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New device allows colonoscopic full-thickness resection of colorectal lesions
Last Updated: 2017-08-23
By Will Boggs MD
NEW YORK (Reuters Health) - A new over-the-scope device allows safe colonoscopic full-thickness resection of colorectal lesions, according to results from the WALL RESECT multicenter trial.
"Every endoscopic resection that cannot be achieved with polypectomy/endoscopic mucosal resection (EMR) but can be achieved with the full-thickness resection device (FTRD) is a procedure saving a patient from surgery!" Dr. Karel Caca from Klinikum Ludwigsburg Medizinische Klinik, in Ludwigsburg, Germany, told Reuters Health by email.
EMR and endoscopic submucosal dissection (ESD) are highly effective for resecting colorectal neoplasms, but they do not allow full-thickness resection without a significant risk of perforation.
Dr. Caca and colleagues from nine centers examined the efficacy and safety of the FTRD over-the-scope system in 181 patients with difficult adenomas, early carcinomas, or subepithelial tumors. The system allows single-step endoscopic full-thickness resection (EFTR) after placement of a modified over-the-scope clip (OTSC).
The target lesion was successfully reached with the FTRD in all patients, and resection was technically successful in 162 patients (89.5%).
Resection was reported to be difficult in 28 procedures, including 13 due to dysfunction of the snare and 15 due to difficult incorporation of lesion into the cap.
The overall rate of histologically complete resection (R0) was 77% (139/181), with R0 rates significantly lower for lesions >20 mm (58.1%) than for lesions 20 mm or smaller (81.2%), the researchers report in Gut, online August 10.
Eighteen patients experienced procedure-related adverse events, including six (3.3%) in whom perforation occurred. Four patients (2.2%) required surgery due to procedure-related adverse events.
At endoscopic follow-up after three months, the clip had spontaneously detached from the colonic wall in 68.8% of patients, and in 10 cases the clip was endoscopically removed.
Residual lesions were observed in 12.3% of patients who had biopsies taken from the resection site. Patients without evidence of residual lesion were scheduled for further follow-up, usually at three years. Patients with residual lesions had earlier follow-up (median, 162 days).
Cure rates were low in the subgroup of patients with carcinomas: 13 patients had curative resection of carcinomas, but 16 patients had incurative resection.
Besides the patients who required surgery for procedure-related adverse events, 11 patients underwent oncological resection due to incurative carcinoma, two patients were referred to surgery due to unsuccessful EFTR, and three patients required surgery due to residual/recurrent adenoma after EFTR that could not be retreated endoscopically.
The researchers note the peristent technical limitations to EFTR: advancing the FTRD to the target lesion can be difficult; visibility during resection can be impaired by the long cap; and the maximum size of lesions that can be successfully resected is limited.
"Further studies are necessary to investigate the role of EFTR for lesions >2 cm and to evaluate long-term outcome," the team concludes.
"Interventional endoscopy is picking up speed, replacing more and more surgical procedures - for the sake of the patients," Dr. Caca said.
Ovesco Endoscopy, which makes the system, provided financial support for the study and lecture fees to two of the 16 authors, including Dr. Caca.