Concerns about the study of Yzet et al. on treatment of residual colorectal neoplasia after endoscopic resection

We read with great interest the article by Yzet et al. [1], which analyzed the efficacy and safety of endoscopic submucosal dissection (ESD) or the full-thickness resection device (FTRD) in the treatment of residual colorectal neoplasia. We agree that both ESD and the FTRD are useful for treating residual colorectal neoplasia, with ESD being more effective; however, we have several concerns about this study.

First, the description of the patients’ original disease is insufficient, especially in terms of the depth of invasion and the presence of lymph node metastasis for cancerous lesions. This is crucial for R0 resection and recurrence rates after ESD or EFTR for residual colorectal tumors.

In addition, the FTRD system is stated to be capable of resecting fibrous lesions of 5–30 mm, depending on the softness of the tissue in the sections; however, in this study, it was also reported as being effective for lesions measuring 30–40 mm. Careful patient selection has been shown to be essential for successful EFTR resection [2]. We wonder whether these larger lesions exceeded the indications for EFTR, thereby resulting in a lower R0 resection rate and a higher recurrence rate. Is it appropriate to apply EFTR in this group?

Furthermore, the adverse events in this study included perforation and bleeding, but should the postoperative infection rate and duration of hospitalization also have been included as adverse events? Notably EFTR wounds are sutured, while ESD wounds are exposed. EFTR requires more extensive resection, increasing the risk of failure to close defects [3], plus patients tend to have longer hospital stays after EFTR treatment [4] and postoperative infections are a common adverse event [5].

Finally, it is worth noting that the choice between the two procedures under consideration was at the physician's discretion, which may have introduced some degree of selection bias.

In conclusion, despite some inherent limitations of this study, ESD and EFTR remain viable treatment options for residual colorectal neoplasia.

Publication History

Article published online:
29 August 2024

• References

• 1 Yzet C, Le Baleur Y, Albouys J. et al. Use of endoscopic submucosal dissection or full-thickness resection device to treat residual colorectal neoplasia after endoscopic resection: a multicenter historical cohort study. Endoscopy 2023; 55: 1002-1009 DOI: 10.1055/a-2116-9930. (PMID: 37500072)
• 2 Høgh A, Deding U, Bjørsum-Meyer T. et al. Endoscopic full-thickness resection (eFTR) in colon and rectum: indications and outcomes in the first 37 cases in a single center. Surg Endosc 2022; 36: 8195-8201 DOI: 10.1007/s00464-022-09263-1. (PMID: 35536486)
• 3 Dalal I, Andalib I. Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER). Transl Gastroenterol Hepatol 2022; 7: 19 DOI: 10.21037/tgh-2020-10. (PMID: 35548477)
• 4 Chiu PWY, Yip HC, Chan SM. et al. Endoscopic full-thickness resection (EFTR) compared to submucosal tunnel endoscopic resection (STER) for treatment of gastric gastrointestinal stromal tumors. Endosc Int Open 2023; 11: E179-E186 DOI: 10.1055/a-1972-3409. (PMID: 36845271)
• 5 Antonino G, Alberto M, Michele A. et al. Efficacy and safety of gastric exposed endoscopic full-thickness resection without laparoscopic assistance: a systematic review. Endosc Int Open 2020; 8: E1173-E1182