Endoscopic Full-Thickness Resection of Subepithelial Lesions of the GI Tract

Introduction

Over the past 15 years, the role of endoscopy in the removal of large and subepithelial lesions has expanded greatly. Whereas expertise in endoscopic submucosal dissection (ESD) has been long established in Asia, the technique has become more widely available in the West. With expanding indications, including the removal of muscularis propria (MP)-originating subepithelial tumors (SETs), the need for a safe and effective method for performing endoscopic full-thickness resection (EFTR) is critical. Suzuki et al (2001) reported on the use of EFTR and endoscopic complete defect closure in one duodenal and two rectal carcinoids, the first English-language report of the technique. Lesions were suctioned and ligated within the cap of the devices, and in the duodenal case, laparoscopic assistance was required for microperforation closure. Since then, a variety of techniques have been reported including those that are laparoscopy-assisted, device-assisted, and those that employ a free-hand approach.

Indications and Contraindications for EFTR

Indications for EFTR are dependent on whether the lesion is in the upper or lower gastrointestinal (GI) tract. The most frequent indication for EFTR is SETs of 5 cm or less in diameter arising from or involving the MP based on endoscopic ultrasound (EUS) or computed tomography (CT) imaging. These lesions are often gastrointestinal stromal tumors (GISTs), and National Comprehensive Cancer Network (NCCN) guidelines recommend removal of known or suspected GISTs that are symptomatic, have high-risk EUS features (including an irregular border, ulceration, cystic spaces, heterogeneity, and echogenic foci), or are greater than or equal to 2 cm in size. Pathologic features that indicate a higher risk of metastasis or recurrence include mitotic index and Ki-67 status. Another indication is recurrence of mucosal lesions following endoscopic mucosal resection (EMR) or ESD at a surgical resection site. Any SET that is symptomatic should also be resected.

Contraindications for EFTR can be divided into patient- and tumor-related factors. Patient-related contraindications include the presence of high surgical risk due to severe comorbidities, including bleeding or coagulation disorders, and severe cardiopulmonary disease; pregnancy; inability to tolerate anesthesia; and anatomic issues that would preclude passage of the EFTR or suturing device. Tumor-related factors that are contraindications are the presence of a large extramural component; tumors with a high risk of lymph node spread or evidence of systemic spread; and features suggestive of aggressive behavior. Notably, carcinomas should be resected with a pre-closure method of EFTR to prevent contamination of the peritioneal cavity with malignant cells.