Endoscopic local resection is increasingly regarded as a feasible alternative to radical
surgery for specific early rectal cancer patients, preserving organ function and reducing
the
incidence of complications [1]
[2]. However, the safe closure of large full-thickness defects after local full-thickness
resection remains challenging [3]. This report describes a novel solution – the application of super minimally invasive
stepwise full-thickness resection combined with an intermittent double-layer closure
technique.
Stepwise full-thickness resection is a new technique that combines endoscopic submucosal
dissection (ESD) with direct full-thickness resection, using the exposed muscular
layer after
ESD for the first layer of closure; then, the second layer of closure is performed
from mucosa
to mucosa.
The patient was an 81-year-old female admitted for early rectal cancer. After a comprehensive
assessment, she underwent super minimally invasive stepwise full-thickness resection
and the defect was successfully closed using the intermittent double-layer closure
technique ([Fig. 1], [Video 1]). The mucosal layer around the lesion was circumferentially resected and trimmed
to the submucosa ([Fig. 1]
a). The intrinsic muscular layer was fully exposed using the tissue clip―rubber band-assisted
traction technique ([Fig. 1]
b). Under a clear field of vision, the location of the central cancer focus was determined,
and the muscular layer was incised until the rectal mesenteric fat tissue was visible.
The full-thickness resection was performed at this site, leaving a defect of approximately
2.5 cm × 2.2 cm, with the full-thickness defect being about 2.0 cm × 1.6 cm ([Fig. 1]
c, d). After hemostasis with electrocautery and cauterization of the wound edge, several
tissue clips were used to align and suture the muscular layer to the muscular layer
([Fig. 1]
e). The wound surface narrowed after the muscular layer closure, and then, the mucosal
layer to mucosal layer was aligned and sutured in the same way, ultimately achieving
a tight closure of the wound ([Fig. 1]
f). The lesion size was recorded from the serosal layer and the mucosal layer, respectively
([Fig. 1]
g, h). The patient had no postoperative bleeding or delayed perforation and was discharged
after one week of recovery.
Fig. 1 The technical steps of intermittent double-layer closure of the wound after super
minimally invasive stepwise full-thickness resection for early rectal cancer. a The mucosal layer was circumferentially incised with an electrocautery knife, and
part of the submucosal layer was stripped. b Tissue clip and rubber band were used to assist in traction, fully exposing the muscular
layer. c After incising the muscular layer, the lesion was resected in full thickness. Extra-luminal
adipose tissue was visible in the surgical area (arrow). d Postoperative wound surface after full-thickness resection of the lesion. e The wound surface of the intrinsic muscular layer was closed with tissue forceps.
f The wound surface of the mucosal layer was closed with tissue forceps, achieving
complete wound closure. g Observation of the serosal surface of the gross specimen, approximately 2.0 cm ×
1.6 cm in size. h Observation of the mucosal surface of the gross specimen, approximately 2.5 cm ×
2.2 cm in size.
Intermittent double-layer closure for full-thickness defect after super minimally
invasive stepwise resection of early rectal cancer.Video 1
The super minimally invasive stepwise resection combined with intermittent double-layer
closure technique can improve the safety of local resection for digestive tract tumors
and is a feasible and effective method. By double-layer suturing of the intrinsic
muscular layer and mucosal layer, it can minimize dead space to the greatest extent,
potentially reduce the risk of infection, and promote healing.
Endoscopy_UCTN_Code_TTT_1AQ_2AK
E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/).
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos.
