Comparison of postpolypectomy bleeding between epinephrine and saline submucosal injection for large colon polyps by conventional polypectomy:A prospective randomized,multicenter study

AIM:To evaluate and compare the clinical outcomes of prophylactic submucosal saline-epinephrine injection and saline injection alone for large colon polyps by conventional polypectomy. METHODS:A prospective study was conducted from July 2003 to July 2004 at 11 tertiary endoscopic centers. Large colon polyps (> 10 mm in diameter) wererandomized to undergo endoscopic polypectomy with submucosal saline-epinephrine injection (epinephrine group) or normal saline injection (saline group). Endoscopic polypectomy was performed by the conventional snare method,and early (< 12 h) and late bleeding complications (12 h-30 d) were observed. RESULTS:A total of 561 polyps in 486 patients were resected by endoscopic polypectomy. Overall,bleeding complications occurred in 7.6% (37/486) of the patients,including 4.9% (12/244) in the epinephrine group,and 10.3% (25/242) in the saline group. Early and late postpolypectomy bleeding (PPB) occurred in 6.6% (32/486) and 1% (5/486) of the patients,respectively,including 4.5% (11/244),0.4% (1/244) in the epinephrine group,and 8.7% (21/242),1.7% (4/242) in the saline group. No significant differences in the rates of overall,early and late PPB were observed between the 2 groups. Multivariate stepwise logistic regression analysis revealed that large size (> 2 cm) and neoplastic polyps were independently and significantly associated with the presence of PPB. CONCLUSION:The prophylactic submucosal injection of diluted epinephrine does not appear to provide an additional advantage over the saline injection alone for the prevention of PPB.

Role of submucosal injection in radiofrequency ablation of gastric low-grade dysplasia:Effects on symptoms and outcomes

Background:To date,there is still a lack of standardized management strategies for gastric low-grade dysplasia(LGD),which is a direct neoplastic precancerous lesion and requires specifically superficial destruction.Radiofrequency ablation(RFA)is expected to be an effective method for gastric LGD,but post-RFA pain may affect patients’satisfaction and compliance.The current study aimed to evaluate the value of a submucosal injection prior to RFA(SI-RFA)for postoperative pain and treatment outcomes.Methods:Between October 2014 and July 2021,gastric LGDs without risk factors(size>2 cm,unclear boundary,and abnormal microsurface and microvascularity)undergoing regular RFA and SI-RFA were retrospectively analyzed.Postoperative pain scores,wound healing,and clinical efficacy were compared.Propensity score matching,stratified analysis,and multivariable logistic regression were performed to control the confounding variables.Results:One hundred and ninety-seven gastric LGDs in 151 patients received regular RFA.Forty-nine gastric LGDs in 36 patients received SI-RFA.Thirty-six pairs of patients were selected for the assessment of postoperative pain by propensity score matching.Compared to regular RFA,SI-RFA significantly decreased the degree and duration of postoperative pain(OR,0.32;95%CI,0.13-0.84;P=0.020),improved wound healing rate(80.0%[36/45]vs.58.9%[89/151],P=0.012),increased the complete ablation rate(91.8%[45/49]vs.86.3%[170/197],χ^(2)=1.094,P=0.295),but correlated with higher rates of local recurrence and progression(25.6%[10/39]vs.13.2%[18/136],χ^(2)=3.471,P=0.062;8.3%[3/36]vs.0.9%[1/116],P=0.042).The multivariable logistic regression model confirmed that submucosal injection was associated with local recurrence(OR,2.93;95%CI,1.13-7.58;P=0.027).Conclusions:Submucosal injections prior to RFA may reduce postoperative pain and scar formation while ensuring complete ablation of gastric LGD.However,local recurrence and progression should be considered seriously.

Liver injury after aluminum potassium sulfate and tannic acid treatment of hemorrhoids

We are reporting a rare case of acute liver injury that developed after an internal hemorrhoid treatment with the aluminum potassium sulfate and tannic acid(ALTA) regimen. A 41-year-old man developed a fever and liver injury after undergoing internal hemorrhoid treatment with a submucosal injection of ALTA with lidocaine. The acute liver injury was classified clinically as hepatocellular and pathologically as cholestastic. We could not classify the mechanism of injury. High eosinophil and immunoglobulin E levels characterized the injury,and a drug lymphocyte stimulation test was negative on postoperative day 25. Fluid replacement for two weeks after hospitalization improved the liver injury. ALTA therapy involves injecting chemicals into the submucosa,from the rectum to the anus,and this is the first description of a case that developed a severe liver disorder after this treatment; hence,an analysis of future cases as they accumulate is desirable.

Novel technique for endoscopic en bloc resection(EMR+)-Evaluation in a porcine model

BACKGROUND Endoscopic en bloc resection of larger polyps is relevant because risk of advanced neoplasia or malignancy correlates with tumor size. Recurrence rates after piecemeal endoscopic mucosal resection (EMR) are high and endoscopic submucosal dissection (ESD) is associated with higher complication rates in the western world. AIM To develop a modified endoscopic en bloc resection technique using an external additional working channel and novel agent for submucosal injection. METHODS EMR+ was considered as modified grasp and snare technique. For simultaneous use of a grasping and cutting device a novel additional working channel was used (AWC■, Ovesco Endoscopy, Tübingen, Germany). AWC■ is installed on the outer surface of the endoscope, covered with a plastic sleeve and designed for single use. For submucosal injection a new agent consisting of poloxamers was used (LiftUp■, Ovesco Endoscopy, Tübingen, Germany). The agent is liquid at room temperature and forms a stable and permanent gel cushion after injection. Safety of LiftUp? has been shown in a pre-clinical study in domestic pigs. LiftUp■ is commercially not yet available but approval is expected in early 2019. EMR+ was first developed ex vivo (explanted pig stomach) and subsequently evaluated in vivo (stomach, porcine model, 3 domestic pigs). Main outcome measurements were: Procedure time, macroscopic en bloc resection and adverse events. RESULTS Concept of EMR+ was first developed ex vivo (explanted pig stomach). Ex vivo, 22 resections were performed after technique was established. Median procedure time (measured from begin of injection to extraction of resection specimen) was 7 min (range 5-11, SD 1.68) and median size of resection specimens was 30 mm × 26 mm × 11 mm ex vivo. Subsequently 13 resections were performed in vivo (stomach, porcine model, 3 domestic pigs). In vivo, median procedure time (measured from begin of injection to extraction of resection specimen) was 5 min (range 3-12, SD 2.72) and median size of resection specimens was 35 mm × 35 mm × 11 mm. In vivo, resection was macroscopic complete in 92.3%, major adverse events were not observed. In one case (7.7%) minor periprocedural bleeding was observed and managed by coagulation. CONCLUSION EMR+ appeared to be effective and safe and was easy and fast to perform in the porcine model. EMR+ needs to be further evaluated clinically in comparative trials.

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

Endoscopic submucosal dissection(ESD)has been clinically proved to have prominent advantages in the treatment of early gastrointestinal cancers over traditional surgery,including less trauma,fewer complications,a quicker recovery and lower costs.During the procedure of ESD,appropriate and multifunctional submucosal injected materials(SIMs)as submucosal cushions play an important role,however,even with many advances in design strategies of SIMs over the past decades,the performance of the submucosal cushions with postoperative management function seems to be still unsatisfactory.In this review,we gave a brief historical recount about the clinical development of SIMs,then some common applications of hydrogels used as SIMs in ESD were summarized,while an account of the universal challenges during ESD procedure was also outlined.Going one step further,some cutting-edge functional strategies of hydrogels for novel applications in ESD were exhibited.Finally,we concluded the advantages of hydrogels as SIMs for ESD as well as the treatment dilemma clinicians faced when it comes to deeply infiltrated lesions,some technical perspectives about linking the clinical demand with commercial supply were also proposed.Encompassing the basic elements of SIMs used in ESD surgery and the corresponding postoperative management requirements,this review could be a good reference for relevant practitioners in expanding the research horizon and improving the well-being index of patients.