Post written by Yasutoshi Shiratori, MD, MPH, PhD, from the Department of Gastroenterology, Division of Gastroenterology, Maimonides Medical Center, Brooklyn, New York, USA.

Endoscopic full-thickness resection (EFTR) using a full-thickness resection device (FTRD; Ovesco Endoscopy AG, Tübingen, Germany) has become a valuable technique for managing nonlifting colonic lesions, such as residual polyps after EMR, with reported high technical success rates.

However, technical failures, including misdeployment of the FTRD clip, remain insufficiently described. We present the case of a 74-year-old man referred for treatment of a residual polyp at the hepatic flexure after EMR. The lesion, accompanied by scarring and an adjacent tattoo, was deemed suitable for EFTR using the FTRD.

After marking the lesion with a coagulation probe, we attached an applicator cap with a preloaded FTRD clip and snare. The lesion was pulled into the cap using the provided grasper, and the clipping wheel was turned followed by snare excision of the target tissue. Although the specimen was successfully excised, the FTRD clip failed to deploy fully, resulting in a 20 × 20-mm mucosal defect consistent with perforation.

The defect was promptly closed using an over-the-scope clip and additional endoclips, including the omentum, ensuring secure closure. The patient experienced no postprocedural adverse events and was discharged the following day. Pathological examination confirmed complete excision of a residual adenoma with negative margins.

EFTR with the FTRD achieves a high R0 resection rate, but systematic reviews have highlighted adverse events such as postprocedural bleeding and appendicitis in 12% to 17% of cases, with perforation because of clipping failure rare (0.4%).¹,² In this case, acute angulation at the hepatic flexure and scope looping likely contributed to the failure.

To enhance safety, operators should straighten the scope in tortuous segments and ensure the white ring—indicating proper clip deployment—moves evenly before proceeding to snare cutting. This case underscores the importance of troubleshooting strategies, such as the immediate application of an over-the-scope clip, in managing rare but significant adverse events of EFTR with an FTRD.

Residual colonic lesion after EMR, with the border marked using a coagulation probe. The lesion is located at the hepatic flexure.

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1. Krutzenbichler I, Dollhopf M, Diepolder H, et al. Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels. Surg Endosc 2021;35:3339-53. ↩︎
2. Dolan RD, Bazarbashi AN, McCarty TR, Thompson CC, Aihara H, et al. Endoscopic full-thickness resection of colorectal lesions: a systematic review and meta-analysis. Gastrointest Endosc 2022;95:216-24.e18. ↩︎