Organ preservation strategies like “watch-and-wait” are increasingly used in LARC
patients
with cCR/near-cCR postneoadjuvant therapy [1 ]. Local recurrence remains critical, with 14.9–25% incidence within 2 years,
necessitating effective salvage interventions [2 ]. While endoscopic techniques provide super minimally invasive solutions for superficial
tumors [3 ], the management of deep local recurrences involving or penetrating the muscularis
propria presents substantial challenges. We describe an innovative stepwise super
minimally
invasive full-thickness resection (sft-SMIR) technique. A 75-year-old female presented
with LARC
in the low rectum (initial staging: cT2–3N0M0). Following short-course radiotherapy
and two
cycles of chemoradiotherapy, she achieved a near-clinical complete response (ncCR).
After
multidisciplinary discussion, sft-SMIR surgery was performed ([Fig. 1 ], [Video 1 ]). First, the laterally spreading tumor (LST) and scars after neoadjuvant therapy
were
fully exposed, and the lesion area was marked ([Fig. 1 ]
a, b ). Second, ESD was performed in the LST and scar surrounding
areas ([Fig. 1 ]
c ). Third, a traction device of a rubber band and clips was
applied to fully expose the intrinsic muscle layer and deep scar areas at the lesion
site. Then,
the intrinsic muscle layer was incised by an electric knife, and the extracellular
mesorectum
was exposed ([Fig. 1 ]
d ). Fourth, the intrinsic muscle layer after ESD and the
full-thickness defect after EFTR were displayed ([Fig. 1 ]
e ). Finally, the closure of the full-thickness defect was
achieved by using clips to seal the muscle layer against the muscle layer ([Fig. 1 ]
f ). The specimen was fixed and photographed with both sides
([Fig. 1 ]
g, h ). Postoperative pathology suggests intramucosal carcinoma
with curative resection.
Fig. 1 sft-SMIR for LARC after achieving ncCR with neoadjuvant therapy. The feature of LST
and scars after neoadjuvant therapy was revealed under white light endoscopy. The
lesion area was marked. a The mucosal and submucosal layers around the scar and LST were dissected. b The traction device was applied, and the full thickness of the rectum was resected.
c The intrinsic muscle layer and the full-thickness defect were displayed. d The full-thickness defect was closed by sealing the muscularis propria with clips.
e Application of a tissue clamp to seal the muscle layer during full-thickness excision
of the wound. The mucosal layer of the gross specimen was shown. f The serosal layer of the gross specimen was shown. Pathological HE staining slides
of lesions were shown.
Stepwise super minimally invasive full-thickness resection of LARC after neoadjuvant
therapy.Video 1
The sft-SMIR technique (ESD-EFTR integration) provides a feasible, super-minimally
invasive salvage strategy for patients with post-ncCR/cCR. By enabling endoscopically
guided, precise full-thickness resection with controlled dissection, this approach
effectively addresses deep muscularis propria involvement while substantially reducing
unnecessary anal sphincter resection compared to traditional salvage surgery.
Endoscopy_UCTN_Code_CPL_1AJ_2AD_3AF
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