This is a relatively new device-assisted technique being adopted increasingly in the USA after initial development and use in Europe. Prior to this, certain cases that required focal full-thickness resection whether as a residual focal adenoma or subepithelial lesion with dense submucosal layer fibrosis; controlled free hand full-thickness resection are sometimes performed during complex endoluminal resection by experts in ESD and third space endoscopy.
This technique incorporates the use of a device attached to the endoscope or colonoscopy and allows for controlled sequential steps with the capture of the target lesion, securing with a large clip deployment followed by resection.
Below is an example of an appendiceal orifice tubulovillous adenoma with extension into the appendiceal orifice where a prior attempt at standard polypectomy was unsuccessful and this patient was subsequently referred for further complex endoluminal resection. This was a successful en bloc resection and confirmed R0 resection by final pathology. No post-procedure adverse events were reported.