Successful endoscopic full-thickness resection and hand suturing for rectal subepithelial tumors

The efficacy of endoscopic full-thickness resection (EFTR) for a rectal subepithelial tumor is a known fact [1] [2] [3]; however, the provision of a secure closure still remains debatable. We report two successful cases of EFTR in which endoscopic hand suturing was employed to close a full-thickness defect.

Case 1: A 75-year-old man was referred for the endoscopic diagnosis and treatment of a rectal subepithelial tumor. Endoscopic ultrasonography-assisted fine-needle aspiration revealed a gastrointestinal stromal tumor (GIST). Case 2: A 77-year-old woman with an 8-mm rectal neuroendocrine tumor (NET) was referred to our department ([Fig. 1] a). EFTR was chosen since endoscopic ultrasonography indicated a suspected continuity between the tumor and the muscularis propria. Removal of lesions from both patients was performed en bloc in a full-thickness fashion ([Video 1], [Fig. 1] b). Subsequently, endoscopic hand suturing was performed using V-loc absorbable barbed sutures (Covidien, Mansfield, Massachusetts, USA) and a flexible needle holder (SutuArt; Olympus, Tokyo, Japan). In Case 1, a mucosal clipping was performed after a muscular-layer suturing by endoscopic hand suturing. In Case 2, a complete muscular-layer suturing was followed by a mucosal suturing in a turned-back fashion due to sufficient residual suture ([Video 1], [Fig. 1] c–e). The procedures required 75 min for excision and 60 min for closure in Case 1; and 19 min for excision and 39 min for closure in Case 2, respectively. Both patients were able to resume their diet on postoperative day 1 and were discharged on postoperative day 3. No postoperative adverse events were observed in either patient. Pathological examination confirmed the complete resection of the low-risk GIST and NET, respectively.

Fig. 1 Rectal endoscopic full-thickness resection followed by a closure with endoscopic hand suturing (Case 2). a The rectal neuroendocrine tumor: Circumferential mucosal incision and submucosal dissection were performed. b A full-thickness defect was created. c The muscular layers were sutured using the endoscopic hand suturing technique. d Muscular layers can be selectively sutured from right to left. The mucosal layers were subsequently continuously sutured from left to right. e The full-thickness defect was completely closed.

Endoscopic hand suturing was performed for the full-thickness defect following the removal of a rectal gastrointestinal stromal tumor (Case 1) and neuroendocrine tumor (Case 2).Video 1

As documented in our report on similar suturing techniques for gastric subepithelial lesions [4], a safe and reliable EFTR for rectal subepithelial tumors is achieved for a full-thickness defect. This technique needs further validation through additional clinical experiences.

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Publication History

Article published online:
14 October 2024

• References

• 1 Rajan E, Song LM. Endoscopic full thickness resection. Gastroenterology 2018; 154: 1925-1937
• 2 Boger P, Rahman I, Hu M. et al. Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry. Eur J Gastroenterol Hepatol 2021; 33: 852-858
• 3 Milatiner N, Khan M, Mizrahi M. Getting the gist of GI stromal tumors: diving deeper than endoscopic submucosal dissection. VideoGIE 2023; 8: 239-241
• 4 Goto O, Koizumi E, Higuchi K. et al. Endoscopic full-thickness resection with double-layer closure by endoscopic hand suturing for a gastric subepithelial tumor. Endoscopy 2022; 54: E964-E965