Is hybrid endoscopic full-thickness resection suggested for large nonlifting colorectal adenomas?

We have read with great interest the article by Meier et al,1Meier B. Elsayed I. Seitz N. et al.Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas.Gastrointest Endosc. 2023; 98: 405-411Google Scholar which retrospectively evaluated hybrid endoscopic full-thickness resection (hybrid EFTR), which combined EMR and EFTR in patients with nonlifting colorectal adenomas of a size at least 25 mm. EFTR was regarded as a choice for lesions located in the deep muscularis propria or adherent to serosa.2Du C. Chai N. Linghu E. et al.Clinical outcomes of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria: a 7-year experience from a large tertiary center in China.Surg Endosc. 2022; 36: 1544-1553Google Scholar Hybrid EFTR seemed to be easily performed; however, it made pathologic evaluation more difficult because resection was performed in a piecemeal manner. The lesions in this study showed a positive lifting sign in peripheral parts and a nonlifting sign in the central part. In our opinion, en bloc resection should be regarded as the goal even for large lesions. Endoscopic submucosal resection should be done for peripheral parts of the lesions without resection, and EFTR should be used for the central part. We think that the size of the central part with nonlifting sign, instead of the size of the lesion itself, should determine the size of the perforation. Piecemeal EMR to reduce the tumor size seems unnecessary. Meier et al1Meier B. Elsayed I. Seitz N. et al.Efficacy and safety of combined EMR and endoscopic full-thickness resection (hybrid EFTR) for large nonlifting colorectal adenomas.Gastrointest Endosc. 2023; 98: 405-411Google Scholar believe that the scope of the full-thickness resection device cap acts as a barrier to EFTR for large lesions, so that they should reduce the size of the lesion before using an over-the-scope clip, which fails to treat large perforation.3Bapaye J. Chandan S. Naing L.Y. et al.Safety and efficacy of over-the-scope clips versus standard therapy for high-risk nonvariceal upper GI bleeding: systematic review and meta-analysis.Gastrointest Endosc. 2022; 96: 712-720.e7Google Scholar,4Dolan R.D. Bazarbashi A.N. McCarty T.R. et al.Endoscopic full-thickness resection of colorectal lesions: a systematic review and meta-analysis.Gastrointest Endosc. 2022; 95: 216-224.e18Google Scholar However, clips in placed in a “side-to-center” manner combined with an endoloop should be considered when the perforation is large.2Du C. Chai N. Linghu E. et al.Clinical outcomes of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria: a 7-year experience from a large tertiary center in China.Surg Endosc. 2022; 36: 1544-1553Google Scholar If the lesions cannot be treated by a full-thickness resection device, it can be resected by knife, followed by closure of the defect by the use of clips in a “side-to-center” manner. In conclusion, we believe that hybrid EFTR is feasible for large nonlifting colorectal adenoma. However, the necessity of piecemeal resection to reduce the size of the lesion should be re-evaluated because methods that enable en bloc resection and successful closure of the perforation exist. All authors disclosed no financial relationships.