Now, More than Ever Before, Colonoscopy Is a Therapeutic Procedure

Once considered a diagnostic procedure, colonoscopy is nowadays increasingly of a therapeutic nature. Taking into account that skilled endoscopists have polyp detection rates approaching 50% in screening colonoscopies and more than 50% after a positive fecal occult blood test [1, 2], colonoscopy is most of the times therapeutic, even in this screening setting. The working channel is at the core of this mindset shift. It allowed different techniques to be developed for minimally invasive endoscopic surgery of early neoplasms of the gastrointestinal tract such as polypectomy, soon followed by endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) [3]. Unfortunately, the histological assessment of the lesion following piecemeal EMR is difficult, and the proportion of recurrence requiring further intervention is high [4, 5]. ESD enables en bloc resection, although with a higher complication rate [4, 6]. Advanced polypectomy techniques are technically demanding, time-consuming, and when the follow-up overhead expenses are considered, the costs increase significantly. Furthermore, the balance between complications and the depth of resection for a curative treatment remains complex. Consequently, other techniques have been developed, such as endoscopic full-thickness resection (EFTR) methods. These procedures allow for endoscopic resection of the entire wall, providing a specimen superior to that achieved by EMR or ESD, without the risk of residual intramural disease. In addition, EFTR procedures can decrease postoperative morbidity and mortality associated with segmental colectomy. EFTR appears to be of paramount relevance in colorectal lesions with negative lifting sign (recurrent, incompletely resected, or even untreated lesions), which are often unsuitable for resection using conventional techniques. Apart from these indications, EFTR may also be used for early carcinomas with indication for endoscopic resection, fibrotic lesions that have been previously sampled, small subepithelial tumors, and lesions located in