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ENDOSCOPIC KNIFE-ASSISTED FULL-THICKNESS RESECTION OF A DEEPLY INVASIVE RECTAL CANCER USING A COMBINATION OF POCKET-CREATION AND SALINE-IMMERSION TECHNIQUES

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Introduction

In patients with rectal cancer, deep submucosal invasion is not an independent risk factor for lymph node metastasis (absolute risk: 2.6%). [1] Total mesorectal excision is associated with high rates of morbidity (12.1%-13.4%) mortality (1%–1.5%) and recurrence (3%–6%).[2,3] Valuable options include Transanal minimally invasive surgery (TAMIS) [4], endoscopic full-thickness resection (FTR) using a dedicated device for rectal lesions up to 20 mm[5] and endoscopic intermuscular dissection (EID) for distal rectal lesions. [6] We describe a case of endoscopic knife-assisted FTR for a deeply invasive T1 proximal rectal cancer.

Aims & Methods

A 61-year-old patient with concomitant esophageal (cT2N0M0) and pharyngeal (cT3N2M0) squamous cell cancers in treatment with chemo-radiotherapy was referred with a incidentally detected rectal lesion. Endoscopy showed a sessile 25-mm proximal rectal lesion with a demarcated and slightly depressed central area (Paris 0-Is+IIc, JNET-3). MRI raised suspicion of muscularis propria involvement. Following a multidisciplinary team discussion, endoscopic resection was chosen considering the patient's active oncologic comorbidities. Due to the lesion size, using a FTR device was not feasible, and EID was unsuitable for the proximal rectum.
Therefore, endoscopic submucosal dissection (ESD) with knife-assisted FTR was performed. Initially, a pocket-creation method was used to reach and assess the point of deepest invasion at the center of the lesion. Loss of the dissection plane due to the lesion adhering to the muscularis propria at its center (revealed by saline-immersion in the pocket) necessitated FTR. Thus, a circular mucosal incision was made, followed by trimming and submucosal dissection to isolate the central deep invasion. Clips, rubber bands, and surgical wires were used to apply traction and enhance access to the resection plane. A full-thickness resection of the muscularis propria with the electrosurgical knife around the center of the lesion was performed. The resection defect was carefully washed with sterile saline and closed with clips. Antibiotic peri-procedural prophylaxis was administered.

Results

The post-procedural course was uneventful, and the patient was discharged home 24 hours after the resection. Histopathology revealed R0 resection of a low-grade intestinal-type adenocarcinoma with a central deep submucosal invasion in contact with the muscular layer without muscularis propria involvement, tumor budding, or perineural invasion (pT1, Kikuchi level sm3). Focal lymphovascular invasion was observed. Given the patient's clinical status endoscopic and radiologic follow-up was advised by a multi-disciplinary team.

Conclusion

The staged approach of pocket creation, assessment of deep SMI and planned endoscopic knife-assisted FTR for a deeply invasive T1 proximal rectal cancer was safe and effective, allowing for R0 deep resection margins.

References

[1] Zwager LW, et al. Deep Submucosal Invasion Is Not an Independent Risk Factor for Lymph Node Metastasis in T1 Colorectal Cancer: A Meta-Analysis. Gastroenterology. 2022
[2] van Oostendorp SE, et al. Local recurrence after local excision of early rectal cancer: a meta-analysis of completion TME, adjuvant (chemo)radiation, or no additional treatment. Br J Surg. 2020
[3] Liu H, et al.; Chinese Transanal Endoscopic Surgery Collaborative (CTESC) Group. Morbidity, Mortality, and Pathologic Outcomes of Transanal Versus Laparoscopic Total Mesorectal Excision for Rectal Cancer Short-term Outcomes From a Multicenter Randomized Controlled Trial. Ann Surg. 2023
[4] Atallah S, Albert M, Larach S. Transanal minimally invasive surgery: a giant leap forward. Surg Endosc. 2010
[5] Dolan RD, et al. Endoscopic full-thickness resection of colorectal lesions: a systematic review and meta-analysis. Gastrointest Endosc. 2022
[6] Moons LMG, et al. Endoscopic intermuscular dissection for deep submucosal invasive cancer in the rectum: a new endoscopic approach. Endoscopy. 2022

Disclosure

DJT Consulting and research founding Olympus, Fujifilm, Pentax

ENDOSCOPIC KNIFE-ASSISTED FULL-THICKNESS RESECTION OF A DEEPLY INVASIVE RECTAL CANCER USING A COMBINATION OF POCKET-CREATION AND SALINE-IMMERSION TECHNIQUES

Maria Eva Argenziano 1, Andrea Sorge 2, Pieter Jan Poortmans 3, Sander Smeets 4, Michele Montori 1, Liesbeth Ferdinande 5, Anne Hoorens 5, Lynn Debels 6, Tamás Tornai 4, Lobke Desomer 7, David James Tate 4

1 University Hospital Ghent, Gent, Belgium|||Clinic of Gastroenterology, Hepatology, and Emergency Digestive Endoscopy, Ancona, Italy

2 University Hospital Ghent, Gent, Belgium|||University of Milan, Milan, Italy

3 University Hospital Ghent, Gent, Belgium|||Vrije Universiteit Brussel, Jette, Belgium

4 University Hospital Ghent, Gent, Belgium

5 University Hospital Gent, Gent, Belgium

6 Vrije Universiteit Brussel, Jette, Belgium

7  AZ Delta campus Rumbeke, Roeselare, Belgium

Event

UEG Week Vienna 2024

Topics

Colorectal

Submission format

Video Case

Session

Video Cases

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

UEG Podcast Episode

UEG Podcast

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Management of gastric preneoplastic lesions (MAPS 3) - what’s new? With Mario Dinis-Ribeiro (Part 1)

Mario Dinis-Ribeiro, Pradeep Mundre

Topics

Stomach & H. Pylori

Published

2025

UEG Mistakes In Articles

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Crohn’s disease (CD) is a chronic inflammatory bowel condition that can present with a wide range of intestinal and extra-intestinal manifestations. This condition can develop at any age and have a significant impact and impairment on quality of life for individuals including on relationships, educational attainment and work productivity. In particular, the time around and after diagnosis often involves the most upheaval for patients, and equally the biggest opportunity for effective intervention. Several recent advances have had a major impact on optimal management of patients with newly diagnosed CD. Here, we discuss the mistakes that are commonly made when managing patients presenting with a new diagnosis of CD. We summarise the evidence base and offer helpful and pragmatic tips for practising clinicians.

Mistakes in newly diagnosed Crohn's disease and how to avoid them

Joana Roseira, Nurulamin Noor

Topics

IBD

Citation

Roseira J and Noor N. Mistakes in newly diagnosed crohn's disease and how to avoid them. UEG Education 2025; 25: 18-23.

Published

2025

UEG Podcast Episode

UEG Podcast

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AI Essentials: Lower GI (UEG Talks rewind)

Louis Liu, Alanna Ebigbo, Pradeep Mundre

Topics

Endoscopy

Published

2025

UEG Mistakes In Articles

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Barrett’s oesophagus is the precursor to oesophageal adenocarcinoma, which carries a poor prognosis, and it is likely that all endoscopists and gastroenterologists will encounter Barrett’s oesophagus in their clinical practice. Careful assessment and management of patients who have Barrett’s oesophagus with endoscopic surveillance and endoscopic endotherapy aim to reduce the risk of progression to invasive adenocarcinoma. Advances in endoscopic diagnosis and therapy should, therefore, help to reduce the risk of progression. As with all premalignant conditions and surveillance programmes, careful multidisciplinary management of the patient is important to reduce the risk of causing them to become unduly concerned. Here, we present some mistakes that in our experience are commonly made in the endoscopic diagnosis and management of Barrett’s oesophagus and give advice on how to avoid them.

Mistakes in the endoscopic diagnosis and management of Barrett’s oesophagus and how to avoid them

Apostolis Papaefthymiou, Cormac Magee, Rehan Jamil Haidry

Topics

Endoscopy Oesophagus

Citation

Haidry RJ and Magee C. Mistakes in the endoscopic diagnosis and management of Barrett’s oesophagus and how to avoid them. UEG Education 2018; 2018: 12–14.

Published

2024

UEG Mistakes In Articles

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Gastric polyps are usually asymptomatic, with more than 90% found incidentally and a prevalence of up to 6% at upper endoscopy. Fundic gland polyps (FGPs) are the gastric polyps most frequently seen in the Western world, largely due to their long-established association with proton pump inhibitor (PPI) usage. In countries where Helicobacter pylori infection is prevalent an endoscopist is more likely to encounter hyperplastic polyps and adenomas, which are known to be associated with a higher malignant potential. Gastric polyps are often regarded as the ‘poor relation’ to their colonic counterparts and as such clinicians often feel unsure how to identify, assess and appropriately manage these lesions. Endoscopists often lack confidence in the endoscopic characterisation of gastric polyps, feel unsure when to biopsy polyps and, if they are biopsying polyps, how many they should sample, and finally they are not always certain what the longer-term management is. The British Society of Gastroenterology (BSG) guidelines provide a useful flowchart and overview of the management of gastric polyps, and the discussion here is based on those guidelines, guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and 12 years of clinical experience.