Effect of endoscopic full-thickness resection assisted by distal serosal turnover with floss traction for gastric submucosal masses

BACKGROUND Complex and high-risk surgical complications pose pressing challenges in the clinical implementation and advancement of endoscopic full-thickness resection(EFTR).Successful perforation repair under endoscopy,thereby avoiding surgical intervention and postoperative complications such as peritonitis,are pivotal for effective EFTR.AIM To investigate the effectiveness and safety of EFTR assisted by distal serosal inversion under floss traction in gastric submucosal tumors.METHODS A retrospective analysis of patients with gastric and duodenal submucosal tumors treated with EFTR assisted by the distal serosa inversion under dental floss traction from January 2023 to January 2024 was conducted.The total operation time,tumor dissection time,wound closure time,intraoperative bleeding volume,length of hospital stay and incidence of complications were analyzed.RESULTS There were 93 patients,aged 55.1±12.1 years.Complete tumor resection was achieved in all cases,resulting in a 100% success rate.The average total operation time was 67.4±27.0 min,with tumor dissection taking 43.6±20.4 min.Wound closure times varied,with gastric body closure time of 24.5±14.1 min and gastric fundus closure time of 16.6±8.7 min,showing a significant difference(P<0.05).Intraoperative blood loss was 2.3±4.0 mL,and average length of hospital stay was 5.7±1.9 d.There was no secondary perforation after suturing in all cases.The incidence of delayed bleeding was 2.2%,and the incidence of abdominal infection was 3.2%.No patient required other surgical intervention during and after the operation.CONCLUSION Distal serosal inversion under dental-floss-assisted EFTR significantly reduced wound closure time and intraoperative blood loss,making it a viable approach for gastric submucosal tumors.

Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

BACKGROUND Gastric stromal tumors,originating from mesenchymal tissues,are one of the most common tumors of the digestive tract.For stromal tumors originating from the muscularis propria,compared with conventional endoscopic submucosal dissection(ESD),endoscopic full-thickness resection(EFTR)can remove deep lesions and digestive tract wall tumors completely.However,this technique has major limitations such as perforation,postoperative bleeding,and post-polypectomy syndrome.Herein,we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR.Feasible treatment options to address this complication are described.CASE SUMMARY A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography,located at the upper gastric curvature adjacent to the stomach fundus,with a smooth surface mucosa and poor mobility.The lesion was 19.3 mm×16.1 mm in size and originated from the fourth ultrasound layer.Computed tomography(CT)revealed no significant evidence of lymph node enlargement or distant metastasis.Using conventional ESD technology for mucosal pre-resection,exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis.Based on its morphology and immunohistochemical expression of CD117 and DOG-1,the lesion was proven to be consistent with a gastric stromal tumor.Six days after exposed EFTR,CT showed a large amount of encapsulated fluid and gas accumulation around the stomach.In addition,gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding.Based on these findings,the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor.The patient received combined treatments,such as hemostasis under gastroscopy,gastrointestinal decompression,and abdominal drainage.All examinations were normal within six months of follow-up.CONCLUSION This patient developed serous surface bleeding in the gastric cavity following exposed EFTR.Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice.The combined treatment may replace certain surgical techniques.

Recent advances and current challenges in endoscopic resection with the full-thickness resection device

Endoscopic full-thickness resection(EFTR)has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract(GIT)not amenable to conventional therapeutic approaches.While various devices and techniques have been described for EFTR,a single,combined fullthickness resection and closure device(full-thickness resection device,FTRD system,Ovesco Endoscopy AG,Tuebingen,Germany)has become commercially available in recent years.Initially,the FTRD system was limited to use in the colorectum only.Recently,a modified version of the FTRD has been released for EFTR in the upper GIT as well.This review provides a broad summary of the FTRD,highlighting recent advances and current challenges.

Extensively infarcted giant solitary hamartomatous polyp treated with endoscopic full-thickness resection:A case report

BACKGROUND Solitary hamartomatous polyps(SHPs)are rare lesions.Endoscopic full-thickness resection(EFTR)is a highly efficient and minimally invasive endoscopic procedure that benefits from complete lesion removal and high safety.CASE SUMMARY A 47-year-old man was admitted to our hospital after experiencing hypogastric pain and constipation for over fifteen days.Computed tomography and endoscopy revealed a giant pedunculated polyp(approximately 18 cm long)in the descending and sigmoid colon.This is the largest SHP reported to date.Having considered the condition of the patient and mass growth,the polyp was removed using EFTR.CONCLUSION On the basis of clinical and pathological evaluations,the mass was considered an SHP.

Closure techniques in exposed endoscopic full-thickness resection:Overview and future perspectives in the endoscopic suturing era

Exposed endoscopic full-thickness resection(EFTR)without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors.To date,various techniques have been used for the closure of the transmural postEFTR defect,mainly consisting in clip-and endoloop-assisted closure methods.However,the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure.The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance,also considering the recent advent of flexible endoscopic suturing.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection(EFTR),with or without laparoscopic assistance,is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors(SMTs)arising from the muscularis propria(MP),especially of the gastric wall.To date,evidence concerning duodenal exposed EFTR is lacking,mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure.However,given the non-negligible morbidity and mortality associated with duodenal surgery,the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers.The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

Repeat full-thickness resection device use for recurrent duodenal adenoma: A case report

BACKGROUND Endoscopic full-thickness resection of adenomas or subepithelial tumors is a novel and promising endoscopic technique.There have been several recent studies of full-thickness resection device(FTRD)use in the colon,but data regarding its use and efficacy in the duodenum are still limited.CASE SUMMARY A 64-year-old female underwent resection of a recurrent adenoma of 7 mm in size in the duodenum after FTRD use for an adenoma eight months prior.The biopsies revealed a low-grade adenoma.The adenoma was removed using the gastroduodenal FTRD,and the pathology results revealed clear margins.Except for minor bleeding that was treated by argon plasma coagulation,no further complications occurred.CONCLUSION Repeat use of the FTRD appears to be a safe and efficacious approach for the treatment of recurrent duodenal lesions.Further prospective studies are needed to investigate the long-term safety and utility of repeat FTRD use after Endoscopic full-thickness resection.

Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer

AIM: To evaluate the efficacy, safety and feasibility of endoscopic full-thickness resection (EFR) for the treatment of gastric submucosal tumors (SMTs) arising from the muscularis propria.

Endoscopic full-thickness resection and laparoscopic surgery for treatment of gastric stromal tumors

AIM: To assess the effectiveness of endoscopic full-thickness resection (EFR) and laparoscopic surgery in the treatment of gastric stromal tumors arising from the muscularis propria.

Endoscopic full-thickness resection using an over-the-scope device:A prospective study

BACKGROUND Endoscopic submucosal dissection to treat mucosal and submucosal lesions sometimes results in low rates of microscopically margin-negative(R0)resection.Endoscopic full-thickness resection(EFTR)has a high R0 resection rate and allows for the definitive diagnosis and treatment of selected mucosal and submucosal lesions that are not suitable for conventional resection techniques.AIM To evaluate the efficacy and safety of EFTR using an over-the-scope clip(OTSC).METHODS This prospective,single-center,non-randomized clinical trial was conducted at the endoscopy center of Shengjing Hospital of China Medical University.The study included patients aged 18-70 years who had gastric or colorectal submucosal tumors(SMTs)(≤20 mm in diameter)originating from the muscularis propria based on endoscopic ultrasound(EUS)and patients who had early-stage gastric or colorectal cancer(≤20 mm in diameter)based on EUS and computed tomography.All lesions were treated by EFTR combined with an OTSC for wound closure between November 2014 and October 2016.We analyzed patient demographics,lesion features,histopathological diagnoses,R0 resection(negative margins)status,adverse events,and follow-up results.RESULTS A total of 68 patients(17 men and 51 women)with an average age of 52.0±10.5 years(32-71 years)were enrolled in this study,which included 66 gastric or colorectal SMTs and 2 early-stage colorectal cancers.The mean tumor diameter was 12.6±4.3 mm.The EFTR procedure was successful in all cases.The mean EFTR procedure time was 39.6±38.0 min.The mean OTSC defect closure time was 5.0±3.8 min,and the success rate of closure for defects was 100%.Histologically complete resection(R0)was achieved in 67(98.5%)patients.Procedure-related adverse events were observed in 11(16.2%)patients.The average post-procedure length of follow-up was 48.2±15.7 mo.There was no recurrence during follow-up.CONCLUSION EFTR combined with an OTSC is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional endoscopic resection techniques.

Endoscopic full-thickness resection to treat active Dieulafoy's disease: A case report

BACKGROUND At present,minimally invasive endoscopic treatment is mostly used for patients with actively bleeding Dieulafoy’s lesions,,as it has the advantages of minimal trauma,short operation time and good hemostatic effect,although bleeding can easily recur postoperatively.Recently,extensive gastric cuneiform resection has been advocated for use in these patients because the constant-diameter artery follows a long path to the gastric mucosa.CASE SUMMARY A 47-year-old man was admitted to the hospital for repeated hematemesis and black stool,and he was diagnosed with Dieulafoy’s disease.We chose a method that not only simulates surgical gastric cuneiform resection but also reduces trauma.We performed enlarged local endoscopic full-thickness resection of the gastric wall and abdominal constant-diameter artery and sutured the gastric wall.Postoperative follow-up showed that the constant-diameter artery had been resected from the gastric wall,which was confirmed to have no blood flow signals by endoscopic ultrasonography.CONCLUSION Endoscopic full-thickness resection of the gastric wall and abdominal constantdiameter artery with suturing of the gastric wall has demonstrated potential as a new treatment for Dieulafoy's disease.

Gastric schwannoma treated by endoscopic full-thickness resection and endoscopic purse-string suture:A case report

BACKGROUND Schwannomas,also known as neurinomas,are tumors that derive from Schwann cells.Gastrointestinal schwannomas are extremely rare,but the stomach is the most common site.Gastric schwannomas are usually asymptomatic.Endoscopy and imaging modalities might offer useful preliminary diagnostic information.However,to diagnose schwannoma,the immunohistochemical positivity for S-100 protein is essential,whereas CD117,CD34,SMA,desmin,and DOG-1 are negative.CASE SUMMARY A 45-year-old female was found to have a gastric mass during a medical examination,which was diagnosed as a gastric schwannoma.We performed endoscopic full-thickness resection and endoscopic purse-string suture.Pathology and immunohistochemical staining confirmed the diagnosis of gastric schwannoma through the positivity of S-100 protein.Furthermore,to exclude the misdiagnosis of gastrointestinal stromal tumor,we performed a mutational detection of the c-Kit and PDGFRA genes.Postoperative follow-up revealed that the patient recovered well.CONCLUSION Immunohistochemical staining is essential for the diagnosis of schwannoma.Endoscopic full-thickness resection is an effective treatment method for gastric schwannoma.

Successful treatment of an enormous rectal mucosa-associated lymphoid tissue lymphoma by endoscopic full-thickness resection:A case report

BACKGROUND Colorectal mucosa-associated lymphoid tissue lymphoma(MALToma),a rare kind of nongastric MALToma,lacks consensus on its endoscopic features and standard therapies.According to previous studies on the clinical characteristics and outcomes of colorectal MALToma,endoscopic resection remains a good therapeutic strategy.CASE SUMMARY A 71-year-old woman suffered intermittent hematochezia for 1 mo,accompanied with abdominal pains but without weight loss,fever,chills or fatigue.Colonoscopy showed a massive hemispheric mass with rough and hyperemic mucosa in the lower rectum.Narrow-band imaging magnifying endoscopy detected some branching abnormal blood vessels and disappearance of glandular structure,which was similar with the tree-like appearance sign in gastric MALToma.Endoscopic ultrasonography revealed the lesion to be hypoechoic,boundary-defined,and echo uniform inside,originating from the muscularis propria.Abdominal enhanced computed tomography(CT)demonstrated a soft tissue mass with defined boundary.No enlarged superficial lymph nodes were detected by B-mode ultrasound.C13-urea breath test and serum Helicobacter pylori antibody were both negative.The patient underwent endoscopic full-thickness resection.Postoperative pathological analysis indicated colorectal MALToma.The patient remained asymptomatic after discharge,and follow-up positron emission tomography–CT and colonoscopy showed no residual lesion,remnants or lymph node metastasis.CONCLUSION This case provides new information on the specific endoscopic features of colorectal MALToma and an alternative treatment for patients.

Endoscopic full-thickness resection: current status

Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However,those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection(EFTR) is an evolving technique,which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.

Endoscopic full-thickness resection for treating small tumors originating from the muscularis propria in the gastric fundus: An improvement in technique over 15 years

BACKGROUND The fundus of the stomach is regarded as a difficult area for endoscopic resection of small tumors originating from the muscularis propria(MP tumors).Three endoscopic resection techniques have been developed to treat these tumors,including ligation-assisted endoscopic full-thickness resection(L-EFTR),snareassisted EFTR(S-EFTR),and endoscopic submucosal dissection-assisted EFTR(EEFTR).To date,no studies have compared these techniques.AIM We aimed to evaluate and compare S-EFTR with L-EFTR and E-EFTR for treating small MP tumors in the gastric fundus.METHODS We retrospectively reviewed patients with primary small MP tumors in the gastric fundus and treated by these three techniques between January 2016 and December 2018 at Shengjing Hospital,China.Standard demographic and clinicopathologic data,including sex,age,tumor size,surgeon details,and pathological results,were collected.Data regarding operation duration,cost,enbloc resection,and severe complications were also extracted and compared.RESULTS A total of 36 patients(27 women)with a mean age of 55.8±10.20 years were included in this study.The mean tumor size was 9.0±3.98 mm.All the methods showed a 100%en-bloc resection rate and 0%severe complication rate.There was no statistically significant difference among the three groups in the operation duration(P=0.148).The cost comparison for the whole procedure was as follows:E-EFTR>L-EFTR>S-EFTR(5837.5±7212.96 CNY,5970.7±3465.27 CNY,5852.0±6438.25 CNY,respectively,P<0.001).CONCLUSION S-EFTR,L-EFT,and E-EFTR are all effective for resection of small MP tumors in the gastric fundus.S-EFTR is superior in terms of cost-effectiveness.

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.

The efficacy of full-thickness endoscopic resection of subepithelial tumors in the gastric cardia

BACKGROUND Gastric subepithelial tumors(SETs)may harbor potential malignancy.Although it is well recognized that large SETs should be resected,the precise treatment strategy remains controversial.Compared to surgical resection,endoscopic resection(ER)has many advantages;however,ER of SETs in the cardia is challenging.AIM To evaluate the safety and efficacy of endoscopic full-thickness resection(EFTR)for the treatment of gastric cardia SETs.METHODS We retrospectively reviewed data from all patients with SETs originating from the muscularis propria layer in the gastric cardia that were treated by EFTR or submucosal tunneling ER(STER)at Zhongshan Hospital Fudan University between November 2014 and May 2022.Baseline characteristics and clinical outcomes,including procedure times and complications rates,were compared between groups of patients receiving EFTR and STER.RESULTS A total of 171 tumors were successfully removed[71(41.5%)tumors in the EFTR and 100(58.5%)tumors in the STER group].Gastrointestinal stromal tumors(GISTs)were the most common SET.The en bloc resection rate was 100%in the EFTR group vs 97.0%in STER group(P>0.05).Overall,the EFTR group had a higher complete resection rate than the STER group(98.6%vs 91.0%,P<0.05).The procedure time was also shorter in the EFTR group(44.63±28.66 min vs 53.36±27.34,P<0.05).The most common major complication in both groups was electrocoagulation syndrome.There was no significant difference in total complications between the two groups(21.1%vs 22.0%,P=0.89).CONCLUSION EFTR of gastric cardia SETs is a very promising method to facilitate complete resection with similar complications and reduced operative times compared to STER.In cases of suspected GISTs or an unclear diagnosis,EFTR should be recommended to ensure complete resection.

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

BACKGROUND 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.AIM To evaluate the efficacy and clinical value of double-nylon purse-string suture in closing postoperative wounds following EFTR of large(≥3 cm)SMTs.METHODS 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.RESULTS 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.CONCLUSION 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.

Technical feasibility of salvage endoscopic full-thickness resection for a giant gastrointestinal stromal tumor located in low rectum after imatinib:a case report

Introduction Gastrointestinal stromal tumors(GISTs)in adults are nearly 10%–30%with a potential malignant tendency[1].Colorectal GISTs account for 5%of all cases and have a higher progression risk with a poor prognosis[2,3].Rectal GISTs usually need radical operations such as laparoscopy to obtain tumor-free margins.Sometimes,it is difficult for surgery to preserve the anal function because of the tumor size and location.Here,we report a case of a 70-year-old female with a giant GIST located in the lower rectum,which was removed by function-preserving endoscopic minimally invasive resection after routine imatinib therapy.

Double-nylon purse-string suture technique: Another addition to the endoscopist's toolbox for full-thickness defect closure

Iatrogenic perforation is the most feared adverse event in endoscopy.With the expansion of interventional endoscopy in favor of traditional surgery,it is now more crucial than ever to develop effective defect closure techniques.This has culminated in the dissemination of multiple novel closure technologies,including through-the-scope clips,over-the-scope clips,through-the-scope suturing and over-the-scope suturing devices.In this editorial,we comment on the recent publication by Wang and colleagues discussing the performance of the double-nylon purse-string suture technique in the closure of large(>3 cm)gastric full-thickness defects.This technique offers a promising,practical and cost-effective approach to closure of large full-thickness defects that can be readily imple-mented across diverse healthcare settings.