Post written by Rahul Karna, MD, from the University of Minnesota, Minneapolis, Minnesota, USA, and Mohammad Bilal, MD, from the University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

In this case, we describe management of a 35-mm malignant colon polyp in a patient at high risk for surgery. Colonoscopic exam revealed a nonpolypoid lesion (Paris classification IIa+IIc) in the transverse colon with features concerning for submucosal invasion (Narrow Band Imaging International Colorectal Endoscopic classification type III, Japanese Narrow Band Imaging Expert Team classification 2B, and Kudo pit pattern type V).

We demonstrate successful R0 resection of the lesion using a hybrid endoscopic submucosal dissection—endoscopic full-thickness resection (ESD-EFTR) technique. Final pathology found a T1 colonic adenocarcinoma with high-risk features. Follow-up surgical resection discovered no residual disease in the colon with negative lymph node sampling.

We chose to present this video to show that hybrid ESD-EFTR is a safe and effective resection strategy in lesions ≥20 mm or those with submucosal fibrosis and invasion.

Endoscopic full-thickness resection is challenging for lesions larger than 30 mm or those with significant fibrosis. Lesions with significant fibrosis or invasion are difficult to pull into the full-thickness resection device cap because of lack of pliability. Performance of initial mucosal incision and partial endoscopic submucosal dissection can make fibrotic and superficially invasive lesions more pliable to be pulled into the full-thickness resection device cap, hence resulting in the lesion being more amenable to resection. This technique can allow successful endoscopic resection of lesions with submucosal invasion in patients deemed unfit for surgery.

It is important for endoscopists to discuss all therapeutic strategies for lesions with suspected submucosal invasion in a multidisciplinary manner with colorectal surgery and oncology weighing all possible risks and outcomes prior to considering the hybrid ESD-EFTR technique for endoscopic resection of lesions.

A, The lesion was marked and submucosal injection was performed. B, Initial circumferential submucosal incision being performed. C, Partial submucosal dissection being performed. D, Grasping forceps used to bring lesion into the full-thickness resection device cap followed by resection. E, Fatty tissue at the site consistent with full-thickness resection. F, Resected specimen.

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