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.

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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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