Endoscopic Full Thickness Resection (EFTR)

Why have I been provided with this leaflet?

Previous tests have shown you have a “polyp” in your large bowel. Most polyps are removed by a small wire loop (snare).

Sometimes, if the polyp is growing deeply, it will require more specialist methods to remove it. 

Because of the location of your polyp, a procedure called Endoscopic Full Thickness Resection (EFTR) is required to remove it.

This leaflet explains to you more about what is involved.

What is a large bowel polyp?

A polyp is a small wart-like growth that sometimes forms on the lining of the bowel. Most polyps do not cause any symptoms, but in some cases, they can cause bleeding or a change in bowel habit.

Most polyps are harmless, but larger polyps have a small chance of containing cancer cells and if they are left to grow, some can become cancerous.

The majority of polyps can be removed using a camera test, such as an endoscopy (down your throat), colonoscopy or flexible sigmoidoscopy (in your bottom). By removing the polyps, your risk of developing bowel cancer is greatly reduced.

Polyps that are growing deeper into the wall of the bowel are more difficult to remove and are more likely to become cancerous if left untreated.

Why have I been referred for an EFTR procedure?

Your polyp may be growing deeper into the lining of the bowel.

This may be because of scarring from previous attempts at removal, or from an early cancer.

Having an EFTR (endoscopy) procedure has been deemed by an experienced Endoscopist as potentially the best option for your polyp to be successfully removed.

What is an Endoscopic Full Thickness Resection (EFTR)?

An Endoscopic Full Thickness Resection EFTR is a specialised procedure.

EFTR is most commonly used to remove benign polyps that have been assessed as requiring deeper resection than is usual for polypectomy.

Previously, difficult or awkward polyps were either partially treated by burning or scraping away.

Occasionally, they were treated by major surgery to remove the area affected. Because of EFTR, more of these polyps can be removed completely, without major surgery.

Occasionally, EFTR is used to remove small cancers. This is either because the cancer is in the early stages, or because a major operation is not possible.

We will usually administer a dose of antibiotic at the time of the procedure, to help prevent any infection. Please let us know if you have any allergies to medications.

1. The polyp is assessed and the edges are marked. The endoscope is then re-inserted with the resection device attached.
   
2. The polyp is grasped with special grasping forceps.
   
3. Forceps are used to pull the polyp into the cap of the device.
   
4. A special clip is closed onto the polyp tissue.
   
5. The polyp tissue above the clip is removed and retrieved inside the device.

The special clip securely holds the bowel tissue together (where the polyp has been removed).

The clip detaches from the healed bowel over time and is usually passed through the bowel without being noticed.

In most cases, you will be able to go home on the same day as the procedure. However, occasionally we may ask you to stay in hospital overnight for observation.

What are the benefits of removing the polyp?

Removal of the polyp will reduce your risk of developing bowel cancer and may treat any symptoms that are being caused by the polyp.

What are the risks of the EFTR?

These are explained in the colonoscopy information leaflet. However, because the polyp is growing into the bowel wall, the risk of perforation or bleeding during polyp removal is higher (although still not common).

The National Institute for Health and Care Excellence (NICE) has reviewed EFTR as a technique for removing polyps growing deep into the bowel wall.

NICE report that because this technique is relatively new, there is limited available evidence surrounding risks associated with the procedure. However, NICE do support using EFTR in certain situations.

A team of experts will have discussed your case to make sure we are recommending this technique appropriately.

The main risks are:

• Perforation – this means a tear in the bowel wall. For EFTR, this occurs in approximately 3 in every 100 patients. Occasionally, perforations heal with antibiotics and bowel rest and sometimes they can be treated with the endoscope. However, an emergency surgical operation is required in about half of cases.

As with any bowel operation, a stoma (bag on your abdomen) may be required, although this would usually be temporary.

• Bleeding – bleeding can happen in about 1 in 30 patients. Sometimes, bleeding occurs during the procedure, but it can also occur up to 14 days afterwards.

If bleeding does occur, it often stops on its own. However, very occasionally it requires a blood transfusion or further endoscopies.

Very rarely, emergency surgery may be needed to stop it. If you take any drugs to thin your blood, you will usually be asked to stop taking these temporarily prior to EFTR.

If you usually take Warfarin, we may arrange for you to have daily injections of heparin instead. This will help to reduce the risk of bleeding.

Most patients do not develop problems while they are not taking their blood thinning medication. However, there is an increased risk of developing blood clots or having a stroke during this time. This is something you may wish to discuss with the Endoscopist prior to your procedure.

• Incomplete removal – sometimes, the Endoscopist cannot remove the entire polyp for technical reasons (e.g. a polyp in a difficult position). If this happens, you may need a further attempt using the endoscope, or an operation that will be planned at a later date.

• Recurrence – Even when all the parts of the polyp seem to have been removed, the polyp can grow back. This is called recurrence.

Depending on the nature of the polyp, this can happen in up to 1 in 5 of patients within a year after initial removal.

  This is why we arrange for routine endoscopy check-ups and usually this can be dealt with during these check-ups. Sometimes, the recurrence may mean a surgical operation is needed to remove the polyp completely.

You may wish to discuss the risks again with the Doctor or nurse who will seek your consent prior to the examination.

EFTR clips and Magnetic resonance imaging (MRI) scans – special precautions.

Although the special clips used in EFTR usually pass once the bowel has healed, sometimes they can remain in place longer term.

Usually, this does not cause a problem; however, because of the magnetic force of an MRI scan, some metal clips can cause concern.

The clips used for EFTR are safe to stay inside during an MRI scan, but may cause some reduction in the quality of the images seen on the scan. Please inform the MRI team prior to your scan.

If you have been told you may need an MRI scan soon, it would be sensible to have the scan before we perform EFTR if possible. Please let the endoscopy team know.

What happens if the Endoscopist does not think that EFTR is possible?

In this case, you will usually be seen in clinic and the clinician will discuss whether an operation would be a better way to remove the polyp.

Are there any other ways of dealing with my polyp?

There are two main alternatives to having an EFTR:

• We could decide to leave the polyp as it is and do nothing.
  
  This option may be preferable in patients who have significant health problems. The rationale being that the polyp is unlikely to cause problems in your remaining lifetime.

• The polyp could be removed by having an operation on the bowel.
  
  This is usually a straightforward procedure which may be an open or key-hole procedure but carries the risks of general anaesthetic and surgical complications, such as infection and delayed healing, which are usually higher than the endoscopy risks.
  
  There is a risk that the join in your bowel may leak, requiring further surgery. It will also leave you with a scar on your abdomen.
  
  Sometimes, surgery can require the formation of a stoma (bag on your abdomen), although this may only be temporary.
  
  The risks of surgery may be considerably higher if you have other medical conditions and if it does include a risk to your life.

There may be other options available to remove the polyp. These will be discussed with you before deciding what the best option for you is.

Does the procedure hurt and will I be in pain?

The procedure may result in some abdominal discomfort as the scope is moved around your bowel. The EFTR procedure is longer than an initial colonoscopy. You may need to lie in a particular position for up to 2 hours to allow the polyp to be removed safely.

You may feel some discomfort for 24 hours following the procedure, but that should then settle.

How will I know the results of my test?

The polyp is usually sent to the pathology laboratory for further analysis. It can take up to 3 weeks before this result is available.

Your Consultant will then be in touch with you regarding these results. Sometimes, decisions about further treatment can only be made once these results are available.

You will usually be sent a further colonoscopy appointment around three to six months after the initial EFTR to check the entire polyp has gone.

Do you need more information?

If you wish to discuss any of this information further, please contact the endoscopy unit on the following number:

University Hospital North Tees: 01642 624387

University Hospital Hartlepool: 01429 522536

References:

NICE (2017) Endoscopic Full thickness removal of non-lifting colonic polyps. Interventional procedures guidance (IPG580). https://www.nice.org.uk/guidance/ipg580  Accessed: 12/10/2021

Ovesco, (2021) Endoscopic Full Thickness Resection (EFTR) with FTRD ® (Patient information leaflet)

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Leaflet Number: PIL1362
Date for Review: 29/08/2028