Combined endoscopic mucosal resection and full-thickness resection for large colorectal polyps: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Combined endoscopic mucosal resection (EMR) with endoscopic Full thickness resection (EFTR) is an emerging technique that has been developed to target colorectal polyps larger than 2 cm. We performed a systematic review and meta-analysis to evaluate this technique for the resection of large colorectal lesions. METHODS: We conducted a comprehensive search of multiple electronic databases from inception through August 2023, to identify studies that reported on hybrid FTR. A random-effects model was employed to calculate the overall pooled technical success, macroscopic complete resection, free vertical margins resection rate, adverse events, and recurrence on follow up. RESULTS: A total of 8 Study arms with 244 patients (30% women) were included in the analysis. The pooled technical success rate was 97% (95% CI 88%-100%, I2 = 79.93%). The pooled rate of macroscopic complete resection was achieved in 95% (95% CI 90%-99%, I2 = 49.98) with a free vertical margins resection rate 88% (95% CI, 78%-96%, I2 = 63.32). The overall adverse events rate was 2% (95% CI 0%-5%, I2 = 11.64) and recurrence rate of 6% (95% CI 2%-12%, I2=20.32). CONCLUSION: Combined EMR with EFTR is effective and safe for resecting large, and complex colorectal adenomas, offering a good alternative for high surgical risk patients. Regional heterogeneity was observed, indicating that outcomes may be impacted by differences in operator expertise and industry training certification across regions. Comparative studies that directly compare combined EMR with EFTR against alternative methods such as ESD and surgical resection are needed.

Gastric defect closure after endoscopic full-thickness resection: the closing while dissecting technique.

BACKGROUND: Complete closure of gastric wall defects is critical following endoscopic full-thickness resection (EFTR). The aim of this study was to evaluate the efficacy, safety, and clinical outcome of a new endoscopic method: closing while dissecting. METHODS: Twenty-seven patients who underwent EFTR were retrospectively analyzed between January 2020 and March 2021. Gastric defects resulting from EFTR were closed using the "interrupted-close during dissection" technique with endoclips. Tumor characteristics, en bloc resection rates, and postoperative adverse events were evaluated. RESULTS: All submucosal tumors were successfully resected and complete resection was histologically confirmed. The mean maximal tumor diameter was 1.3 cm (ranging from 0.8 to 3.0 cm). The majority of these tumors were gastrointestinal stromal tumors (n = 20), Leiomyoma (n = 3), schwannomas (n = 2), others included fibroma (n = 1) and neurogenic tumor (n = 1). There were no cases of hemorrhage, peritonitis, or delayed perforation. Four patients complained of slight abdominal pain, but no hyperpyrexia or serious elevated white blood cell count was detected in the first 24 h after treatment. All wounds were healed on follow-up endoscopy 3 months after the procedure. The mean follow-up duration was 8.5 months (ranging from 3 to 17) and no tumor recurrences were observed. CONCLUSIONS: The feasibility and safety of this interrupted-close during dissection approach allows for clinical applications in EFTR of gastric submucosal tumors.

OTSC assisted EFTR for the treatment of GIST: 40 cases analysis.

BACKGROUND AND AIMS: To verify the safety and efficacy of over-the-scope clip (OTSC)-assisted endoscopic full-thickness resection (EFTR) for the excision of stromal tumors. MATERIAL AND METHODS: Forty patients with gastric stromal tumors treated in the Department of Gastroenterology, Binzhou Medical University Hospital from December 2015 to March 2017 were included in this study. The surgical procedures included marking the lesion boundaries, cutting open the top surface of the lesion, installing an OTS, sucking the lesion into the transparent cap of the anatomical clip which was then released, application of an endoloop for EFTR, and confirming the complete resection and pathological examination of the lesion. Statistical analysis of the tumor site and size, operation time, success rates, complications, pathological examination results, and follow-up status was performed. RESULTS: The average operation duration was 38.40 ± 24.9 min. Three cases had an incomplete resection, but the lesion was later found to have fallen off together with the OTSC. Therefore, the treatment success rate was 100%. Postoperative pathological examination revealed leiomyomas in four cases and stromal tumors in the remaining 36 cases. CONCLUSIONS: OTSC-assisted EFTR is safe and effective for resection of gastrointestinal stromal tumors, especially for those <20 mm in size.

Endoscopic full thickness resection vs. transanal endoscopic microsurgery for local treatment of rectal neuroendocrine tumors - a retrospective analysis.

PURPOSE: Local treatment of small well-differentiated rectal neuroendocrine tumors (NETs) is recommended by current guidelines. However, although several endoscopic methods have been established, the highest R0 rate is achieved by transanal endoscopic microsurgery (TEM). Since a recently published study about endoscopic full thickness resection (eFTR) showed a R0 resection rate of 100%, the aim of this study was to evaluate both methods (eFTR vs. TEM). METHODS: We retrospectively analyzed all patients with rectal NET treated either by TEM (1999-2018) or eFTR (2016-2019) in two tertiary centers (University Hospital Wuerzburg and Ulm). We analyzed clinical, procedural, and histopathological outcomes in both groups. RESULTS: Twenty-eight patients with rectal NET received local treatment (TEM: 13; eFTR: 15). Most tumors were at stage T1a and grade G1 or G2 (in the TEM group two G3 NETs were staged T2 after neoadjuvant chemotherapy). In both groups, similar outcomes for en bloc resection rate, R0 resection rate, tumor size, or specimen size were found. No procedural adverse events were noted. Mean procedure time in the TEM group was 48.9 min and 19.2 min in the eFTR group. CONCLUSION: eFTR is a convincing method for local treatment of small rectal NETs combining high safety and efficacy with short interventional time.

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.

Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection.

BACKGROUND AND AIMS: Endoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs. METHODS: Between September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients' baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed. RESULTS: In total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0-5) vs. 3 (1-5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up. CONCLUSION: For treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.

Intra-abdominal pressure during endoscopic full-thickness resection comparing manual and automatic control insufflation: a block-randomized porcine study.

BACKGROUND AND STUDY AIMS: An automatic carbon dioxide (CO2) insufflating system (SPACE) was developed to stabilize intra-lumenal pressure (ILP) during endoscopic interventions. This study investigated whether SPACE could improve the control and monitoring of extra-lumenal intra-abdominal pressure (IAP) after establishing a perforation during endoscopic full-thickness resection (EFTR) of the gastric wall in porcine models. MATERIALS AND METHODS: After first establishing the optimal preset pressure for gastric EFTR in four pigs, we compared IAP dynamics during EFTR between manual insufflation and SPACE using a block-randomized study (n = 10). IAP was percutaneously monitored and plotted on a timeline graph every 5 s. The maximal IAP and the area under the IAP curve exceeding 10 mmHg (AUC≥10 mmHg) were compared between groups, with the agreement between IAP and endolumenally monitored ILP also analyzed for animals in the SPACE group. RESULTS: In the first study, 8 mmHg was identified as the most preferable preset pressure after establishment of the perforation. In the randomized study, the mean maximal IAP in the SPACE group was significantly lower than that in the manual insufflation group (11.0 ± 2.0 mmHg vs. 17.0 ± 3.5 mmHg; P = 0.03). The mean AUC≥10 mmHg was also significantly smaller in the SPACE group. Bland-Altman analysis demonstrated agreement between IAP and ILP within a range of ± 1.0 mmHg. CONCLUSIONS: SPACE could be used to control and safely monitor IAP during gastric EFTR by measuring ILP during perforation of the gastric wall.

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.

Endoscopic resection for gastric schwannoma with long-term outcomes.

BACKGROUND: Gastric schwannoma is not so recognized by clinicians as its counterparts. The efficacy of endoscopic resection has not been described yet. Our aim was to assess the efficacy and safety of endoscopic resection in the management of gastric schwannoma. METHODS: Retrospective data were reviewed from January 2008 to December 2013 in our center. Fourteen patients who had endoscopic resection with the final pathology result of gastric schwannoma were included in the study. RESULTS: Of the 14 patients, there were 12 females and two males. The median age was 59 years (range 32-83). Thirteen tumors (92.9 %) were from the muscularis propria and one located in the submucosa. Endoscopic en bloc resection was achieved in 12 patients (12/14, 85.7 %), including seven cases of endoscopic full-thickness resection (EFTR). The mean resected tumor size was 1.73 ± 1.10 cm (range 0.3-4.0 cm). In one case, endoscopic resection was suspended due to the limited experience of EFTR during the early period of the study. In another case, due to the difficult tumor location (gastric angle) and extraluminal growth pattern, the patient was referred to laparoscopic surgery. In the 12 successful endoscopic resection cases, during the median follow-up time of 4 years (range 17-77 months, one patient lost), no tumor residue, recurrence or metastasis was found. CONCLUSIONS: Endoscopic resection is safe and effective in treating gastric schwannoma with excellent long-term outcomes. However, it should be performed with caution because schwannoma is mainly located in the deep muscular layer, which leads to the full-thickness resection of gastric wall.

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.

Effects of Endoscopic Submucosal Excavation With Non-Submucosal Injection on Stromal Tumors in Stomach.

Background and Aim: Endoscopic submucosal excavation (ESE) is commonly used to treat gastrointestinal stromal tumors (GISTs), especially for tumor sizes within 2 cm; compared with the conventical ESE, the efficacy and safety of the no-submucosal injection (NSI) ESE remains unclear. The aim of this study was to assess the clinical efficacy and safety of NSI-ESE for gastric stromal tumors. Methods: ESE was performed in 102 patients at our hospital between January 2018 and January 2020, and the clinical features, surgical outcomes, complications, cost of performance, pathological diagnosis, and risk classification were evaluated. Results: All tumors were completely resected by endoscopic resection (ER), with a complete resection rate of 100%. It was achieved by ESE/EFTR (endoscopic full-thickness resection) in 49 cases with submucosal injection, and by ESE/EFTR in 53 cases with NSI-ESE. The mean surgical time in cases with submucosal injection was 25.86 ± 4.45 min, compared to the cases without submucosal injection (17.23 ± 3.47 min), and the difference was significant (p < 0.001); the exposure time of tumor, the time of complete excavation of tumor, procedure cost, and hospital stay in the NSI-ESE group were all lower than those cases with submucosal injection (p < 0.05). In the risk classification, 95 (93.1%) cases had a very low risk, 4 (4.0%) cases had a low risk, and 2 (2.0%) cases had a high risk. No recurrence or metastasis was observed during the follow-up period of 18 ± 6 months (range: 13-25 months). Conclusions: NSI-ESE is a feasible, effective, and safe treatment for gastric GISTs; compared to the conventional ESE, NSI-ESE has the following advantages: it decreases procedure time, it lowers the risk of perforation, and it is cost-effective.

Modified endoscopic full-thickness resection of gastric stromal tumor originating from the muscularis propria layer.

Endoscopic full-thickness resection (EFTR) is emerging as an approach to resect gastric gastrointestinal stromal tumors originating from the muscularis propria layer (MP-GISTs) because several established endoscopic closure methods and tools have been developed. However, EFTR is performed difficultly due to three challenges: limited luminal insufflation and visualization, insufficient operating space, and inadequate exposure of cutting line. Therefore, we performed a novel method of clip- and snare-assisted EFTR (also named as m-EFTR or chen-EFTR) to resect a MP-GIST. This m-EFTR (chen-EFTR) provides a novel approach to resect MP-GISTs through providing distinct endoscopic visualization, adequate exposure of cutting line and sufficient operating space.

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.

Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland.

BACKGROUND: Endoscopic full thickness resection (EFTR) by the Full Thickness Resection Device (FTRD) has recently been introduced as a method to allow resection of certain lesions such as adenomatous polyps that would not be resectable by standard polypectomy techniques. We report our clinical experience with FTRD procedures, assessing technical success, completeness of resection (R0 status), rate of histologically proven FTR and safety. PATIENTS AND METHODS: We conducted a retrospective analysis of 33 consecutive patients with colonic polyps treated with FTRD from May 2015 to November 2016. RESULTS: Indications mainly were adenoma recurrence or residual adenoma with nonlifting sign after previous polypectomy. In the 31 cases amenable to EFTR, resection was en bloc and histologically complete (R0) in 87.9% (29/33) of patients. Histologically confirmed complete full thickness resection (FTR) was achieved in 80.6% (25/31). Three post-procedure bleedings and one perforation were seen. CONCLUSION: FTRD offers an additional endoscopic approach to treat nonlifting colorectal lesions. EFTR by FTRD appears to be feasible and efficacious in the resection of benign neoplasms of up to 30 mm in diameter and may be an alternative to surgery in selected patients. Given a significant rate of complications, safety is a concern and needs to be assessed in larger prospective studies.

Endoscopic Full-thickness Resection (EFTR) for Gastrointestinal Subepithelial Tumors.

There has been booming interest in the endoscopic full-thickness resection (EFTR) technique since it was first described. With the advent of improved and more secure endoscopic closure techniques and devices, such as endoscopic suturing devices, endoscopists are empowered to perform more aggressive procedures than ever. This article focuses on the procedural technique and clinical outcomes of EFTR for gastrointestinal subepithelial tumors.

Hybrid surgery for early gastric cancer.

Endoscopic submucosal dissection (ESD) is the most suitable treatment option in terms of minimally invasive treatment for potential node-negative early gastric cancers (EGCs). Furthermore, making the resection area of the primary lesion as small as possible is ideal for the patient's quality of life, even for potential node-positive EGC. An endoluminal approach is a reasonable option with which to minimize stomach resection area, because this procedure can be accurately demarcated from the inside. From this point of view, endoscopic full-thickness resection (EFTR) may be optimal, while laparoscopic assistance would be more desirable to create a more secure procedure. However, hybrid EFTR for EGCs has two limitations, which must be solved. First, concerns regarding iatrogenic tumor seeding via transluminal communication between the inside and outside of the tract exist. The second limitation relates to the determination of lymphadenectomy. Conventional lymphadenectomy, which involves the removal of the majority of feeding arteries, can lead to necrosis of the remaining gastric wall. Therefore, the resection area of lymphadenectomy should also be carefully determined. To address these two problems, a non-exposed hybrid EFTR combined with sentinel node navigation surgery (SNNS) would be the most ideal method of minimally invasive surgery for EGCs.

A Western Perspective on "New NOTES" from POEM to Full-thickness Resection and Beyond.

Most new natural orifice translumenal endoscopic surgery procedures originated in Asia; therefore, most data come from operators and a health care environment different from those in the West. We provide a Western perspective. We discuss East-West differences; review areas in which the United States is leading the way; and discuss the vagaries of coding and reimbursement. In the United States, reimbursement remains problematic. A Current Procedural Terminology code for peroral endoscopic myotomy is inevitable given the rapidly accumulating overwhelmingly positive outcomes data. However, coordinated efforts may help accelerate the process.