Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection

Abstract

Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices.

Figure 1

Endoscopic closure of an artificial ulcer with conventional clips and an OTSC system. (a) A large tumor, measuring 55 mm in diameter, located in the upper rectum. (b) A large mucosal defect after colorectal ESD. (c) Complete closure was performed using an OTSC system. (d) The endoscopic view at postoperative day 333.

Figure 2

Difficult lesions with endoscopic treatment. (a) Deeper invasion of the submucosa in colorectal cancer. (b) A laterally spreading tumor occupying more than one-third of the bowel circumference or spanning more than two haustral folds. (c) Remnant lesion. (d) A large pedunculated polyp.

Figure 3

EFTR using ESD devices. (a) The mucosa was cut circumferentially, and the submucosal layer was then cut. (b) Next, we created a small hole in the muscular layer using a needle-type knife. (c) Equidistant small dots enabled the correct resection of the muscular layer using the ITknife.

Figure 4

(a) Double-armed bar suturing system (DBSS). (b) Endoscopic view by using mechanical counter traction device. (c) Endoscopic suturing in animal experimental model.