Endoscopic full-thickness resection for early colorectal cancer

Published:January 14, 2019DOI:

      Background and Aims

      Current international guidelines recommend endoscopic resection for T1 colorectal cancer (CRC) with low-risk histology features and oncologic resection for those at high risk of lymphatic metastasis. Exact risk stratification is therefore crucial to avoid under-treatment as well as over-treatment. Endoscopic full-thickness resection (EFTR) has shown to be effective for treatment of non-lifting benign lesions. In this multicenter, retrospective study we aimed to evaluate efficacy, safety, and clinical value of EFTR for early CRC.


      Records of 1234 patients undergoing EFTR for various indications at 96 centers were screened for eligibility. A total of 156 patients with histologic evidence of adenocarcinoma were identified. This cohort included 64 cases undergoing EFTR after incomplete resection of a malignant polyp (group 1) and 92 non-lifting lesions (group 2). Endpoints of the study were: technical success, R0-resection, adverse events, and successful discrimination of high-risk versus low-risk tumors.


      Technical success was achieved in 144 out of 156 (92.3%). Mean procedural time was 42 minutes. R0 resection was achieved in 112 of 156 (71.8%). Subgroup analysis showed a R0 resection rate of 87.5% in Group 1 and 60.9% in Group 2 (P < .001). Severe procedure-related adverse events were recorded in 3.9% of patients. Discrimination between high-risk versus low-risk tumor was successful in 155 of 156 cases (99.3%). In Group 1, 84.1% were identified as low-risk lesions, whereas 16.3% in group 2 had low-risk features. In total, 53 patients (34%) underwent oncologic resection due to high-risk features whereas 98 patients (62%) were followed endoscopically.


      In early colorectal cancer, EFTR is technically feasible and safe. It allows exact histological risk stratification and can avoid surgery for low-risk lesions. Prospective studies are required to further define indications for EFTR in malignant colorectal lesions and to evaluate long-term outcome.

      Graphical abstract


      CRC (colorectal cancer), EFTR (endoscopic full-thickness resection), ESD (endoscopic submucosal dissection), FTRD (full-thickness resection device), R0 (microscopically complete resection), T1 (Tumor stage according to TNM classification)
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      1. Colorectal cancer: fact sheet 2018, The Global Cancer Observatory. Available at: Accessed September 18, 2018.

        • Fisher D.A.
        • Shergill A.K.
        • Early D.S.
        • et al.
        • ASGE Standards of Practice Committee
        Role of endoscopy in the staging and management of colorectal cancer.
        Gastrointest Endosc. 2013; 78 (Erratum in: Gastrointest Endosc 2013;78:559): 8-12
        • Ferlitsch M.
        • Moss A.
        • Hassan C.
        • et al.
        Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
        Endoscopy. 2017; 49: 270-297
        • Tanaka S.
        • Kashida H.
        • Saito Y.
        • et al.
        JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection.
        Dig Endosc. 2015; 27: 417-434
        • Aepli P.
        • Criblez D.
        • Baumeler S.
        • et al.
        Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): clinical experience from two tertiary referral centers in Switzerland.
        United European Gastroenterol J. 2018; 6: 463-470
        • Andrisani G.
        • Pizzicannella M.
        • Martino M.
        • et al.
        Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: a single-centre study.
        Dig Liver Dis. 2017; 49: 1009-1013
        • Fähndrich M.
        • Sandmann M.
        Endoscopic full-thickness resection for gastrointestinal lesions using the over-the-scope clip system: a case series.
        Endoscopy. 2015; 47: 76-79
        • Richter-Schrag H.J.
        • Walker C.
        • Thimme R.
        • et al.
        Full thickness resection device (FTRD). Experience and outcome for benign neoplasms of the rectum and colon. [German].
        Chirurg. 2016; 87: 316-325
        • Schmidt A.
        • Bauerfeind P.
        • Gubler C.
        • et al.
        Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience.
        Endoscopy. 2015; 47: 719-725
        • Schmidt A.
        • Beyna T.
        • Schumacher B.
        • et al.
        Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications.
        Gut. 2018; 67: 1280-1289
        • Valli P.V.
        • Mertens J.
        • Bauerfeind P.
        Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD®).
        Surg Endosc. 2018; 32: 289-299
        • Vitali F.
        • Naegel A.
        • Siebler J.
        • et al.
        Endoscopic full-thickness resection with an over-the-scope clip device (FTRD) in the colorectum: results from a university tertiary referral center.
        Endosc Int Open. 2018; 6: E98-E103
        • Andrisani G.
        • Pizzicannella M.
        • Di Matteo F.M.
        Endoscopic full-thickness resection of synchronous adenocarcinomas of the distal rectum.
        Case Rep Gastroenterol. 2017; 11: 78-84
        • Soriani P.
        • Tontini G.E.
        • Neumann H.
        • et al.
        Endoscopic full-thickness resection for T1 early rectal cancer: a case series and video report.
        Endosc Int Open. 2017; 5: E1081-E1086
        • Wedi E.
        • Orlandini B.
        • Gromski M.
        • et al.
        Full-thickness resection device for complex colorectal lesions in high-risk patients as a last-resort endoscopic treatment: initial clinical experience and review of the current literature.
        Clin Endosc. 2018; 51: 103-108
        • Asayama N.
        • Oka S.
        • Tanaka S.
        • et al.
        Endoscopic submucosal dissection as total excisional biopsy for clinical T1 colorectal carcinoma.
        Digestion. 2015; 91: 64-69
      2. Ito S, Hotta K, Imai K, et al. Treatment strategy for local recurrences after endoscopic resection of a colorectal neoplasm. Surg Endosc. Epub 2018 Jul 24.

        • Hassan C.
        • Repici A.
        • Sharma P.
        • et al.
        Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis.
        Gut. 2016; 65: 806-820
        • Kuroki Y.
        • Hoteya S.
        • Mitani T.
        • et al.
        Endoscopic submucosal dissection for residual/locally recurrent lesions after endoscopic therapy for colorectal tumors.
        J Gastroenterol Hepatol. 2010; 25: 1747-1753
        • Kikuchi R.
        • Takano M.
        • Takagi K.
        • et al.
        Management of early invasive colorectal cancer. Risk of recurrence and clinical guidelines.
        Dis Colon Rectum. 1995; 38: 1286-1295
        • Yoda Y.
        • Ikematsu H.
        • Matsuda T.
        • et al.
        A large-scale multicenter study of long-term outcomes after endoscopic resection for submucosal invasive colorectal cancer.
        Endoscopy. 2013; 45: 718-724
        • Ahlenstiel G.
        • Hourigan L.F.
        • Brown G.
        • et al.
        • Australian Colonic Endoscopic Mucosal Resection (ACE) Study Group
        Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon.
        Gastrointest Endosc. 2014; 80: 668-676
        • Ishiguro A.
        • Uno Y.
        • Ishiguro Y.
        • et al.
        Correlation of lifting versus non-lifting and microscopic depth of invasion in early colorectal cancer.
        Gastrointest Endosc. 1999; 50: 329-333
        • Overwater A.
        • Kessels K.
        • Elias S.G.
        • et al.
        • Dutch T1 CRC Working Group
        Endoscopic resection of high-risk T1 colorectal carcinoma prior to surgical resection has no adverse effect on long-term outcomes.
        Gut. 2018; 67: 284-290
      3. Däster S, Eppenberger-Castori S, Hirt C, et al. High frequency of CD8 positive lymphocyte infiltration correlates with lack of lymph node involvement in early rectal cancer. Dis Markers. Epub 2014 Dec 30.

        • Ling A.
        • Löfgren-Burström A.
        • Larsson P.
        • et al.
        TAP1 down-regulation elicits immune escape and poor prognosis in colorectal cancer.
        Oncoimmunology. 2017; 6: e1356143

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