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Full-Thickness-Resection-Device (FTRD)

Die endoskopische Vollwandresektion für das Rektum und Kolon

Full thickness resection device (FTRD)

Experience and outcome for benign neoplasms of the rectum and colon

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Zusammenfassung

Hintergrund

Eine Vollwandresektion im Kolon und Rektum ist einer endoskopischen Submukosadissektion (ESD) im Hinblick auf Kuration, En-bloc-Resektion und R0-Status überlegen. Das Full-Thickness-Device (FTRD, Ovesco, Germany) ist das erste kommerziell erhältliche endoskopische System, das eine peritoneale Verschlusstechnik mit nachfolgender Vollwandresektion in einem Schritt realisiert.

Ziel

In dieser Studie wurde das FTRD in Bezug auf die Effektivität einer histologisch nachgewiesenen Vollwandresektion, den R0-Status und die Sicherheit im Rektum und Kolon überprüft.

Methodik

Zwischen November 2014 und Juni 2015 wurden in unserer interdisziplinären Endoskopie 20 Patienten am Rektum und Kolon mit dem FTRD behandelt und retrospektiv ausgewertet.

Ergebnis

Folgende Indikationen wurden im Rektum (n = 11) und Kolon (n = 9) behandelt: endoskopisch inkomplett abgetragene T1-Karzinome (n = 6) und neuroendokrine Tumoren (n = 2), inkomplett abgetragene tubulovillöse, villöse und serratierte Adenome mit niedrigen und hochgradigen intraepithelialen Neoplasien (n = 9), primäre Adenome (n = 3) ohne Vorbiopsie. Der technische Erfolg lag bei 75 %. Drei technische Versager indizierten in zwei Fällen eine konventionelle und in einem Fall eine operative Nachresektion der duplizierten Darmwand. Eine konventionell beendete Resektion führte zu einer thermischen Spätperforation, die eine Segmentresektion indizierte. In einem Fall konnte die Läsion im Zökum zwar erreicht, aber nicht abgetragen werden. Die histologisch gesicherte Vollwandresektion betrug 60 % (85,7 % im Kolon, 54,6 % im Rektum). R0-Resektionen wurden in 80 % der Patienten erreicht. Zwei Patienten wurden onkologisch reseziert. Die mediane Größe der Resektate betrug 5 cm2 (1,6–12,9 cm2).

Schlussfolgerung

Das FTRD ermöglicht es dem interventionellen Endoskopiker erstmals, Vollwandresektionen des unteren Gastrointestinaltrakts standardisiert, sicher und effektiv durchzuführen. Limitierende Faktoren sind die Größe der Zielläsion, Gewebefibrosierung und die Wandstärke des zu behandelnden Darmabschnitts. Aus diesen Gründen empfiehlt es sich, bereits im Rahmen der Screeningkoloskopie mithilfe spezieller Aufsatzkappen, die dem FTRD entsprechend dimensioniert sein sollten, eine Simulation der Resektion durchzuführen.

Abstract

Background

The diagnostic validity of a full-thickness resection is higher compared to endoscopic mucosal resection (EMR) or endoscopic mucosal dissection (ESD). Whereas transanal endoscopic microsurgery techniques (TEM, TAMIS) are established therapeutic procedures in the rectum no established and safe minimally invasive or endoscopic procedure exists in the colon.

Aim

In this study the novel endoscopic full thickness resection device (FTRD, Ovesco, Germany) was investigated concerning success rates with histologically proven full thickness resections, R0 status as well as patient and device safety for the rectum and colon.

Method

In the period from November 2014 to June 2015 full thickness resections in the rectum and colon were performed with the FTRD in 20 patients. Data on technical success, R0 resection rate and histologically confirmed full thickness resections were retrospectively analyzed.

Results

The following indications were treated in the rectum (n = 11) and colon (n = 9): T1 carcinoma (n = 6) and neuroendocrine tumors (n = 2), untreated and nonlifting adenomas (n = 3) and incomplete resection of adenomas with low and high grade dysplasia (n = 9). The technical success rate was 75 %, 3 technical failures made a conventional polypectomy necessary in 2 patients and in 1 patient an operative resection of the duplicated intestinal wall had to be performed. The median endoscopic follow-up time was 61.5 days (n = 10) and in 7 patients the clip had dislodged at the first follow-up. A thermal perforation in one case of conventional polypectomy gave rise to indications for a partial resection of the colon. In one patient the lesion in the cecum could be reached but not treated for technical reasons. The histological R0 rate was 80 %, whereas the full thickness resection rate was 60 % (85.7 % in the colon and 54.6 % in the rectum). In two patients with carcinoma and incomplete FTRD, surgical treatment was performed. The median size of the resection specimen was 5  cm2 (range 1.6–12.9  cm2).

Conclusion

The results show that FTRD is a safe and effective instrument for use in the lower gastrointestinal tract. Limitations of the FTRD system concerning full thickness resection are scarring, fibrosis and thickness of the intestinal wall, especially in the lower rectum; therefore, it is suggested that a simulation with a tube similar in size to the FTRD should be performed during the screening colonoscopy in order to establish whether an endoscopic resection with FTRD is possible.

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Authors and Affiliations

  1. Interdisziplinäre Gastrointestinale Endoskopie, Kliniken für Innere Medizin II, Universitätsklinik Freiburg, Sir Hans A. Krebs Strasse, 79106, Freiburg im Breisgau, Deutschland

    H.-J. Richter-Schrag, C. Walker, R. Thimme & A. Fischer

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Correspondence to H.-J. Richter-Schrag.

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H.-J. Richter-Schrag, C. Walker, R. Thimme und A. Fischer geben an, dass kein Interessenkonflikt besteht.

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Richter-Schrag, HJ., Walker, C., Thimme, R. et al. Full-Thickness-Resection-Device (FTRD). Chirurg 87, 316–325 (2016). https://doi.org/10.1007/s00104-015-0091-z

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  • DOI: https://doi.org/10.1007/s00104-015-0091-z

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