Clinical Case Summary

Introduction

Among the various forms of NOTES (Natural Orifice Transluminal Endoscopic Surgery), Endoscopic Full-Thickness Resection (EFTR) is a minimally invasive endoscopic surgical technique that allows radical resection of epithelial neoplasia with significant fibrosis or suspected deep submucosal invasion.
We describe our initial experience with non-tunnelled exposed EFTR for rectal lesions, with subsequent closure of the defect using an endoscopic suturing device.

Aims & Methods

We performed a retrospective analysis of 11 consecutive patients treated at our centre with non-tunnelled exposed EFTR for removal of 11 lesions located in the distal rectum, below the peritoneal reflection. Indications included 7 recurrences of previous mucosectomy, 1 large circumferential lesion without evidence of submucosal invasion, 2 lesions with suspected submucosal invasion (without imaging evidence of overt muscular invasion) and 1 T3 N0 adenocarcinoma of the pelvic RM treated with neoadjuvant radiotherapy in a patient unfit for surgery. The transmural defect was closed by endoscopic suturing.
Technical success, safety and R0 resection were evaluated.

Results

All lesions were successfully treated by EFTR and no intraoperative or postoperative complications were observed.
EFTR was R0 in 8/11 patients: 1 patient underwent surgery due to high risk of lymph node metastasis.
In 3/11 patients EFTR was R1: in 2 patients the vertical margins were involved by neoplastic tissue and the patients underwent surgery, in 1 patient only the horizontal margins were involved and no endoscopic or histological evidence of recurrence was seen at 12 months.
EFTR proved to be curative in 8 out of 11 patients.

Conclusion

Our initial experience shows that rectal EFTR is a feasible and safe technique, useful for resection of complicated lesions with curative or at least diagnostic intent. Larger randomised trials are needed to better define the clinical benefits and long-term outcomes of rectal EFTR in selected patients.

Clinical Case Summary

Background: Colorectal anastomotic strictures affect up to 30% of colorectal cancer surgery patients, but complete obstruction is rare. Endoscopic approaches, relying on successful guidewire passage through the stenosis followed by dilation or stent placement, may avoid surgical revision. In cases of insurmountable strictures in patients with colostomy, guidewire passage under endoscopic ultrasound (EUS) or direct endoscopic guidance, using transillumination, can be considered.
Methods: A 78-year-old underwent urgent high anterior resection with a transverse loop colostomy due to an occlusive rectal tumor. By postoperative day 8, he had anastomotic leakage, requiring reintervention. Ten months post-surgery, colonoscopy showed a complete unnegotiable anastomotic stricture. A pediatric colonoscope was inserted through the colostomy, and a therapeutic gastroscope was introduced via the rectum, both advanced to opposing sides of the stricture. Fluoroscopic confirmation of scope positions was followed by transillumination-guided puncture of the colonic side of the stricture with a 6 Fr cystotome. A guidewire was passed through the fistula and retrieved using forceps in a rendezvous manner. Balloon dilation of the fistula up to 4 mm enabled the deployment of a 16x20 mm lumen-apposing metal stent (LAMS). Contrast medium injection confirmed the correct positioning and patency of the LAMS. The patient was discharged home on the same day.
Results: At the 3-month follow-up sigmoidoscopy, the anastomosis was patent, while the stent had migrated and was removed. Colostomy reversal was successfully performed one day later. At the 6-month follow-up, the patient reported regular bowel movements without any residual symptoms.
Conclusion: Freestyle puncture of the excluded rectum using a cystotome followed by LAMS apposition during a dual endoscopic-fluoroscopic procedure seems to be a safe and effective treatment for recanalizing complete colorectal anastomotic strictures.

References

Clinical Case Summary

A 76-year-old male patient was referred to our Centre for investigation of hematochezia since one month. He had a medical history of arterial hypertension, type 2 diabetes mellitus and hypercholesterolaemia. His daily therapy regimen includes dapaglifozin, metformin, ramipril and omegastatin. Except for mild, normochromic, normocytic anemia (haemoglobin 12.8 g/dL), elevated fibrinogen (531 mg/dL), glucose (136 mg/dL) and creatinine (1.6 mg/dL), his routine blood work was normal.
Colonoscopy revealed a 20 mm granular homogeneous lateral spreading tumor (LST) of the caecum, a 25 mm pedunculated polyp of the sigma and several flat, raised formations of brownish appearance, ranging between 5 and 30 mm of the rectum. All lesions were removed en bloc using diatermic and cold snare.
The histopathological examination revealed LST and the pedunculated polyp as tubulo-villous adenomas with high grade dysplasia; flat lesions were described as “flaps of colic mucosa with micronodular accumulations of histiocytes in the lamina propria and associated presence of calcific spheroid bodies with concentric lamellar architecture with a target arrangement (Michaelis-Gutman bodies), compatible with malacoplakia”. It is a rare inflammatory condition typically affecting diabetic or immunocompromised patients, caused by a macrophagic dysfunction that results in incomplete digestion of phagocytosed bacteria which, in turn, accumulate in the cell cytoplasm producing a granulomatous reaction. Apart from the genito-urinary tract, the gastrointestinal tract, particularly the sigmoid colon and rectum, represents the second most commonly affected area. Colorectal malakoplakia is usually an incidental finding, often found in association with adenomas and adenocarcinomas. Malacoplakia is a benign, self-limiting disease; however, its endoscopic aspect can range from polyps to lumps or plaques and it could enter in the differential diagnosis with other diseases or advanced cancers.

Introduction

Treatment of complex fistula and residual anastomotic insufficiencies remain a challenge even in an interdisciplinary setting. Endoscopic standard techniques for closure like clips, OTSC or SEMS are limited to special indications. Endoscopic suturing may offer an approach to close complex fistula orifices.

Aims & Methods

Endoscopic suturing was used for interventional closure of complex insufficiencies in the lower GI-tract. 5 consecutive patients were treated using standard Endosuturing (SutuArt, Olympus) or modified suture strategy using an additional working channel (ACEES). In three patients residual insufficiencies in the rectum were visible after complex vacuum therapy. In one patient a recto-vaginal fistula was clinical apparent. In one patient an iatrogenic perforation was occurred within dilation therapy for anastomotic stenosis. Due to size or location of the defects a standard closure technique was either not applicable or failed in a prior attempt.

Results

Technical success, defined as macroscopic defect closure, was achievable in 5 of 5 patients. Mean time for intervention was 57(±14)min. For 3 patients bimanual work using additional working channel enhanced endoscopic suturing (ACEES) was performed. In endoscopic surveillance permanent closure was achieved in 4 of 5 patients.

Conclusion

Endoscopic suturing is a newly available technique. Beyond its basic indication for defect closure after ESD this procedure, also in combination with bimanual suturing (ACEES), may offer an excellent opportunity for treatment of complex fistula.

Disclosure

nothing to disclose

Introduction

Endoscopic hemostasis using clips is widely used as a safe and effective first-line treatment for colonic diverticular bleeding, but rebleeding after hemostasis remains a common issue. In recent years, the Over-the-Scope Clip (OTSC) has gained attention as a new endoscopic treatment device due to its stronger tissue grasping ability and potentially higher hemostatic effectiveness compared to conventional clips. However, clinical cases remain limited, and more evidence is needed. This study evaluates the outcomes of colonic diverticular bleeding treated with OTSC.

Aims & Methods

The purpose of this study was to compare conventional clip hemostasis and additional treatment with OTSC for colonic diverticular bleeding. The subjects were patients at our institution from April 2014 to April 2024 in whom the bleeding source was endoscopically identified and treated. Patients treated with clips alone were classified into the clip group, while those who underwent additional OTSC treatment at the same site after clip treatment to prevent rebleeding were classified into the OTSC group. The clip and OTSC groups included 65 and 11 patients, respectively. There were no significant differences between the groups in terms of sex (female/male: 12/53 vs. 4/7), age (median: 64 [35-96] vs. 70 [53-84]), or anticoagulant use (14/65 vs. 3/11). Rebleeding was defined as the appearance of visible bloody stool after endoscopic treatment, and it was the primary endpoint.

Results

Rebleeding occurred in 33 of 65 cases in the clip group and 0 of 11 cases in the OTSC group, showing a significant difference in rebleeding rate (0% [0/11] vs. 50.0% [33/66]; P < 0.05). Multivariate analysis identified OTSC as an independent preventive factor for rebleeding (p = 0.001). No complications such as bowel perforation, diverticulitis (localized infection), or intestinal stenosis were observed in either group. Furthermore, when comparing costs, including readmissions due to rebleeding, the average cost in the clip group (15 out of 66 cases readmitted) was €5897 ± 3907, with a median of €4302. In the OTSC group (0 readmissions), the average cost was €4580 ± 2143, with a median of €4284, indicating that OTSC treatment was not inferior in cost-effectiveness compared to clip treatment (p = 0.124).

Conclusion

Treatment using OTSC significantly reduced rebleeding compared to conventional clip treatment, demonstrating high safety and comparable cost-effectiveness, suggesting it is an effective treatment method.