Post written by Maria Eva Argenziano, MD, from the Clinic of Gastroenterology, Hepatology and Emergency Digestive Endoscopy, Università Politecnica delle Marche, Ancona, Italy, Department of Gastroenterology & Hepatology, University Hospital Ghent, and Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium, and David James Tate, MBBS, MA (Cantab), MRCP, PhD, from the Department of Gastroenterology & Hepatology, University Hospital Ghent, and Faculty of Medicine and Health Sciences, University of Ghent.

This video showcases knife-assisted full-thickness resection (kFTR) guided by the pocket detection method for endoscopic resection of a deeply invasive rectal cancer. The patient, a 61-year-old with oncologic comorbidities, presented with a 25-mm proximal rectal lesion with suspected deep submucosal invasion. Given the lesion’s size and location, conventional device-assisted full-thickness resection was infeasible.

Instead, a pocket was created toward the area of the most disordered vascular pattern, enabling exposure of the muscle-retracting sign (MRS) that confirmed deep submucosal invasion. MRS guided the decision to enter the muscular plane to achieve complete resection without adverse events. Histopathology confirmed R0 resection of an adenocarcinoma (pT1b, Kikuchi level sm3).

This case highlights the clinical feasibility and safety of kFTR for deeply invasive rectal lesions on the posterior rectal wall, particularly in patients unfit for surgery. The pocket detection method allowed for accurate identification of deep submucosal invasion, ensuring focal but radical excision of the invasive component. Because of the limitations of standard full-thickness resection devices for larger lesions, this technique represents a viable alternative for selected cases.

When standard device-assisted full-thickness resection is impossible, kFTR may be a safe and feasible alternative for resection of deeply invasive rectal lesions to achieve R0 resection, especially in extraperitoneal rectal lesions.

Nowadays, advanced endoscopic resection techniques have an expanding role in managing rectal cancer, reducing the need for more-invasive surgical approaches. The combination of the pocket detection method, MRS identification, and kFTR might become a safe and effective method for achieving complete endoscopic resection in carefully selected patients. However, further studies are needed to validate the feasibility, safety, and long-term oncologic outcomes of these innovative techniques.

A, The large nonpedunculated colorectal polyp from the study located in the proximal rectum with a depressed central area (Paris 0-Is+c, JNET-3). B, Endoscopic image of the suspected muscle-retracting sign (MRS) within the submucosal tunnel. C, First muscularis propria (MP) incision 3 mm caudal to the MRS. D, Completed circumferential muscular incision. E, Defect after removal of the lesion. F, Defect closure with through-the-scope clips.

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