcifying fibrous tumors of the gastrointestinal tract.

Calcifying fibrous tumors (CFTs) are rare mesenchymal lesions that can occur in various sites throughout the body, including the tubular gastrointestinal (GI) tract. To analyze the clinical findings of 36 patients with GI tract CFTs to provide guidance for diagnosis and treatment. This retrospective study included 36 patients diagnosed with CFTs of the GI tract. We collected demographic and clinical information and conducted regular follow-ups to assess for local recurrence. The stomach was the most commonly involved site, accounting for 72.2% of the 36 CFTs. Endoscopic mucosal resection (n = 1, 2.8%), endoscopic submucosal dissection (n = 14, 38.9%), endoscopic full-thickness resection (n = 16, 44.4%), and submucosal tunneling endoscopic resection (n = 5, 13.9%) were used to resect calcifying fibrous tumors. Overall, 34 (94.4%) CFTs underwent complete endoscopic resections with a mean procedure time of 39.8 ± 29.8 min. The average maximum diameter of the tumors was 10.6 ± 4.3 cm. No complications, such as bleeding or perforation, occurred during an average hospital stay of 2.9 ± 1.2 d. In addition, two patients developed new growth of CFTs near the primary tumor sites, and none of the patients developed distant metastases during the follow-up period. GI tract CFTs are rare and typically benign tumors that can be effectively managed with endoscopic procedures.

Effects of full-thickness wedge resection on ocular surface and in vivo confocal microscopy findings in floppy eyelid syndrome patients.

To evaluate the effect of full-thickness wedge resection (FTWR) on ocular surface and in vivo confocal microscopy (IVCM) findings in patients with floppy eyelid syndrome (FES). The study included two groups: a surgical treatment (ST) group (26 eyes) consisting of patients who underwent FTWR surgery, and a conservative treatment (CT) group (30 eyes). Pre-treatment and post-treatment ocular surface disease index (OSDI), tear break-up time (TBUT), corneal fluorescein staining (CFS), IVCM findings along with the body mass index (BMI), FES grade, the presence and the treatment of obstructive sleep apnea syndrome (OSAS) were recorded and compared between the groups. The groups were comparable in terms of BMI, FES grade, and OSAS data. After six months, TBUT in the ST group significantly increased to 12.92 ± 1.15, compared to 8.10 ± 1.60 in the CT group (p = 0.000). The CFS and OSDI scores were significantly lower in the ST group (0.15 ± 0.37, 18.0 ± 8.3, respectively) compared to the CT group (0.90 ± 0.61, 27.3 ± 9.3, respectively) (p = 0.000). IVCM analysis revealed a significant decrease in dendritic cell count (ST: 22.0 ± 12.4, CT: 39.5 ± 15.1, p = 0.000) and nerve tortuosity (ST: 1.38 ± 0.64, CT: 2.00 ± 0.59, p = 0.000), with a significant increase in total nerve density (ST: 4.27 ± 0.83, CT: 3.57 ± 0.90, p = 0.002) in the ST group compared to the CT group after six months. In our retrospective cohort, FTWR surgery was shown to be an effective and reliable surgical treatment for FES, improving both ocular surface and IVCM findings. Patients with moderate to severe stages of FES not responding to conservative treatment may benefit from eyelid tightening.

Easy and Feasible Closure for a Large Perforation After Gastric Full-Thickness Resection: Clipping Method with Symmetrical Anchors.

Easy and Feasible Closure for a Large Perforation After Gastric Full-Thickness Resection: Clipping Method with Symmetrical Anchors.

Endoscopic resection of gastric gastrointestinal stromal tumor using clip-and-cut endoscopic full-thickness resection: a single-center, retrospective cohort in Korea.

To overcome the technical limitations of classic endoscopic resection for gastric gastrointestinal stromal tumors (GISTs), various methods have been developed. In this study, we examined the role and feasibility of clip-and-cut procedures (clip-and-cut endoscopic full-thickness resection [cc-EFTR]) for gastric GISTs. Medical records of 83 patients diagnosed with GISTs after endoscopic resection between 2005 and 2021 were retrospectively reviewed. Moreover, clinical characteristics and outcomes were analyzed. Endoscopic submucosal dissection (ESD) and cc-EFTR were performed in 51 and 32 patients, respectively. The GISTs were detected in the upper third of the stomach for ESD (52.9%) and cc-EFTR (90.6%). Within the cc-EFTR group, a majority of GISTs were located in the deep muscularis propria or serosal layer, accounting for 96.9%, as opposed to those in the ESD group (45.1%). The R0 resection rates were 51.0% and 84.4% in the ESD and cc-EFTR groups, respectively. Seven (8.4%) patients required surgical treatment (six patients underwent ESD and one underwent cc-EFTR,) due to residual tumor (n=5) and post-procedure adverse events (n=2). Patients undergoing R0 or R1 resection did not experience recurrence during a median 14-month follow-up period, except for one patient in the ESD group. cc-EFTR displayed a high R0 resection rate; therefore, it is a safe and effective therapeutic option for small gastric GISTs.

Endoluminal and next generation robotics in colorectal surgery

Innovative approaches leverage cutting-edge technologies to advance the field of minimally invasive colorectal surgery. The implementation of complex endoluminal and transluminal procedures is challenging and requires extensive training. Recent technological advances not only enable improved detection of colorectal neoplasms with the support of computer science, but also enhanced surgical treatment with robotic instrumentation. Early diagnosis will revolutionize colorectal cancer treatment by avoiding surgery, as has been demonstrated in the treatment of early-stage gastric cancer using third-space endoscopy. Automated colorectal cancer screening with polyp detection and classification can change the therapeutic strategy and orient towards resection during endoscopy, including full-thickness resection, with endoscopic bimanual suturing to close the defect. Several therapeutic flexible endoscopic robotic systems are expected to provide surgery-like dexterity for endo- and transluminal approaches by enabling tissue triangulation while lowering the technical hurdles for endoscopic submucosal dissection and other highly sophisticated procedures such as endoscopic creation or revision of anastomoses. In the curvilinear anatomy of the colon and rectum, navigation assistance for improved spatio-temporal orientation will aid in the detection and documentation of lesions and facilitate their localization for excision and follow-up. Flexible robotic systems encourage surgeons as well as gastroenterologists to perform advanced intra- and transluminal resections.

Role of the artificial intelligence in the management of T1 colorectal cancer

Approximately 10% of submucosal invasive (T1) colorectal cancers demonstrate extraintestinal lymph node metastasis, necessitating surgical intervention with lymph node dissection. The ability to identify T1b (submucosal invasion depth ≥ 1000 µm) as a risk factor for lymph node metastasis via pre-treatment endoscopy is crucial in guiding treatment strategies. Accurately distinguishing T1b from T1a (submucosal invasion depth < 1000 µm) or dysplasia remains a significant challenge for artificial intelligence (AI) systems, which require high and consistent diagnostic capabilities. Moreover, as endoscopic therapies like endoscopic full-thickness resection and endoscopic intermuscular dissection evolve, and the focus on reducing unnecessary surgeries intensifies, the initial management of T1 colorectal cancers via endoscopic treatment is anticipated to increase. Consequently, the development of highly accurate and reliable AI systems is essential, not only for pre-treatment depth assessment but also for post-treatment risk stratification of lymph node metastasis. While such AI diagnostic systems are still under development, significant advancements are expected in the near future to improve decision-making in T1 colorectal cancer management.

The case of endoscopic extraction of a foreign body of the gastric antral wall using full-thickness resection

The case of endoscopic extraction of a foreign body of the gastric antral wall using full-thickness resection

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.

Endoscopic Resection Techniques for Precancerous and Early Cancerous Lesions in the Rectum

Today, endoscopy plays a decisive role not only in the detection of colorectal adenomas and carcinomas, but also in the treatment of precancerous lesions, in particular flat adenomas and early carcinomas. In recent years, endoscopic submucosal dissection (ESD) has become increasingly important alongside classic polypectomy and mucosal resection after saline injection using a snare (EMR). Using ESD the lesion is marked, injected submucosally using viscous substances and the mucosa incised and tunneled with a transparent cap and a fine diathermy knife. Particularly in the case of widespread and high-risk lesions ESD enables a quasi-surgical "en bloc" resection almost regardless of size, with a histological R0 resection rate of far over 90% in specialized centers. ESD enables an excellent histopathological evaluation and has a low recurrence risk of 1-3%. Endoscopic full-thickness resection using a dedicated device (FTRD system) represents another addition to the armamentarium. It can be used for circumscribed submucosal, suspicious or scarred changes up to 2cm in the middle and upper rectum. Endoscopic intermuscular dissection (EID) enables histopathological analysis of the complete submucosa beyond the mucosa and upper submucosal layer by including the circular inner muscle layer within the resection specimen. It reduces basal R1 situations and offers a new perspective for T1 carcinomas through curative, organ-preserving endoscopic therapy, especially in the case of deep submucosal infiltration alone, without other risk factors for metastases. Indications, the procedure itself and significance of the various techniques for premalignant and early malignant lesions in the rectum are presented.

Modified Mustardé and Superolateral Periosteal Flaps for Full-Thickness Defects of Medial and Central Lower Eyelid: A Case Series.

Reconstructing full-thickness defects involving 50% to 75% of the horizontal length of the lower eyelid after medial and central full-thickness block resection can be challenging. As a disadvanatge, 1-stage reconstructions may require a free graft reconstruction of the posterior lamella. In addition, 2-stage reconstructions are associated with several complications, including erythema, and the eye must be temporarily closed after surgery. The present study describes a single-surgeon retrospective case series. Five patients diagnosed with basal cell carcinoma underwent wide full-thickness block resection with optimal excision margins (3-5 mm). Subsequently, 1-stage reconstruction was performed using the modified Mustardé flap, incised using the transconjunctival approach. This flap comprised the skin, muscle, tarsus, and conjunctival flap raised from the lateral canthus through a lateral cantholysis procedure, and then extended to the lateral cheek. The flap was medially transposed to cover the medial and central lower eyelid defect. The superolateral periosteal flap was harvested from the superolateral orbital rim attached to the lateral border of the tarsus of the modified Mustardé flap. The lateral forniceal conjunctiva was released from the retractor and advanced superiorly to cover the inner surface. The study included 3 men and 2 women, with a mean age of 71 years (range, 62-90 years). Histological evaluations confirmed tumor-free margins in all cases. The average follow-up duration was 20 months (6-60 months), with no tumor recurrence. None of the patients developed long-term complications, such as ectropion, entropion, lagophthalmos, trichiasis, symblepharon, erythema, wound dehiscence, or flap necrosis. All patients had minimal scarring, and no secondary surgical interventions were necessary. This case series demonstrates the efficacy of the combined modified Mustardé and superolateral periosteal flaps in 1-stage reconstruction of full-thickness defects involving 50% to 75% of the horizontal length of the medial and central lower eyelid without compromising functional and aesthetic outcomes.

Endoscopic Management of Gastro-Entero-Pancreatic Neuroendocrine Tumours: An Overview of Proposed Resection and Ablation Techniques.

A literature search of MEDLINE/PUBMED was conducted with the aim to highlight current endoscopic management of localised gastro-entero-pancreatic NETs. Relevant articles were identified through a manual search, and reference lists were reviewed for additional articles. The results of the research have been displayed in a narrative fashion to illustrate the actual state-of-the-art of endoscopic techniques in the treatment of NETs. Localised NETs of the stomach, duodenum and rectum can benefit from advanced endoscopic resection techniques (e.g., modified endoscopic mucosal resection, endoscopic full thickness resection, endoscopic submucosal dissection) according to centre expertise. Radiofrequency thermal ablation can be proposed as an alternative to surgery in selected patients with localised pancreatic NETs.

Surgical tips and tricks for laparoscopic intragastric surgery for submucosal tumors relative to the esophagogastric junction.

Recent reports have described the practicality of laparoscopic intragastric surgery (l-IGS) as an alternative for resecting submucosal tumors (SMTs) near the esophagogastric junction (EGJ), where excision using an exogastric approach would be difficult. However, even using IGS to perform a full-thickness resection of SMTs that are in or extremely close to the EGJ is very difficult to do safely and avoid disrupting or causing stenosis of the EGJ, without advanced experience. This study retrospectively examined the usefulness of l-IGS for gastric SMTs located in or extremely close to the EGJ. Fourteen patients with gastric SMTs < 2cm of the EGJ and underwent l-IGS were eligible for this study. We examined the tumor location, operative time, intraoperative hemorrhage, degree of deformation, gastroesophageal reflux disease, perioperative complications, and recurrence. Furthermore, we compared patients with tumors in the EGJ with those with tumors near the EGJ and patients in whom three-port l-IGS was performed with those who underwent single-incision laparoscopic surgery. The average tumor size, operative time, intraoperative hemorrhage, and postoperative hospitalization of the 14 patients were 30.9 ± 21.3mm, 125.2 ± 31.1min, 30.7 ± 103.3mL, and 9.2 ± 3.1d, respectively. No differences in these parameters according to the type of l-IGS or tumor location were observed. All patients underwent l-IGS without complications and were free from EGJ deformation or esophagitis. We believe that l-IGS is useful for gastric SMTs located < 2cm of the EGJ as it can be safely performed for difficult tumor locations and does not cause deformation of the EGJ.

Exposed endoscopic full-thickness resection with reopenable clip-over-the-line method for a duodenal neuroendocrine tumor.

Exposed endoscopic full-thickness resection with reopenable clip-over-the-line method for a duodenal neuroendocrine tumor.

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.