Commentary

Endoscopic full-thickness resection (EFTR) is increasingly used for local resection of suspected T1 colorectal carcinoma (CRC), completing scar excision after an R1/Rx resection of pT1 CRC, and for nonlifting residual or recurrent adenoma. The technique has some important advantages such as an en bloc resection for optimal histological evaluation, the high chance of obtaining an R0 resection especially at the vertical margin, and the technical ability to remove complex polyps by endoscopy, where more conventional techniques would likely fail. Recent publications including large cohorts have shown that the EFTR technique is both safe and effective in a large number of selected and deemed suitable cases.

With growing experience with EFTR, the borders are being pushed to more difficult locations such as for polyps on the ileocecal valve. Although only the tissue held by the grasping forceps should be included in the over-the-scope (OTS) clip, there is a fear that the proximal lip could be drawn into the OTS clip, especially when suction is additionally used, resulting in complete closure of the ileocecal valve. In this video case presented by Meiborg and colleagues, the authors used a 7-Fr double-pigtail catheter to prevent complete closure of the valve. This may be a helpful auxiliary technique to support successful EFTR of polyps on the ileocecal valve. The EFTR technique has some “blind spot” moments where control of what tissue is grasped in the OTS clip is limited. During EFTR, the tissue is pulled into the cap with a grasping forceps, as far as possible but to a level that the white ring of the full-thickness resection device system can still be visualized to assure successful placement of the OTS clip. The overview is already limited by the cap itself, but disappears to a considerable degree once the tissue has been pulled into the cap. The double-pigtail catheter may push the proximal lip away from the cap. However, in the part of the video where the tissue was pulled into the cap, the pigtail catheter itself was not visualized against the cap. So it remains uncertain whether it rather helps in locating the ileocecal valve just prior to grasping the target tissue with the forceps, or whether it really pushes the proximal valve away during OTS clip placement. It is also questionable whether placement of the double-pigtail catheter is necessary when only the pulling technique is used rather than applying suction: with suction, adjacent tissue may also be drawn into the cap but this is unlikely to occur when only traction is used. Although suction facilitates successful inclusion of target tissue into the cap, it adds another uncontrolled component to the EFTR. However, placement of the double-pigtail device is simple, and if deemed to be needed to prevent complete closure, it is easy to apply.

One could debate, however, whether EFTR should be the technique of first choice to remove treatment-naïve noninvasive 20-mm polyps in the proximal colon. Previous reports have shown that endoscopic mucosal resection (EMR) can be highly successful in these locations, and is much cheaper, more widely available, and associated with a lower risk of complications.

Publication History

Article published online:
25 May 2023