Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels

Endoscopic full thickness resection: techniques, applications, outcomes

INTRODUCTION

Endoscopic full-thickness resection (EFTR) represents a pivotal advancement in the minimally invasive treatment of gastrointestinal lesions, offering a novel approach for the management of lesions previously deemed challenging or unreachable through conventional endoscopic techniques.

AREAS COVERED

This review discusses the development, methodologies, applications, and clinical outcomes associated with EFTR, including exposed and device-assisted EFTR (DA-EFTR), the integration of endoscopic mucosal resection (EMR) with EFTR in hybrid techniques, and the collaborative approach between laparoscopic and endoscopic surgery (LECS). It encapsulates a comprehensive analysis of the various EFTR techniques tailored to specific lesion characteristics and anatomical locations, underscoring the significance of technique selection based on the lesion's nature and situational context.

EXPERT OPINION/COMMENTARY

The review underscores EFTR's transformative role in expanding therapeutic horizons for gastrointestinal tumors, emphasizing the importance of technique selection tailored to the unique attributes of each lesion. It highlights EFTR's capacity to facilitate organ-preserving interventions, thereby significantly enhancing patient outcomes and reducing procedural complications. EFTR is a cornerstone in the evolution of gastrointestinal surgery, marking a significant leap forward in the pursuit of precision, safety, and efficacy in tumor management.

Device-assisted endoscopic full-thickness resection in colorectum: Systematic review and meta-analysis

OBJECTIVES

Endoscopic full-thickness resection (EFTR) is emerging as an effective modality for mucosal and submucosal lesions in the colorectum. In this systematic review and meta-analysis, we aimed to analyze the success and safety of device-assisted EFTR in the colon and rectum.

METHODS

A literature search was performed in the Embase, PubMed, and Medline databases for studies evaluating device-assisted EFTR between inception to October 2022. The primary outcome of the study was clinical success (R0 resection) with EFTR. Secondary outcomes included technical success, procedure duration, and adverse events.

RESULTS

In all, 29 studies with 3467 patients (59% male patients, 3492 lesions) were included in the analysis. The lesions were located in right colon (47.5%), left colon (28.6%), and rectum (24.3%). EFTR was performed for subepithelial lesions in 7.2% patients. The pooled mean size of the lesions was 16.6 mm (95% confidence interval [CI] 14.9-18.2, I2 98%). Technical success was achieved in 87.1% (95% CI 85.1-88.9%, I2 39%) procedures. The pooled rate of en bloc resection was 88.1% (95% CI 86-90%, I2 47%) and R0 resection was 81.8% (95% CI 79-84.3%, I2 56%). In subepithelial lesions, the pooled rate of R0 resection was 94.3% (95% CI 89.7-96.9%, I2 0%). The pooled rate of adverse events was 11.9% (95% CI 10.2-13.9%, I2 43%) and major adverse events requiring surgery was 2.5% (95% CI 2.0-3.1%, I2 0%).

CONCLUSION

Device-assisted EFTR is a safe and effective treatment modality in cases with adenomatous and subepithelial colorectal lesions. Comparative studies are required with conventional resection techniques, including endoscopic mucosal resection and submucosal dissection.

Endoscopic full-thickness resection vs. endoscopic submucosal dissection of residual/recurrent colonic lesions on scars: a retrospective Italian and Japanese comparative study

BACKGROUND AND AIMS

Endoscopic treatment of recurrent/residual colonic lesions on scars is a challenging procedure. In this setting, endoscopic submucosal dissection (ESD) is considered the first choice, despite a significant rate of complications. Endoscopic full-thickness resection (eFTR) has been shown to be well-tolerated and effective for these lesions. The aim of this study is to conduct a comparison of outcomes for resection of such lesions between ESD and eFTR in an Italian and a Japanese referral center.

METHODS

From January 2018 to July 2020, we retrospectively enrolled patients with residual/recurrent colonic lesions, 20 treated by eFTR in Italy and 43 treated by ESD in Japan. The primary outcome was to compare the two techniques in terms of en-bloc and R0-resection rates, whereas complications, time of procedure, and outcomes at 3-month follow-up were evaluated as secondary outcomes.

RESULTS

R0 resection rate was not significantly different between the two groups [18/20 (90%) and 41/43 (95%); P= 0.66]. En-bloc resection was 100% in both groups. No significant difference was found in the procedure time (54 min vs. 61 min; P= 0.9). There was a higher perforation rate in the ESD group [11/43 (26%) vs. 0/20 (0%); P= 0.01]. At the 3-month follow-up, two lesions relapsed in the eFTR cohort and none in the ESD cohort (P= 0.1).

CONCLUSION

eFTR is a safer, as effective and equally time-consuming technique compared with ESD for the treatment of residual/recurrent colonic lesions on scars and could become an alternative therapeutic option for such lesions.

AI-2 quorum sensing controlled delivery of cytolysin-A by tryptophan auxotrophic low-endotoxic Salmonella and its anticancer effects in CT26 mice with colon cancer

INTRODUCTION

The limitations of conventional cancer therapies necessitate target-oriented, highly invasive, and safe treatment approaches. Hence, the intrinsic anti-tumor activity of Salmonella can offer better options to combat cancers.

OBJECTIVES

This study aims to utilize attenuated Salmonella and deliver cytolytic protein cytolysin A (ClyA) under quorum sensing (QS) signaling for precise localized expression in tumors but not in healthy organs.

METHODS

The therapeutic delivery strain was imposed with tryptophan auxotroph for selective colonization in tumors by trpA and trpE deletion, and lipid-A and O-antigen were altered by pagL and rfaL deletions using lambda red recombination method. The strain was transformed with the designed QS-controlled ClyA expression vector which was validated by western blot. The in vivo passaged therapeutic strain was used for treatment four times at a weekly interval, with a dose of 5 × 106 CFU/mouse for cancer therapy.

RESULTS

The attenuated strain induced minimal endotoxicity-related cytokines TNF-α, IL-1β, and IFN-γ and exhibited adequate colonization despite earlier exposure in mice. The QS-controlled ClyA expression was confirmed by western blot from bacterial cultures grown at different cell densities. The results demonstrated that the in vivo passaged strain preferentially colonized the tumor after vacating the spleen, liver, and lung, leaving no outward histological scars. The anti-cancer effect of the designed construct was evaluated in the murine CT26 colon cancer model. The expression of ClyA increased tumoricidal activity by 67 % compared to vector control.

CONCLUSION

Hence, the anti-tumor effect of the engineered Salmonella strain was improved by ClyA expression via QS activation after achieving the threshold bacterial cell density. Further, immunohistochemical staining of the tumor and other organs corroborated the QS-controlled tumor-specific expression of ClyA. Overall, the results imply that the developed anti-cancer Salmonella has low endotoxicity and QS-controlled expression of ClyA as beneficial safety elements and supports recurrent Salmonella inoculation by O-antigen deficiency.

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.

Optimising Outcomes and Surveillance Strategies of Rectal Neuroendocrine Neoplasms

Rectal neuroendocrine neoplasms are increasing in incidence, in part due to increased endoscopic procedures being performed for bowel cancer screening. Whilst most of these lesions are low-grade well-differentiated neuroendocrine tumours, they can have a varied clinical behaviour. Frequently, these lesions are incorrectly characterised at endoscopy and, therefore, incompletely excised using standard polypectomy techniques. Furthermore, some cases are not fully staged prior to or post resection. In this article we discuss the endoscopic and surgical options available to improve the likelihood of achieving an R0 resection and the staging procedures that should be used in these NETs. We also review factors that may suggest a higher risk of nodal involvement or recurrence. This information may help determine whether endoscopic or surgical resection techniques should be considered. In cases of R1 resection we discuss the management options available and the long-term surveillance options and when these should be offered to patients.

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 for Colorectal Lesions: A Systematic Review and Meta-Analysis

INTRODUCTION

Endoscopic full-thickness resection (EFTR) with an over-the-scope full-thickness resection device is a relatively new technique for the resection of colorectal lesions. Multiple centers have published the results of case series and observational cohorts regarding the use of this technique for managing difficult polyps. This study aims to aggregate the results of these studies to determine the effectiveness and safety of this technique in the resection of these technically challenging colonic lesions.

METHODS

MEDLINE, EMBASE, and CENTRAL were searched. Articles were included if they reported technical success rate for EFTR of colonic lesions. The primary outcome was technical success rate and secondary outcomes included rate of R0 resection and overall 30-d morbidity. DerSimonian and Laird random-effects meta-analysis of proportions was used to generate effect sizes for pooled outcomes.

RESULTS

From 2211 citations, 21 studies with 1539 patients (mean age 67.2 y, 39.5% female) undergoing 1551 procedures were included. Difficult to resect benign lesions were the most commonly excised lesions (hyperplastic: 35.9%; adenomas: 30.2%), followed by T1 adenocarcinomas (25.6%) and neuroendocrine tumors (6.1%). Technical success rate was 89% (95% confidence interval [CI] 87-92), and R0 resection rate was 79% (95% CI 76-82). Mean procedure time was 53.5 min and mean specimen size was 17.5 mm. Overall 30-d morbidity was 11% (95% CI 7-13), and incidences of perforation and postpolypectomy bleeding were 2% (95% CI 1-2) and 5% (95% CI 3-7), respectively. Lesion recurrence at 3-mo follow-up was 8%.

CONCLUSIONS

EFTR requires further large sample size, comparative studies with reporting of long-term oncologic data. However, preliminary findings indicate that it is a safe and effective technique with high rates of technical success and acceptable rates of R0 resection when employed by experienced endoscopists for high-risk colonic lesions.

Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a multicenter international experience

BACKGROUND

Endoscopic resection of lesions involving the appendiceal orifice remains a challenge. We aimed to report outcomes with the full-thickness resection device (FTRD) for the resection of appendiceal lesions and identify factors associated with the occurrence of appendicitis.

METHODS

This was a retrospective study at 18 tertiary-care centers (USA 12, Canada 1, Europe 5) between November 2016 and August 2020. Consecutive patients who underwent resection of an appendiceal orifice lesion using the FTRD were included. The primary outcome was the rate of R0 resection in neoplastic lesions, defined as negative lateral and deep margins on post-resection histologic evaluation. Secondary outcomes included the rates of: technical success (en bloc resection), clinical success (technical success without need for further surgical intervention), post-resection appendicitis, and polyp recurrence.

RESULTS

66 patients (32 women; mean age 64) underwent resection of colonic lesions involving the appendiceal orifice (mean [standard deviation] size, 14.5 (6.2) mm), with 40 (61 %) being deep, extending into the appendiceal lumen. Technical success was achieved in 59/66 patients (89 %), of which, 56 were found to be neoplastic lesions on post-resection pathology. Clinical success was achieved in 53/66 (80 %). R0 resection was achieved in 52/56 (93 %). Of the 58 patients in whom EFTR was completed who had no prior history of appendectomy, appendicitis was reported in 10 (17 %), with six (60 %) requiring surgical appendectomy. Follow-up colonoscopy was completed in 41 patients, with evidence of recurrence in five (12 %).

CONCLUSIONS

The FTRD is a promising non-surgical alternative for resecting appendiceal lesions, but appendicitis occurs in 1/6 cases.

Hybrid resection of large colorectal adenomas combining EMR and FTRD

BACKGROUND

The introduction of the full-thickness resection device (FTRD) allowed resection of difficult adenomas in the duodenum and colorectum with non-lifting. The main limitation of this endoscopic technique is the lesion size. We describe a hybrid approach combining endoscopic mucosal resection (EMR) and FTRD in a cohort of 17 patients to reduce tumor size and enable full-thickness resection.

METHODS

Retrospective analysis from data of 17 patients who underwent hybrid EMR-FTRD for large adenomas in the colorectum at our institution. Technical success, histological confirmation of margin-free resection and adverse advents were studied.

RESULTS

16 of 17 (94.1%) lesions could be resected macroscopically complete with confirmed full-thickness resection. Histological work-up of the full-thickness specimens showed free lateral margins in 13 patients (76.4%), unclear margins in two patients (11.8%) and positive margins in two patients (11.8%). There were no immediate perforation or major bleeding, however one patient showed a stenosis after resection in the follow-up endoscopy. Follow-up endoscopy was available in 12 patients. In two of 12 patients a recurrent adenoma was detected.

CONCLUSIONS

Hybrid EMR-EFTR in the colorectum seems to be a safe and effective technique for large non-lifting lesions with positive lifting signs in the margins. Further prospective evaluation of efficacy, safety and long-term outcome of this hybrid technique is necessary.