Solutions for submucosal injection: What to choose and how to do it

Abstract

During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.

Histopathological Findings Related to ORISE™ Injectable Submucosa Lifting Agent Used in the Endoscopic Mucosal Resection of Bowel Neoplasms: A Review of Three Cases

“…Endoscopic mucosal resection of bowel lesions is a relatively new procedure increasingly utilized in the removal of large, flat sessile polyps [1]. Successful EMR is dependent on expanding the submucosal space to create adequate elevation of the surface neoplastic mucosa and thus aid in the complete resection of the lesion while minimising risk of thermal or mechanical injury to the bowel wall which could result in perforation or excessive bleeding [2]. Ideal submucosal injection solutions should have the following characteristics: (1) provide a long-lasting and high submucosal cushion, (2) safe and nontoxic, (3) inexpensive, (4) readily available, (5) easy to inject, and (6) preserve specimen tissue for accurate histopathological lesion assessment [3,4].…”

Viscosity and degradation controlled injectable hydrogel for esophageal endoscopic submucosal dissection

“…An ideal submucosal injection should consider the following characteristics: safety, low cost, easy to obtain, facile to prepare and inject, able to maintain a long-lasting submucosal cushion for an operation, and no damage to the surrounding tissues [ 6 , 40 ]. All of these propelled us to consider a gel by combining with gelatin through a mild Schiff bonding with aldehyde modified alginate.…”

ORISE Gel: A Submucosal Lifting Agent Mimics Mucin in Endoscopic Resection Specimen

“…ORISE Gel is a proprietary viscous fluid that was recently approved by the Food and Drug Administration as an injection fluid for gastrointestinal ER. 5 In this case presentation, we report the histologic appearance of the ORISE Gel in the EMR specimen. Histologically, ORISE Gel appears as an amorphous substance and closely resembles gastrointestinal mucin.…”