Cylindrical unblocked endoscopic full thickness resection for recalcitrant circoferential adenoma at retrogal anastomosis. I would like to thank my collaborators shown here. My disclosures, the other authors don't have disclosures. Colorectal freehand EFTI is relatively rare. It's most common in the left column. Indications most commonly include recalcitrant adenomas to achieve definitive R0 resection. Other indications include subepithelial tumors usually smaller than 5 cm without malignant features for definitive diagnosis and unblocked resection and the somewhat controversial indication of resection of deep carcinomas in order to achieve precise staging and R0 resection in high surgical risk patients. We'll focus on a case of a recalcitrant adenoma with use of EFTR to achieve definitive R0 resection. This is the case, 70 year old, with multiple comorbidities, had chemo and radiation and a low anterior resection for rectal cancer in 2009. He developed recurrent adenoma at the LAAR staple line, underwent 3 EMR procedures in the past 4 years, but there is persistent adenoma with complete circoferential involvement of the staple line and we proposed a tunneled circoferential EFTR to achieve resection. Our plan was to start initially posteriorly and tunnel across the anastomosis and then do that also anteriorly, starting with ESD, then proceeding with full thickness resection in the area under the staple line where the adenoma is located and then returning back to the submucosal plane on the oral side of the lesion using traction to keep the specimen from accordioning. And then as shown here, start posteriorly and then proceed anteriorly and on the lateral edges to achieve a complete unblocked cylindrical resection. This is the adenoma circoferentially at the staple line, I apologize a bit about the nature of the video, it was done in a live course and this was recorded off an iPhone instead of through the monitor. So you can see here I completed the posterior resection including a full thickness resection of the muscle and staple line posteriorly. I am now using a second clip to modify the vector of the traction, you can see I am holding the clip without deploying it and pulling on the suture to bring the other clip in a different direction so that we can now proceed from a posterior tunnel resection to an anterior one. We are now in the full thickness portion where we are cutting the muscle of the rectum along with surgical scar. The initial part was again ESD but now we are under the staple line as shown by the staples here, so in this case to achieve complete eradication of the adenoma which is fused to the staple line, we need to excise the staple scar along with the staples, some minor bleeding is controlled with a knife. We are trying to preserve this plane shown here of the fascia separating the muscle of the rectum and the perirectal fat. A lot of this plane is obliterated by scar tissue, however, the beneficial effect of the scar tissue is in avoiding leak of air or luminal contents. Now after we completed anterior dissection to some degree, we are also working on the right anterior lateral side. Again, we are trying to stay in a plane located between fat and muscularis propria or within the surgical scar. So here again we are dissecting the muscle. You can see now we are getting into an area of fibrosis in the area of the surgical anastomosis. Again, traction is important in the cylindrical resections, it is often used in esophageal cylindrical resections of barrettes for the same reason, to avoid accordioning of the specimen. Now we get into a difficult area on the right anterior lateral area of the resection, there is sutures in addition to staples fusing all the layers and we are staying on a plane now deep to the surgical staples and sutures. We use underwater technique which has multiple advantages, the water pressure can achieve traction, you can prevent fat from soiling the lens, you can magnify and avoid any halation effects that cause a whiteout and a blurred vision. So multiple advantages and also you can achieve reasonable magnification, further magnification. We see we are under near focus which is very useful in underwater technique. So we complete the resection, the specimen is just being held by the staple, the clip and the line. We remove it with a rat tooth forceps and we have a cylindrical specimen, complete excision. These are the marks on the oral side marking the extent of the lesion and the anal side and we place it around the syringe, it is about 600 meters long, you can see in the middle the muscularis and staple line completely excised along with the adenoma. Again, no free pathway to the peritoneum, the erectile fat preserved, avoiding soilage. The patient required multiple dilations to 15 mm every few weeks via the complete R0 resection of the adenoma. In conclusion, adenoma recurrence after surgical anastomosis can occur due to the challenges of ensuring a negative margin, particularly in low rectal tumors. Redo surgery at a low rectal anastomosis can be challenging with high risk of complications, including the need of permanent colostomy. Conversely, freehand EFTR has a more favorable risk profile in the subperitoneal pelvic space, especially with dense post-surgical scar tissue providing a seal against air escape or peritoneal soiling. It does require, however, advanced ESD skills. Thank you.

recalcitrant adenoma

EFTR

R0 resection

LAAR

tunneled circumferential EFTR