Endoscopic full-thickness resection (eFTR) of colorectal lesions: results from the Dutch colorectal eFTR registry

Abstract

Background Endoscopic full-thickness resection (eFTR) is a minimally invasive resection technique that allows definite diagnosis and treatment for complex colorectal lesions ≤ 30 mm unsuitable for conventional endoscopic resection. This study reports clinical outcomes from the Dutch colorectal eFTR registry. Methods Consecutive patients undergoing eFTR in 20 hospitals were prospectively included. The primary outcome was technical success, defined as macroscopic complete en bloc resection. Secondary outcomes were: clinical success, defined as tumor-free resection margins (R0 resection); full-thickness resection rate; and adverse events. Results Between July 2015 and October 2018, 367 procedures were included. Indications were difficult polyps (non-lifting sign and/or difficult location; n = 133), primary resection of suspected T1 colorectal cancer (CRC; n = 71), re-resection after incomplete resection of T1 CRC (n = 150), and subepithelial tumors (n = 13). Technical success was achieved in 308 procedures (83.9 %). In 21 procedures (5.7 %), eFTR was not performed because the lesion could not be reached or retracted into the cap. In the remaining 346 procedures, R0 resection was achieved in 285 (82.4 %) and full-thickness resection in 288 (83.2 %). The median diameter of resected specimens was 23 mm. Overall adverse event rate was 9.3 % (n = 34/367): 10 patients (2.7 %) required emergency surgery for five delayed and two immediate perforations and three cases of appendicitis. Conclusion eFTR is an effective and relatively safe en bloc resection technique for complex colorectal lesions with the potential to avoid surgery. Further studies assessing the role of eFTR in early CRC treatment with long-term outcomes are needed.

Reply to Dr. Bronswijk

“…Therefore, we cannot draw conclusions on the risk of secondary appendicitis in relation to appendiceal orifice involvement. We agree that it would be valuable to predict which patients are at risk of developing secondary appendicitis, especially as the incidence of appendicitis in our study was significant (20 %) [1]. The question why some patients develop secondary appendicitis is probably as interesting as why the majority do NOT develop appendicitis, even though a vital part of the remaining appendix is closed by a clip.…”

“…Of the remaining four patients with ≥ 75 % appendiceal orifice involvement, three underwent a previous appendectomy [3]. Unfortunately, data on the degree of appendiceal orifice involvement is missing in most studies [1,4]. Therefore, we cannot draw conclusions on the risk of secondary appendicitis in relation to appendiceal orifice involvement.…”

“…We thank Dr. Bronswijk for his interest and discussion of our recent article [1]. Dr. Bronswijk hypothesized that endoscopic full-thickness resection (eFTR) for lesions with extensive involvement of the appendiceal orifice might be associated with a lower risk of secondary appendicitis compared with lesions with partial appendiceal orifice involvement owing to pre-existent appendiceal obstruction.…”

Safety and efficacy of band ligation and auto-amputation as adjunct to EMR of colonic large laterally spreading tumors, and polyps not amenable to routine polypectomy

“…As such, it is important to adequately sample any lesion considered for BLA to confirm the degree of dysplasia present. Recent techniques such as endoscopic submucosal dissection [20][21][22] and endoscopic full-thickness resection 23,24 have the advantage of providing complete histological evaluation of an LST. Unfortunately, these techniques are not yet widely available and also have a significant perforation rate.…”

Endoscopic full-thickness resection and post-procedural appendicitis: every advantage has its disadvantage

“…In the November issue of Endoscopy, the Dutch endoscopic full-thickness resection (eFTR) group shared the results of their 3-year colorectal eFTR registry [1]. In this large prospective study, 65 out of 367 patients (17.7 %) required additional surgery, in three cases because of iatrogenic appendicitis.…”