Submucosal Injection of 0.4% Hydroxypropyl Methylcellulose Facilitates Endoscopic Mucosal Resection of Early Gastrointestinal Tumors

Arantes, Vitor; Albuquerque, Walton; Benfica, Edgard; Duarte, Dezimar Luis; Lima, David Correa Alves De; Vilela, Sueli; Lima, G. F.; Sakai, Paulo; Maluf‐Filho, Fauze; Artifon, Everson Luiz de Almeida; Halwan, Bhawna; Kumar, Atul

doi:10.1097/mcg.0b013e3181d6bd8e

Cited by 30 publications

(13 citation statements)

References 26 publications

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“…Other variants of the technique include the use of 2-channel endoscopes, cap-fitted endoscopes, and band ligation. In addition to saline solution, other submucosal injection solutions include mannitol, sodium hyaluronate, dextrose, glycerol, fibrinogen, and hydroxypropyl methylcellulose (2,15,19,20,21) . EMR has represented a major advance in therapy by allowing the resection of superficial lesions and also allowing the removal of large sessile lesions and laterally spreading tumors (LST).…”

Section: Introductionmentioning

confidence: 99%

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Santos¹,

Malaman²,

Pereira-Lima

2011

Arq. Gastroenterol.

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-Context -Endoscopic mucosal resection is a minimally invasive technique used in the treatment of colorectal neoplasms, including early carcinomas of different size and morphology. Objectives -To evaluate procedure safety, efficacy, outcomes, and recurrence rate in endoscopic mucosal resection of colorectal lesions. Methods -A total of 172 lesions in 156 patients were analyzed between May 2003 and May 2009. All lesions showed pit pattern suggestive of neoplasia (Kudo types III-V) at high-magnification chromocolonoscopy with indigo carmine. The lesions were evaluated for macroscopic classification, size, location, and histopathology. Lesions 20 mm or smaller were resected en bloc and lesions larger than 20 mm were removed using the piecemeal technique.Complications and recurrence were analyzed. Patients were followed up for 18 months. Results -There were 83 (48.2%) superficial lesions, 57 (33.1%) depressed lesions, 44 (25.6%) laterally spreading tumors, and 45 (26.2%) protruding lesions. Mean lesion size was 11.5 mm ± 9.6 mm (2 mm-60 mm). Patients' mean age was 61.6 ± 12.5 years (34-93 years). Regarding lesion site, 24 (14.0%) lesions were located in the rectum, 68 (39.5%) in the left colon, and 80 (46.5%) in the right colon (transverse, ascending, and cecum). There were 167 (97.1%) neoplasms: 142 (82.5%) adenomatous lesions, 24 (14.0%) intramucosal carcinomas, and 1 (0.6%) invasive carcinoma. En bloc resection was performed in 158 (91.9%) cases and piecemeal resection in 14 (8.1%). Bleeding occurred in 5 (2.9%) cases. Recurrence was observed in 4.1% (5/122) of cases and was associated with lesions larger than 20 mm (P<0.01), piecemeal resection (P<0.01), advanced neoplasm (P = 0.01), and carcinoma compared to adenoma (P = 0.04). Conclusions -Endoscopic mucosal resection of colorectal lesions is a safe and effective procedure, with low complication and local recurrence rates. Recurrence is associated with lesions larger than 20 mm and carcinomas.

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Section: Introductionmentioning

confidence: 99%

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Santos¹,

Malaman²,

Pereira-Lima

2011

Arq. Gastroenterol.

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“…Such an optimal agent for submucosal injection should be cost-effective, readily available, easy to inject and provide a durable cushion with minimal damage of the surrounding tissues at the site of injection. Previous studies have shown that the use of hyaluronic acid, hydroxypropyl methylcellulose or glycerol provides dextrose water, albumin and sodium alginate, and have a lasting elevating effect (6,7,10,11,21,22). A recent study reported that carbon dioxide (CO 2 ) could be a satisfactory submucosal injection agent during ESD (21).…”

Section: Discussionmentioning

confidence: 99%

A pilot animal and clinical study of autologous blood solution compared with normal saline for use as an endoscopic submucosal cushion

Wen

Shi

Yan

et al. 2012

Experimental and Therapeutic Medicine

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Normal saline is the most popular agent used during endoscopic submucosal injection. However, endoscopists have never identified an optimal submucosal injection solution, which is not only safe and cost-effective but has a unique lifting ability with endoscopic submucosal cushion and causes less tissue damage. This study aimed to evaluate the effectiveness and microscopic characteristics of a blood solution, including whole blood and plasma solution, as a submucosal cushioning agent, compared with normal saline. Endoscopic submucosal dissection (ESD) procedures in pig stomachs were performed by injecting plasma solution (n=4) and normal saline (n=4). A total of 38 patients with gastrointestinal neoplasms underwent endoscopic musocal resection (EMR) procedures. Of 38 EMRs, 7 used whole blood injection, and 31 of 38 acting as the control group used normal saline. A tissue damage scoring system was developed based on injection-induced hydrops and tears for the evaluation of tissue damage. In animal experiments, the lifting time of the injection with normal saline in the pig colon was shorter than that of the group with plasma solution (18.25±5.44 min vs. 6.5±2.38 min, P=0.007). In animal experiments with ESD procedures in the stomach, the hydrops in the normal saline injection group were more extensive than those in the group with plasma (P=0.011). The degree of tearing in the group with normal saline was observed to be less than that in the group with plasma (P=0.008). In patients with EMR, using the histological scoring method, it was determined that the degree of hydrops in the group with normal saline injection was more extensive than that in the group with whole blood (P<0.001). The effective submucosal tearing in the group with normal saline was less than that in the group with blood (P<0.001). The blood solution, including whole blood and plasma solution, as a novel submucosal injection agent, may outperform normal saline with a unique lifting ability, less pronounced tissue damage and marked effective submucosal blunt dissection.

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“…Multiple studies have demonstrated longer lasting cushions made with various agents including hyaluronic acid (HA), hydroxypropyl methylcellulose (HPMC), succinylated gelatin, glycerol, and a fibrinogen solution. [26][27][28][29][30][31][32] Currently, there are no injection solutions that are specifically approved for EMR by the U.S. Food and Drug Administration; therefore, all solutions mentioned in this document would be considered off-label. A 0.4% solution of HA is approved as an injection solution for Endoscopic mucosal resection submucosal injection in Japan (MucoUp; Johnson & Johnson, Tokyo, Japan) and has been demonstrated to sustain mucosal lifting longer than saline solution, reducing the volume of injection solution necessary to complete an endoscopic resection.…”

Section: Submucosal Injection Solutionsmentioning

confidence: 97%

“…35 HPMC has also been demonstrated to be effective in mucosal lifting for EMR. 29,30,36 HPMC preparations are available in the United States as ophthalmic lubricants and are typically viscous solutions and must be diluted to 0.3% to 0.8% to facilitate injection. The use of succinylated gelatin as a submucosal injection solution for colonic EMR has been demonstrated to facilitate removal of large colonic lesions (>20 mm) in fewer pieces for piecemeal EMR in a randomized, double-blind trial compared with normal saline solution.…”

Section: Submucosal Injection Solutionsmentioning

confidence: 99%

Endoscopic mucosal resection

Hwang¹,

Konda²,

Dayyeh³

et al. 2015

Gastrointestinal Endoscopy

163

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EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.

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Submucosal Injection of 0.4% Hydroxypropyl Methylcellulose Facilitates Endoscopic Mucosal Resection of Early Gastrointestinal Tumors

Abstract: HPMC solution (0.4%) provides an effective submucosal fluid cushion and is safe for endoscopic resection of early gastrointestinal neoplastic lesions.

Cited by 30 publications

References 26 publications

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

Endoscopic mucosal resection in colorectal lesion: a safe and effective procedure even in lesions larger than 2 cm and in carcinomas

A pilot animal and clinical study of autologous blood solution compared with normal saline for use as an endoscopic submucosal cushion

Endoscopic mucosal resection

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