Response

We thank Chen et al1Du C. Cheng B. Chai N. et al.Is hybrid endoscopic full-thickness resection suggested for large nonlifting colorectal adenomas?.Gastrointestinal Endosc. 2023; 98: 1041Abstract Full Text Full Text PDF Google Scholar for their comments on our study,2Meier 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: 405-411Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar and we would like to address some of the concerns that have been raised. We included nonlifting colonic epithelial lesions caused by submucosal scarring or submucosal invasion. We did not include lesions located in the deep muscularis propria or adherent to the serosa because of the high risk of lymph node metastasis with indication for surgical resection. There is no doubt that en bloc resection should always be preferred over piecemeal resection whenever it can be achieved safely and efficiently in a timely manner, and endoscopic submucosal dissection (ESD) is the way to go, especially in the stomach or the rectum. However, compared with colonic ESD, nonexposed endoscopic full-thickness resection (EFTR) with a full-thickness resection device (FTRD) is less invasive, is associated with fewer adverse events, and is far easier to adopt. Initial tumor size reduction might be reasonable to overcome the technical limitation of the FTRD and allow for resection of larger lesions (>25 mm). Chen et al1Du C. Cheng B. Chai N. et al.Is hybrid endoscopic full-thickness resection suggested for large nonlifting colorectal adenomas?.Gastrointestinal Endosc. 2023; 98: 1041Abstract Full Text Full Text PDF Google Scholar suggest ESD as part of exposed EFTR for larger nonlifting lesions in the colon. This technique has been shown to be effective and safe in the stomach3Zhou P. Yao L. Qin X. et al.Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria.Surg Endosc. 2011; 25: 2926-2931Crossref PubMed Scopus (248) Google Scholar,4Antonino G. Alberto M. Michele A. et al.Efficacy and safety of gastric exposed endoscopic full-thickness resection without laparoscopic assistance: a systematic review.Endosc Int Open. 2020; 8: E1173-E1182Crossref PubMed Google Scholar and might be an option in the rectum. However, data on exposed EFTR in the colon are scarce, and adverse event rates >50% have been reported.5Brigic A. Symons N. Faiz O. et al.A systematic review regarding the feasibility and safety of endoscopic full thickness resection (EFTR) for colonic lesions.Surg Endosc. 2013; 27: 3520-3529Crossref PubMed Scopus (20) Google Scholar Defect closure in the colon can be challenging, and the risk of fecal peritoneal contamination is high. Additionally, resection of nonlifting lesions always harbors the risk of revealing early carcinoma, and especially in this situation, peritoneal contamination needs to be strictly avoided. From our point of view, nonexposed EFTR should always be preferred over exposed EFTR in the colon, especially in the right side of the colon. Finally, further management of “advanced” colorectal adenoma certainly is an individual decision that depends on different factors. In this context, we believe that hybrid EFTR provides a powerful, safe, and effective option. B. Meier is the recipient of research support and lecture fees from Ovesco Endoscopy AG. K. Caca is the recipient of fees for FTRD training courses and lecture fees from Ovesco Endoscopy AG.