Usefulness of epinephrine-added injection solution to reduce procedure time for gastric endoscopic submucosal dissection

Abstract

Background and study aims Epinephrine-added submucosal injection solution is used to facilitate hemostasis of non-variceal upper gastrointestinal bleeding and to prevent delayed bleeding of large pedunculated colorectal lesions. However, its benefit in gastric endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unclear. The effectiveness of epinephrine-added injection solution for outcomes of gastric ESD was examined using propensity score matching analysis. Patients and methods A total of 1,599 patients with solitary EGC (83 with non-epinephrine-added solution and 1,516 with epinephrine-added solution) between 2011 and 2018 were enrolled. Propensity scores were calculated to balance the distribution of baseline characteristics: age, sex, tumor location, specimen size, presence of ulcer scar, tumor depth, histological tumor type, and operators’ experience, and 1:3 matching was performed. En bloc resection rate, mean procedure time, delayed bleeding rate, and perforation rate were compared between the non-epinephrine (n = 79) and epinephrine (n = 237) groups. Results Mean procedure time was significantly shorter in the epinephrine group than in the non-epinephrine group (60 vs. 78 min, P < 0.001). No significant difference was found in the rate of en bloc resection (both 99 %), incidence of delayed bleeding (both 6 %), or perforation (0 vs. 0.8 %) between the two groups. In multiple linear regression analysis, use of epinephrine-added solution was independently associated with short procedure time (P < 0.001) after adjustment for other covariates. Conclusion The results suggest that epinephrine-added injection solution is useful for reduction of gastric ESD procedure time, warranting validation in a randomized controlled trial.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

“…Regarding additional substances that can be added to normal isotonic saline, even though there is little evidence for or against the practice, most endoscopists use some kind of blue dye to improve visualization by creating contrast with mucosal and muscle layers, and also diluted adrenaline. The latter showed decreased procedural time in a propensity-matched study, probably because of less intraprocedural bleeding and improved visualization [55].…”

A review of hydrogels used in endoscopic submucosal dissection for intraoperative submucosal cushions and postoperative management

“…Hence, hemostasis in time is necessary and common therapeutic strategies to halt bleeding include drugs, argon plasma coagulation, electrocoagulation and hemostatic clips. Due to its potential to reduce bleeding, diluted epinephrine (1:50 000–1:200 000) is frequently added to the submucosal injection fluid [ 65 ]. But the administration of epinephrine submucosally has the potential to cause systemic consequences, including life-threatening hypertension, cardiac tachycardia and intestinal ischemia [ 66 ].…”

Technical Advances in Endoscopic Resection Techniques for Lower GI Malignancies

“…A systematic review from 2016 [78] did not find significant benefits of alternative agents in terms of en bloc resection, curative resection, or adverse events.Another cheap and well-known add-on is the adjunction of epinephrine 0.001% to the saline solution. In a large Japanese retrospective case-matched study [79] with proper multivariate analysis, the adjunction of epinephrine solution was associated with a reduction in procedure duration and the occurrence of early bleeding but not of delayed bleeding or perforation.Several solutions have been developed by various manufacturers to address this issue [80‒82]. However, over the last few years, concerns and warnings have been raised about the safety of some of these solutions [83] because they can cause undesirable effects such as the occurrence of an inflammatory reaction and post-procedure pain, granulomas at the resection site [84], retractile scarring that prevents a second ESD in case of recurrence, among others.…”

“…Another cheap and well-known add-on is the adjunction of epinephrine 0.001% to the saline solution. In a large Japanese retrospective case-matched study [79] with proper multivariate analysis, the adjunction of epinephrine solution was associated with a reduction in procedure duration and the occurrence of early bleeding but not of delayed bleeding or perforation.…”