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.
Key points
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Endoscopic full-thickness resection (EFTR) is a minimally invasive technique that has produced promising clinical outcomes as a minimally invasive natural orifice transluminal endoscopic surgery approach to the resection of gastrointestinal subepithelial tumors.
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Emerging suturing devices simplify closure of the full-thickness defect produced by EFTR. However, the mainstay closure technique in Asia, where EFTR is mostly performed, is still metallic endoscopic clips.
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Challenges still exist in professional training, device promotion, and development.
Video content accompanies this article at www.giendo.theclinics.com
Introduction
Endoscopists have become more and more aggressive in regard to endoscopic resection as they progress from established expertise in endoscopic mucosal resection (EMR) to an ever-expanding experience in endoscopic submucosal dissection (ESD) techniques for the en bloc resection of superficial gastrointestinal (GI) lesions arising from the mucosal and submucosal layers. New techniques were developed to excavate muscularis propria (MP)-originating subepithelial tumors (SETs). These techniques, often referred to as endoscopic submucosal excavation (ESE) or endoscopic muscularis dissection (EMD), are best suited for SETs without any extraluminal growth component. Furthermore, from an oncologic standpoint, these techniques cannot guarantee a negative resection margin of muscularis-based tumors such as GI stromal tumors (GISTs) because the muscularis is not removed in toto but, instead, subjected to partial excavation. Both of these issues with ESE or EMD can be addressed by endoscopic full-thickness resection (EFTR). EFTR was first described in 1998 by Suzuki and colleagues. Based on experience with EMR using a ligation device, they reported a new technique for the treatment of early GI tumors, namely EFTR with the use of a ligation device (EFTR-L), followed by endoscopic complete defect closure. Later, in 2001, the same group reported the usefulness of this technique for SETs (2 rectal and 1 duodenal neuroendocrine tumors). EFTR-L was used to perform en bloc resection of these lesions that appeared to have been small (size is not provided), potentially 10 mm or less because the lesions were small enough to be suctioned and ligated within the cap of the ligation device. They report using a proprietary device for tissue apposition and closure before resecting the ligated lesions consisting of a detachable metallic snare with an anchoring needle at its tip. In the case of the duodenal lesion, laparoscopic intervention was needed to suture a microperforation. EFTR can be performed with or without laparoscopic assistance. This article focuses on the techniques and outcomes of pure EFTR without laparoscopic assistance. For an overview of device-assisted EFTR with specialized devices, refer to recent reviews. (See Kim HH, Uedo N: Hybrid NOTES: Combined Laparo-Endoscopic Full-Thickness Resection Techniques , in this issue.) Furthermore, the focus is on free-hand EFTR, which uses the same implements as ESD but in a way to effect deeper dissection through the muscularis and/or serosa (see later discussion).
Introduction
Endoscopists have become more and more aggressive in regard to endoscopic resection as they progress from established expertise in endoscopic mucosal resection (EMR) to an ever-expanding experience in endoscopic submucosal dissection (ESD) techniques for the en bloc resection of superficial gastrointestinal (GI) lesions arising from the mucosal and submucosal layers. New techniques were developed to excavate muscularis propria (MP)-originating subepithelial tumors (SETs). These techniques, often referred to as endoscopic submucosal excavation (ESE) or endoscopic muscularis dissection (EMD), are best suited for SETs without any extraluminal growth component. Furthermore, from an oncologic standpoint, these techniques cannot guarantee a negative resection margin of muscularis-based tumors such as GI stromal tumors (GISTs) because the muscularis is not removed in toto but, instead, subjected to partial excavation. Both of these issues with ESE or EMD can be addressed by endoscopic full-thickness resection (EFTR). EFTR was first described in 1998 by Suzuki and colleagues. Based on experience with EMR using a ligation device, they reported a new technique for the treatment of early GI tumors, namely EFTR with the use of a ligation device (EFTR-L), followed by endoscopic complete defect closure. Later, in 2001, the same group reported the usefulness of this technique for SETs (2 rectal and 1 duodenal neuroendocrine tumors). EFTR-L was used to perform en bloc resection of these lesions that appeared to have been small (size is not provided), potentially 10 mm or less because the lesions were small enough to be suctioned and ligated within the cap of the ligation device. They report using a proprietary device for tissue apposition and closure before resecting the ligated lesions consisting of a detachable metallic snare with an anchoring needle at its tip. In the case of the duodenal lesion, laparoscopic intervention was needed to suture a microperforation. EFTR can be performed with or without laparoscopic assistance. This article focuses on the techniques and outcomes of pure EFTR without laparoscopic assistance. For an overview of device-assisted EFTR with specialized devices, refer to recent reviews. (See Kim HH, Uedo N: Hybrid NOTES: Combined Laparo-Endoscopic Full-Thickness Resection Techniques , in this issue.) Furthermore, the focus is on free-hand EFTR, which uses the same implements as ESD but in a way to effect deeper dissection through the muscularis and/or serosa (see later discussion).
Indications and contraindications for endoscopic full-thickness resection
Over the past 4 to 5 years, EFTR has been in clinical use in a few elite centers with advanced expertise in endoscopic resection but there is still no consensus about indications or suitability of EFTR. EFTR allows complete resection of tumors, hence reduces the risk of residual tumor, and improves accuracy of pathologic diagnosis and staging. Sumiyama and Gostout proposed that the EFTR technique can be used to resect large laterally spreading tumors and submucosal tumors arising from the submucosa or MP. The group at Endoscopy Center of Zhongshan Hospital proposed indications and contraindications of EFTR ( Box 1 ).
| Indications |
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| Contraindications |
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Though there is no firm consensus on the exact indications, it is universally agreed that the EFTR procedure should only be carried out by very skilled endoscopists who have mastered ESD, the parent technique for all new natural orifice transluminal endoscopic surgery (NOTES) procedures, including EFTR. EFTR is most frequently used in SETs originating from the MP in the upper GI tract. However, recent publications have also demonstrated the feasibility of EFTR for SETs in the lower GI tract.
Preoperative preparations
Before the procedure, the patient should have a preparation similar to that required before general GI surgery. The following should be emphasized:
- 1.
Medical staff and endoscopic accessories
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EFTR is a complex procedure and requires at least 2 trained nurses or technicians and an experienced endoscopist. The success of EFTR depends on the operator’s technical skill. The EFTR operator must have mastered electrosurgical, hemostatic and closure techniques, and devices to achieve efficient and complete resection while minimizing and appropriately managing adverse events. The instruments for EFTR are essentially the same as those used for ESD. Occasionally, in EFTR procedures, a dual-channel endoscope (GIF-2T240, Olympus Corporation, Tokyo, Japan) and grasping forceps (FG-8U-1, Olympus Corporation, Tokyo, Japan) can be used to prevent the tumor from falling into the abdominal cavity. For closure of the GI wall defect, in most clinical settings in which advanced suturing devices are not commercially available (as is the case in Asia currently), purse-string closure via metallic clips and Endoloops (MAJ-254 or MAJ-340, Olympus Corporation, Tokyo, Japan) is the most commonly used technique.
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Multidisciplinary collaboration
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Complex procedures such as EFTR require multidisciplinary support from various departments including anesthesia, surgery, gastroenterology, pathology, and intensive care.
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Bowel preparation
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Good bowel preparation is necessary for EFTR. Dietary modification and oral laxatives (polyethylene glycol) are used to prepare the colon for colonic lesions. Milk and high-sugar foods are not recommended to prevent flatulence. Patients fast for 8 hours before the procedure.
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Prophylactic antibiotics
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Half an hour before EFTR, all patients receive intravenous infusion of a third-generation cephalosporin.
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Operational approach
A transparent cap is usually attached to the tip of scope (D-201–10,704, Olympus Corporation, Tokyo, Japan) to ensure better view, tissue traction, and positioning; and to facilitate hemostasis in case of bleeding.
Herein, only the technique of pure or free-hand EFTR is discussed. The operational approach can be described as follows : ( Fig. 1 , [CR] )
- 1.
After making several marking dots with an electrosurgical knife around the lesion, a mixture solution (100 mL of normal saline, 1 mL of indigo carmine, and 1 mL of 1:1000 epinephrine solution) is injected into the submucosa. Precutting of the mucosal and submucosal layer around the lesion is performed per typical ESD technique with the usual ESD accessories. To ensure a better view for the ensuing resection of the deeper layers, the mucosa and submucosa covering the luminal aspect of the lesion are sometimes resected with a snare to expose the lesion itself and facilitate margin assessment during the remainder of the resection.
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A circumferential incision is made through the MP layer around the lesion, again using ESD technique and a Hook knife (KD-620LR, Olympus Corporation, Tokyo, Japan) or other similar ESD knife, depending on operator experience and preference.
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Due to the close relation between subepithelial GI tumors and the serosal layer that is frequently present, complete resection of the lesion and associated MP while preserving an intact serosal layer is often not possible. Hence, resection of the serosa around the lesion is often inevitable because the MP is being excised by use of the Hook knife or other suitable needle knife (KD-10Q-1, Olympus Corporation, Tokyo, Japan), thus creating an active perforation of the GI wall.
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Completion of the full-thickness resection of the tumor may require switching from the Hook knife to an insulated-tip knife (KD-610 L, KD-611 L, Olympus Corporation, Tokyo, Japan) to avoid injury of adjacent organs or structures in the peritoneal or chest cavities in the absence of laparoscopic overview or assistance. A dual-channel endoscope is sometimes used with a forceps grasping the tumor before the final cut freeing the tumor from the GI wall to avoid having the tumor fall into the peritoneal cavity, which could complicate retrieval. Finally, the tumor, including its surrounding MP and serosa, is removed via the mouth (or anus for lower tract EFTR). During resection, the highest priority is the safe and complete removal of the tumor without interruption of the tumor capsule.
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Closure of the gastric wall defect in a periphery-to-center manner can be performed simply with standard endoscopic clips when the size of the full-thickness defect is smaller than the width of the open clip. When the diameter of the defect is slightly larger than the width of the open clip, it can be reduced by air suction and then still be managed by standard clips. However, when the defect is larger than 15 to 20 mm, it may be difficult to approximate and close securely with standard through-the-scope clips. Such larger defects can be managed by clips combined with Endoloops ( Fig. 2 ) or by the omental-patch method. By this method, the greater omentum is sucked into the gastric cavity and the defect is closed by affixing the omentum to the edges of the defect with standard endoscopic clips.
Fig. 2
Purse-string suture of a full-thickness gastric wall defect. ( A ) A full-thickness wall defect after tumor removal. ( B , C ) The purse-string suture was performed by the combined application of clip and Endoloop. The Endoloop was placed above the defect, then the loop clipped with the edge of wall defect, nicely and evenly. ( D ) The defect was tucked underneath the string and the Endoloop tightened to achieve full-thickness closure of the defect.
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A 20-gauge needle is inserted in right upper quadrant to relieve the pneumoperitoneum during the procedure ( Fig. 3 ). Patients are kept nil by mouth after surgery and nursed in semi-Fowlers position. A nasogastric tube is routinely placed to deflate the stomach; in addition, it helps to detect early postprocedural bleeding.
Related posts:
The New NOTES Expands Interventional Endoscopy
The New NOTES: More “E” and Less “S” Leads to Success!
Submucosal Tunneling Endoscopic Resection (STER) and Other Novel Applications of Submucosal Tunneling in Humans
Non-Exposure, Device-Assisted Endoscopic Full-thickness Resection
New NOTES Clinical Training and Program Development
Pre-clinical Training for New Notes Procedures
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