A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions



Introduction of the full-thickness resection device (FTRD) has allowed endoscopic resection of difficult lesions such as those with deep wall origin/infiltration or those located in difficult anatomic locations. The aim of this study is to assess the outcomes of the FTRD among its early users in the USA.


Patients who underwent endoscopic full-thickness resection (EFTR) for lower gastrointestinal tract lesions using the FTRD at 26 US tertiary care centers between 10/2017 and 12/2018 were included. Primary outcome was R0 resection rate. Secondary outcomes included rate of technical success (en bloc resection), achievement of histologic full-thickness resection (FTR), and adverse events (AE).


A total of 95 patients (mean age 65.5 ± 12.6 year, 38.9% F) were included. The most common indication, for use of FTRD, was resection of difficult adenomas (non-lifting, recurrent, residual, or involving appendiceal orifice/diverticular opening) (66.3%), followed by adenocarcinomas (22.1%), and subepithelial tumors (SET) (11.6%). Lesions were located in the proximal colon (61.1%), distal colon (18.9%), or rectum (20%). Mean lesion diameter was 15.5 ± 6.4 mm and 61.1% had a prior resection attempt. The mean total procedure time was 59.7 ± 31.8 min. R0 resection was achieved in 82.7% while technical success was achieved in 84.2%. Histologically FTR was demonstrated in 88.1% of patients. There were five clinical AE (5.3%) with 2 (2.1%) requiring surgical intervention.


Results from this first US multicenter study suggest that EFTR with the FTRD is a technically feasible, safe, and effective technique for resecting difficult colonic lesions.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4



Adverse event


Argon plasma coagulation


Endoscopic full-thickness resection


Endoscopic mucosal resection


Endoscopic submucosal dissection


Full-thickness resection device




Over-the-scope clip


  1. 1.

    Raju GS, Lum PJ, Ross WA, Thirumurthi S, Miller E, Lynch PM, Lee JH, Bhutani MS, Shafi MA, Weston BR, Pande M, Bresalier RS, Rashid A, Mishra L, Davila ML, Stroehlein JR (2016) Outcome of EMR as an alternative to surgery in patients with complex colon polyps. Gastrointest Endosc 84:315–325

    Article  Google Scholar 

  2. 2.

    Moss A, Williams SJ, Hourigan LF, Brown G, Tam W, Singh R, Zanati S, Burgess NG, Sonson R, Byth K, Bourke MJ (2015) Long-term adenoma recurrence following wide-field endoscopic mucosal resection (WF-EMR) for advanced colonic mucosal neoplasia is infrequent: results and risk factors in 1000 cases from the Australian Colonic EMR (ACE) study. Gut 64:57–65

    Article  Google Scholar 

  3. 3.

    Oka S, Tanaka S, Saito Y, Iishi H, Kudo SE, Ikematsu H, Igarashi M, Saitoh Y, Inoue Y, Kobayashi K, Hisabe T, Tsuruta O, Sano Y, Yamano H, Shimizu S, Yahagi N, Watanabe T, Nakamura H, Fujii T, Ishikawa H, Sugihara K (2015) Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 110:697–707

    Article  Google Scholar 

  4. 4.

    Burgess NG, Bourke MJ (2016) Endoscopic resection of colorectal lesions: the narrowing divide between East and West. Dig Endosc 28:296–305

    Article  Google Scholar 

  5. 5.

    Agapov M, Dvoinikova E (2014) Factors predicting clinical outcomes of endoscopic submucosal dissection in the rectum and sigmoid colon during the learning curve. Endosc Int Open 2:E235–240

    Article  Google Scholar 

  6. 6.

    He YQ, Wang X, Li AQ, Yang L, Zhang J, Kang Q, Tang S, Jin P, Sheng JQ (2015) Factors for Endoscopic submucosal dissection in early colorectal neoplasms: a single center clinical experience in China. Clin Endosc 48:405–410

    Article  Google Scholar 

  7. 7.

    Lee SP, Kim JH, Sung IK, Lee SY, Park HS, Shim CS, Han HS (2015) Effect of submucosal fibrosis on endoscopic submucosal dissection of colorectal tumors: pathologic review of 173 cases. J Gastroenterol Hepatol 30:872–878

    Article  Google Scholar 

  8. 8.

    Mizushima T, Kato M, Iwanaga I, Sato F, Kubo K, Ehira N, Uebayashi M, Ono S, Nakagawa M, Mabe K, Shimizu Y, Sakamoto N (2015) Technical difficulty according to location, and risk factors for perforation, in endoscopic submucosal dissection of colorectal tumors. Surg Endosc 29:133–139

    Article  Google Scholar 

  9. 9.

    Hong SN, Byeon JS, Lee BI, Yang DH, Kim J, Cho KB, Cho JW, Jang HJ, Jeon SW, Jung SA, Chang DK (2016) Prediction model and risk score for perforation in patients undergoing colorectal endoscopic submucosal dissection. Gastrointest Endosc 84:98–108

    Article  Google Scholar 

  10. 10.

    Fahndrich M, Sandmann M (2015) Endoscopic full-thickness resection for gastrointestinal lesions using the over-the-scope clip system: a case series. Endoscopy 47:76–79

    PubMed  Google Scholar 

  11. 11.

    Monkemuller K, Peter S, Toshniwal J, Popa D, Zabielski M, Stahl RD, Ramesh J, Wilcox CM (2014) Multipurpose use of the 'bear claw' (over-the-scope-clip system) to treat endoluminal gastrointestinal disorders. Dig Endosc 26:350–357

    Article  Google Scholar 

  12. 12.

    Schmidt A, Bauerfeind P, Gubler C, Damm M, Bauder M, Caca K (2015) Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy 47:719–725

    Article  Google Scholar 

  13. 13.

    Andrisani G, Pizzicannella M, Martino M, Rea R, Pandolfi M, Taffon C, Caricato M, Coppola R, Crescenzi A, Costamagna G, Di Matteo FM (2017) Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: a single-centre study. Dig Liver Dis 49:1009–1013

    Article  Google Scholar 

  14. 14.

    Valli PV, Mertens J, Bauerfeind P (2018) Safe and successful resection of difficult GI lesions using a novel single-step full-thickness resection device (FTRD((R))). Surg Endosc 32:289–299

    CAS  Article  Google Scholar 

  15. 15.

    Schmidt A, Beyna T, Schumacher B, Meining A, Richter-Schrag HJ, Messmann H, Neuhaus H, Albers D, Birk M, Thimme R, Probst A, Faehndrich M, Frieling T, Goetz M, Riecken B, Caca K (2018) Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 67:1280–1289

    Article  Google Scholar 

  16. 16.

    Schmidt A, Damm M, Caca K (2014) Endoscopic full-thickness resection using a novel over-the-scope device. Gastroenterology 147:740–742.e742

    Article  Google Scholar 

  17. 17.

    Richter-Schrag HJ, Walker C, Thimme R, Fischer A (2016) Full thickness resection device (FTRD). Experience and outcome for benign neoplasms of the rectum and colon. Chirurg 87:316–325

    Article  Google Scholar 

  18. 18.

    Sarker S, Gutierrez JP, Council L, Brazelton JD, Kyanam Kabir Baig KR, Monkemuller K (2014) Over-the-scope clip-assisted method for resection of full-thickness submucosal lesions of the gastrointestinal tract. Endoscopy 46:758–761

    Article  Google Scholar 

  19. 19.

    Lagoussis P, Soriani P, Tontini GE, Neumann H, Pastorelli L, de Nucci G, Vecchi M (2016) Over-the-scope clip-assisted endoscopic full-thickness resection after incomplete resection of rectal adenocarcinoma. Endoscopy 48(Suppl 1):E59–E60

    PubMed  Google Scholar 

  20. 20.

    Soriani P, Tontini GE, Neumann H, de Nucci G, De Toma D, Bruni B, Vavassori S, Pastorelli L, Vecchi M, Lagoussis P (2017) Endoscopic full-thickness resection for T1 early rectal cancer: a case series and video report. Endosc Int Open 5:E1081–1086

    Article  Google Scholar 

  21. 21.

    Aepli P, Criblez D, Baumeler S, Borovicka J, Frei R (2018) Endoscopic full thickness resection (EFTR) of colorectal neoplasms with the Full Thickness Resection Device (FTRD): Clinical experience from two tertiary referral centers in Switzerland. United Eur Gastroenterol J 6:463–470

    Article  Google Scholar 

  22. 22.

    Quirke P, Risio M, Lambert R, von Karsa L, Vieth M (2011) Quality assurance in pathology in colorectal cancer screening and diagnosis-European recommendations. Virchows Arch 458:1–19

    Article  Google Scholar 

  23. 23.

    Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, Mergener K, Nemcek A Jr, Petersen BT, Petrini JL, Pike IM, Rabeneck L, Romagnuolo J, Vargo JJ (2010) A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 71:446–454

    Article  Google Scholar 

  24. 24.

    Aslanian HR, Sethi A, Bhutani MS, Goodman AJ, Krishnan K, Lichtenstein DR, Melson J, Navaneethan U, Pannala R, Parsi MA, Schulman AR, Sullivan SA, Thosani N, Trikudanathan G, Trindade AJ, Watson RR, Maple JT (2019) ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection. VideoGIE 4:343–350

    Article  Google Scholar 

  25. 25.

    Isomoto H, Nishiyama H, Yamaguchi N, Fukuda E, Ishii H, Ikeda K, Ohnita K, Nakao K, Kohno S, Shikuwa S (2009) Clinicopathological factors associated with clinical outcomes of endoscopic submucosal dissection for colorectal epithelial neoplasms. Endoscopy 41:679–683

    CAS  Article  Google Scholar 

  26. 26.

    Hori K, Uraoka T, Harada K, Higashi R, Kawahara Y, Okada H, Ramberan H, Yahagi N, Yamamoto K (2014) Predictive factors for technically difficult endoscopic submucosal dissection in the colorectum. Endoscopy 46:862–870

    Article  Google Scholar 

  27. 27.

    Saito Y, Uraoka T, Yamaguchi Y, Hotta K, Sakamoto N, Ikematsu H, Fukuzawa M, Kobayashi N, Nasu J, Michida T, Yoshida S, Ikehara H, Otake Y, Nakajima T, Matsuda T, Saito D (2010) A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 72:1217–1225

    Article  Google Scholar 

  28. 28.

    Bucalau AM, Lemmers A, Arvanitakis M, Blero D, Neuhaus H (2018) Endoscopic Full-thickness resection of a colonic lateral spreading tumor. Dig Dis 36:252–256

    Article  Google Scholar 

  29. 29.

    Bronzwaer ME, Bastiaansen BA, Koens L, Dekker E, Fockens P (2018) Endoscopic full-thickness resection of polyps involving the appendiceal orifice: a prospective observational case study. Endosc Int Open 6:E1112–1119

    Article  Google Scholar 

  30. 30.

    Ahlenstiel G, Hourigan LF, Brown G, Zanati S, Williams SJ, Singh R, Moss A, Sonson R, Bourke MJ (2014) Actual endoscopic versus predicted surgical mortality for treatment of advanced mucosal neoplasia of the colon. Gastrointest Endosc 80:668–676

    Article  Google Scholar 

  31. 31.

    Kuellmer A, Mueller J, Caca K, Aepli P, Albers D, Schumacher B, Glitsch A, Schafer C, Wallstabe I, Hofmann C, Erhardt A, Meier B, Bettinger D, Thimme R, Schmidt A (2019) Endoscopic full-thickness resection for early colorectal cancer. Gastrointest Endosc 89:1180–1189.e1181

    Article  Google Scholar 

  32. 32.

    Schreiner P, Valli P, Marques Maggio E, Bauerfeind P (2018) Simultaneous endoscopic full-thickness resection of two synchronous colonic granular cell tumours. BMJ Case Rep. https://doi.org/10.1136/bcr-2017-222223

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information




MK, YI, and KV were involved in the study planning, interpretation of the data, and development of the manuscript. DD, GI, JT, and TA were involved in critically revising the manuscript for important intellectual content. All remaining authors involved in performing the procedure and data extraction. All authors approved the final submitted draft of this manuscript.

Corresponding author

Correspondence to Mouen A. Khashab.

Ethics declarations


Dr. Khashab is consultant for Boston Scientific, Medtronic, and Olympus. Dr. Ian Grimm is a consultant for Boston Scientific. Dr. Irani is a consultant for Boston Scientific. Dr. Kumbhari is a consultant for ReShape Life Sciences, Apollo Endosurgery, Medtronic, and Boston Scientific. Dr. Nikhil is a consultant for Apollo Endosurgery, Boston scientific, and Olympus. Dr. Amateau is a consultant for Merit Endoscopy, Boston Scientific, US Endoscopy, and Neurotronic and the recipient of research support from Cook Medical. Dr. Smallfield has research funding from CSA medical and C2 therapeutics. Dr. Aadam AA is a consultant for Boston Scientific. Dr. Diehl Md Consultant for Boston Scientific, Olympus, Pentax, Cook Medical, Merit, ConMed, US Endoscopy, Medtronic, Lumendi. Dr. Chang consultant for Apollo, Boston Scientific, Cook, Covidien, Erbe, Endogastric Solutions, Mauna Kea Mederi, Medtronic, Olympus, Ovesco, Pentax, Torax. Dr. Samarasena has educational grant from Cook and consultant for Mauna Kea, Medtronic, Olympus, Pentax, US Endoscopy. Dr. Al-Haddad received research and teaching support from Boston Scientific. Dr. Pohl received grants from Boston Scientific, US Endoscopy, and Aries/Cosmo Pharamceuticals. Dr. Templeton is a consultant for Boston Scientific and Medtronic. Dr. Ginsberg is a consultant for Olympus Inc. and Boston Scientific. Dr. Fukami is consultant for Boston Scientific and Olympus. Dr. Sharaiha is consultant for Boston Scientific, Olympus, Apollo, and Medtronic. Dr. Ichkhanian, Dr. Vosoughi, Dr. James, Dr. Hajifathalian, Dr. Tokar, Dr. Lee, Dr. Mizrahi, Dr. Barawi, Dr. Friedland, Dr. Korc, Dr. Kowalski, Dr. Novikov, Dr. Oza, Dr. Panuu, Dr. Lajin, Dr. Kumta, Dr. Tang, Dr. Naga, and Dr. Brewer have no conflicts of interest or financial ties to disclose

Ethical approval

IRB approval for this study across the multiple centers performed in accordance with the principles of the Declaration of Helsinki. The formal informed consent was waived.

Informed consent

The formal informed consent was waived.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary file1 (MP4 91407 kb)

Supplementary file2 (DOCX 16 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ichkhanian, Y., Vosoughi, K., Diehl, D.L. et al. A large multicenter cohort on the use of full-thickness resection device for difficult colonic lesions. Surg Endosc 35, 1296–1306 (2021). https://doi.org/10.1007/s00464-020-07504-9

Download citation


  • Full-thickness resection device
  • Endoscopic full-thickness resection
  • FTRD
  • Difficult adenomas