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Yang Y, Wang T, Xiao M, Hou Z, Liu Y, Zhang K, Yang L, Sun S. Polysaccharides as submucosal injection materials (SIMs) in endoscopic resection: A comprehensive review. Carbohydr Polym 2025; 355:123360. [PMID: 40037734 DOI: 10.1016/j.carbpol.2025.123360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2024] [Revised: 01/31/2025] [Accepted: 02/05/2025] [Indexed: 03/03/2025]
Abstract
Submucosal injection materials (SIMs) play a vital role in the endoscopic treatment of benign and early malignant gastrointestinal lesions by effectively elevating lesions while significantly reducing the risks of thermal injury and bleeding. However, the traditional use of normal saline (NS) presents challenges due to its rapid absorption, which necessitates frequent reapplications and complicates procedural efficiency. Therefore, there is a pressing need for ideal SIMs that are cost-effective, readily available, and suitable for personalized therapy, while also demonstrating excellent biocompatibility and physicochemical stability. Recent advancements have highlighted the potential of polysaccharide-based natural polymers, such as sodium hyaluronate, cellulose, starch derivatives, chitosan, and sodium alginate, due to their superior biocompatibility and biodegradability. These polysaccharides have exhibited enhanced operational characteristics and therapeutic efficacy in animal and clinical studies. Nevertheless, ongoing research must address several challenges, including optimizing cost-effectiveness, improving mechanical strength and bioactivity, and mitigating intraoperative and postoperative complications. This review systematically examines the progress of polysaccharide-based natural polymers in SIMs, evaluates their current status and challenges in both research and clinical applications, and proposes future directions to enhance their utilization in gastrointestinal endoscopic therapy.
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Affiliation(s)
- Yaochen Yang
- Research Center for Biomedical Materials, Shenyang Key Laboratory of Biomedical Polymers, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China; Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Tingting Wang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Miaomiao Xiao
- Research Center for Biomedical Materials, Shenyang Key Laboratory of Biomedical Polymers, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Zhipeng Hou
- Research Center for Biomedical Materials, Shenyang Key Laboratory of Biomedical Polymers, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China
| | - Yang Liu
- Innovative Engineering Technology Research Center for Cell Therapy, Shengjing Hospital of China Medical University, Shenyang, Liaoning 110022, China
| | - Kai Zhang
- Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Liqun Yang
- Research Center for Biomedical Materials, Shenyang Key Laboratory of Biomedical Polymers, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China.
| | - Siyu Sun
- Research Center for Biomedical Materials, Shenyang Key Laboratory of Biomedical Polymers, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China; Department of Gastroenterology, Endoscopic Center, Engineering Research Center of Ministry of Education for Minimally Invasive Gastrointestinal Endoscopic Techniques, Shengjing Hospital of China Medical University, Shenyang 110004, China.
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Qin G, Wu R, Wang Q, Sun M, Li Y, Duan S, Xu FJ. Injectable Hyaluronic Acid-Based Hydrogels for Rapid Endoscopic Submucosal Dissection. ACS Biomater Sci Eng 2024; 10:7657-7666. [PMID: 39563065 DOI: 10.1021/acsbiomaterials.4c01703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2024]
Abstract
Endoscopic submucosal dissection (ESD) is a widely used procedure for the treatment of early and precancerous gastrointestinal lesions and has become the standard treatment. In this procedure, the commonly used materials have a short retention time and a limited lifting capacity, which will prolong the duration of the ESD procedure. Furthermore, these liquids tend to diffuse after ESD surgery, failing to adequately protect the wound. Therefore, we designed and developed injectable hydrogels based on hyaluronic acid. A series of oxidized hyaluronic acid (OHA) and hydrazide hyaluronic acid (AHA) were synthesized, and 16 kinds of injectable hydrogels were fabricated to investigate the effects of molecular structures on the properties of the hydrogels. Among these, the O1A3 hydrogel exhibited a suitable injection performance, gelation time, and mechanical properties, along with good blood and cell compatibility in vitro. Subsequently, in a porcine model of the ESD procedure, the results demonstrated that the O1A3 hydrogel exhibited a good retention time and lifting performance while also significantly reducing the operation time from 1-2 h to ∼10 min. Furthermore, the adhesive property of the O1A3 hydrogel on small bleeding spots and wounds could be observed, which was beneficial in protecting the wound from the complex environment of the gastrointestinal tract. The present work of injectable hyaluronic acid-based hydrogels could be promising to improve the efficiency of ESD surgery.
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Affiliation(s)
- Geng Qin
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Ruonan Wu
- State Key Laboratory of Chemical Resource Engineering, Key Lab of Biomedical Materials of Natural Macromolecules (Beijing University of Chemical Technology), Ministry of Education, Beijing Laboratory of Biomedical Materials, Beijing University of Chemical Technology, Beijing 100029, China
| | - Qianqian Wang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Meizhou Sun
- State Key Laboratory of Chemical Resource Engineering, Key Lab of Biomedical Materials of Natural Macromolecules (Beijing University of Chemical Technology), Ministry of Education, Beijing Laboratory of Biomedical Materials, Beijing University of Chemical Technology, Beijing 100029, China
| | - Yang Li
- State Key Laboratory of Chemical Resource Engineering, Key Lab of Biomedical Materials of Natural Macromolecules (Beijing University of Chemical Technology), Ministry of Education, Beijing Laboratory of Biomedical Materials, Beijing University of Chemical Technology, Beijing 100029, China
| | - Shun Duan
- State Key Laboratory of Chemical Resource Engineering, Key Lab of Biomedical Materials of Natural Macromolecules (Beijing University of Chemical Technology), Ministry of Education, Beijing Laboratory of Biomedical Materials, Beijing University of Chemical Technology, Beijing 100029, China
| | - Fu-Jian Xu
- State Key Laboratory of Chemical Resource Engineering, Key Lab of Biomedical Materials of Natural Macromolecules (Beijing University of Chemical Technology), Ministry of Education, Beijing Laboratory of Biomedical Materials, Beijing University of Chemical Technology, Beijing 100029, China
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Tang Z, Yang X, Zhang K, Fang K. Modifying Cotton Fabric Properties by Controlling HPMC Viscosity Grade to Limit Ink Spreading and Penetration. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2024; 40:18581-18588. [PMID: 39161096 DOI: 10.1021/acs.langmuir.4c01999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/21/2024]
Abstract
In cotton fabric inkjet printing, the spreading and penetration of the ink seriously damage printing resolution and color strength. In this study, hydroxypropyl methyl cellulose (HPMC) with varying viscosity grades (6, 30, 100, 400, and 4000 mPa·s) were used for fabric pretreatment to reduce the ink spreading and penetration. The results indicated that HPMC with a high viscosity grade enhanced the ability of pretreatment paste to form a continuous HPMC film on the fiber surface. A continuous film could greatly increase the hydrophobicity of the fabric, thereby restricting the spreading and penetration of ink. Meanwhile, ink migration was also limited by the paste connected to the fibers and the swelling of the film, which was more significant at higher HPMC viscosity grades. However, the increase of the HPMC viscosity grade was not conducive to dye fixation. Additionally, HPMC with a viscosity grade of 100 mPa·s was considered a reasonable choice, which could improve printing resolution and color strength in industrial applications. This research provides a new approach for optimizing pretreatment paste to achieve high-quality printed products.
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Affiliation(s)
- Zhiyuan Tang
- College of Textiles & Clothing, Qingdao University, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province and the Ministry of Education, Qingdao 266071, China
- State Key Laboratory for Biofibers and Eco-textiles, Qingdao 266071, China
- Shandong Key Laboratory of Textile Materials for Healthcare, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province, Qingdao 266071, China
- University Laboratory for Low Carbon and Functional Textiles of Shandong Province, Qingdao 266071, China
| | - Xueyuan Yang
- College of Textiles & Clothing, Qingdao University, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province and the Ministry of Education, Qingdao 266071, China
- State Key Laboratory for Biofibers and Eco-textiles, Qingdao 266071, China
- Shandong Key Laboratory of Textile Materials for Healthcare, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province, Qingdao 266071, China
- University Laboratory for Low Carbon and Functional Textiles of Shandong Province, Qingdao 266071, China
| | - Kun Zhang
- College of Textiles & Clothing, Qingdao University, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province and the Ministry of Education, Qingdao 266071, China
- State Key Laboratory for Biofibers and Eco-textiles, Qingdao 266071, China
- Shandong Key Laboratory of Textile Materials for Healthcare, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province, Qingdao 266071, China
- University Laboratory for Low Carbon and Functional Textiles of Shandong Province, Qingdao 266071, China
| | - Kuanjun Fang
- College of Textiles & Clothing, Qingdao University, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province and the Ministry of Education, Qingdao 266071, China
- State Key Laboratory for Biofibers and Eco-textiles, Qingdao 266071, China
- Shandong Key Laboratory of Textile Materials for Healthcare, Qingdao 266071, China
- Collaborative Innovation Center for Eco-textiles of Shandong Province, Qingdao 266071, China
- University Laboratory for Low Carbon and Functional Textiles of Shandong Province, Qingdao 266071, China
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Huang L, Jiang Y, Zhang P, Li M, Liu B, Tang K. Injectable Modified Sodium Alginate Microspheres for Enhanced Operative Efficiency and Safety in Endoscopic Submucosal Dissection. Biomacromolecules 2024; 25:2953-2964. [PMID: 38652682 DOI: 10.1021/acs.biomac.4c00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
Endoscopic submucosal dissection (ESD) is an effective method for resecting early-stage tumors in the digestive system. To achieve a low injection pressure of the injected fluid and continuous elevation of the mucosa following injection during the ESD technique, we introduced an innovative injectable sodium-alginate-based drug-loaded microsphere (Cipro-ThSA) for ESD surgery, which was generated through an emulsion reaction involving cysteine-modified sodium alginate (ThSA) and ciprofloxacin. Cipro-ThSA microspheres exhibited notable adhesiveness, antioxidant activity, and antimicrobial properties, providing a certain level of postoperative wound protection. In vitro cell assays confirmed the decent biocompatibility of the material. Lastly, according to animal experiments involving submucosal elevation of porcine colons, Cipro-ThSA microspheres ensure surgically removable lift height while maintaining the mucosa for approximately 246% longer than saline, which could effectively reduce surgical risks while providing sufficient time for operation. Consequently, the Cipro-ThSA microsphere holds great promise as a novel submucosal injection material, in terms of enhancing the operational safety and effectiveness of ESD surgery.
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Affiliation(s)
- Luzhan Huang
- School of Materials Science and Engineering, Zhengzhou University, Zhengzhou 450001, China
| | - Yongchao Jiang
- School of Materials Science and Engineering, Zhengzhou University, Zhengzhou 450001, China
| | - Pengcheng Zhang
- School of Materials Science and Engineering, Zhengzhou University, Zhengzhou 450001, China
| | - Muhan Li
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Bingrong Liu
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China
| | - Keyong Tang
- School of Materials Science and Engineering, Zhengzhou University, Zhengzhou 450001, China
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Kang JW, Chen PJ, Chen CY, Riley G, Wang YS, Kuo HY, Chuang CH. Development of a hybrid hydrogel for submucosal injection in endoscopic resection of gastrointestinal neoplasm: From laboratory to clinical trial. Endosc Int Open 2023; 11:E1026-E1034. [PMID: 38835638 PMCID: PMC11148844 DOI: 10.1055/a-2161-2100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/25/2023] [Indexed: 06/06/2024] Open
Abstract
Background and study aims Submucosal injection solution is essential for successful endoscopic resection of the early gastrointestinal tumor. We evaluated a new endoscopic hydrogel for submucosal injection and its clinical feasibility. Patients and methods A hydrogel (AceGel) containing 0.4% sodium alginate and 2% calcium lactate was developed for ex vivo and animal studies. Subsequently, a prospective, single-arm study was conducted to assess its feasibility and safety in humans. Patients with gastrointestinal neoplasms undergoing endoscopic resection were enrolled. All patients underwent endoscopic surveillance after 4 weeks and outpatient follow-up at week 6. Afterward, they received endoscopic follow-up according to the medical routine. Results In the ex vivo experiments, the submucosal elevation height of AceGel was equivalent to sodium hyaluronate and superior to saline or glycerol. Animal studies showed that the excised wounds healed well without surrounding tissue damage. Twelve patients participated in the clinical trial, including three, two, and seven patients with esophageal, gastric, and colonic lesions, respectively. The mean neoplasm size and submucosal injection volumes were 24.0±8.6 mm and 22.8±19.9 mL, respectively. All patients had adequate wound healing on 4-week surveillance endoscopy, and none had serious adverse events during 6-week follow-up. Moreover, endoscopic follow-up showed complete wound healing after 6 to 46 months without local mucosal inflammation in all patients. Conclusions AceGel is good for endoscopic submucosal injection and demonstrated its usefulness in durable mucosal elevation for endoscopic therapy in preclinical tests. This clinical trial shows its safety and feasibility in all participating patients.
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Affiliation(s)
- Jui-Wen Kang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Po-Jun Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiung-Yu Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Guillermo Riley
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yao-Sheng Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsin-Yu Kuo
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chiao-Hsiung Chuang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Shah RH, Amin S. Building the Toolbox of Devices to Optimize a Practice in Submucosal Endoscopy. Gastrointest Endosc Clin N Am 2023; 33:15-28. [PMID: 36375879 DOI: 10.1016/j.giec.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic submucosal dissection (ESD) is a technically complex and still evolving procedure. As a result, there are many advances in the technology and tools available to assist the endoscopist. This article delves into the various tools developed for ESD including electrosurgical knives, caps, injection agents, and traction devices. The authors discuss tools available as well as their respective pros, cons, and technical considerations for use. Overall, the choice of tools depends on a multitude of factors from availability, cost, lesion characteristics, and the endoscopist's familiarity and proficiency.
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Affiliation(s)
- Rahil H Shah
- Department of Medicine, University of Miami/Jackson Memorial Hospital, 1611 Northwest 12th Avenue, C-600D, Miami, FL 33136, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miller School of Medicine at the University of Miami, 1120 Northwest 14th Street, Clinical Research Building, Suite 11145 (D-49), Miami, FL 33136, USA.
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Bulking agents in gastrointestinal endoscopy: present applications and future advances. Curr Opin Gastroenterol 2022; 38:472-480. [PMID: 35881970 DOI: 10.1097/mog.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Bulking agents are inert materials injected into an organ to affect the physical properties of the organ for a therapeutic purpose. Various agents have been developed to aid in the treatment of diseases like gastroesophageal reflux disease (GERD), fecal incontinence, obesity, malignancy, hemostasis, and tissue dissection. Here, we review the state of the art in bulking agents in gastrointestinal endoscopy, past failures, current limitations, and where we see the field heading in the future. RECENT FINDINGS Though bulking agents have been trialed for various different gastrointestinal diseases, there are currently limited uses in gastrointestinal endoscopy. Though various agents have been trialed for GERD, numerous complications and adverse events have limited its current use. However, for the treatment of fecal incontinence endoscopic bulking agent therapy is a reasonable option. Though in early stages of exploration, bulking agent therapy for enteric protection from radiotherapy may be a promising tool to improve treatment of pancreatic cancer. Bulking agents for tissue dissection have substantially improved lifting agents and complex polyp removal. Bulking agent therapy has not really been explored for endoscopic bariatric therapy or hemostasis but may be a fruitful area for exploration in the future. SUMMARY Bulking agent therapy has been trialed for various gastrointestinal diseases with mixed success. There is currently a therapeutic roll in the endoscopic management of fecal incontinence and tissue dissection. A future role in the treatment of GERD, obesity, malignancy, and hemostasis seem feasible.
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Mann R, Gajendran M, Umapathy C, Perisetti A, Goyal H, Saligram S, Echavarria J. Endoscopic Management of Complex Colorectal Polyps: Current Insights and Future Trends. Front Med (Lausanne) 2022; 8:728704. [PMID: 35127735 PMCID: PMC8811151 DOI: 10.3389/fmed.2021.728704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022] Open
Abstract
Most colorectal cancers arise from adenomatous polyps and sessile serrated lesions. Screening colonoscopy and therapeutic polypectomy can potentially reduce colorectal cancer burden by early detection and removal of these polyps, thus decreasing colorectal cancer incidence and mortality. Most endoscopists are skilled in detecting and removing the vast majority of polyps endoscopically during a routine colonoscopy. Polyps can be considered “complex” based on size, location, morphology, underlying scar tissue, which are not amenable to removal by conventional endoscopic polypectomy techniques. They are technically more challenging to resect and carry an increased risk of complications. Most of these polyps were used to be managed by surgical intervention in the past. Rapid advancement in endoscopic resection techniques has led to a decreasing role of surgery in managing these complex polyps. These endoscopic resection techniques do require an expert in the field and advanced equipment to perform the procedure. In this review, we discuss various advanced endoscopic techniques for the management of complex polyps.
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Affiliation(s)
- Rupinder Mann
- Department of Internal Medicine, Saint Agnes Medical Center, Fresno, CA, United States
- *Correspondence: Rupinder Mann
| | - Mahesh Gajendran
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Chandraprakash Umapathy
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Abhilash Perisetti
- Department of Gastroenterology and Hepatology, The University of Arkansas for Medical Sciences, Little Rock, AR, United States
- Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, IN, United States
| | - Hemant Goyal
- The Wright Center for Graduate Medical Education, Scranton, PA, United States
| | - Shreyas Saligram
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
| | - Juan Echavarria
- Division of Gastroenterology, Long School of Medicine, University of Texas Health San Antonio, San Antonio, TX, United States
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Injectable Thermosensitive Chitosan Solution with β-Glycerophosphate as an Optimal Submucosal Fluid Cushion for Endoscopic Submucosal Dissection. Polymers (Basel) 2021; 13:polym13111696. [PMID: 34067377 PMCID: PMC8196954 DOI: 10.3390/polym13111696] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/16/2021] [Accepted: 05/19/2021] [Indexed: 01/27/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is a surgical procedure to remove early neoplastic lesions in the gastrointestinal tract with the critical issue of perforation. A submucosal fluid cushion, such as normal saline, is used as a cushioning agent to prevent perforation; however, its cushioning maintenance is insufficient for surgery. In this study, we introduce an injectable thermosensitive chitosan solution (CS) with β-glycerophosphate (β-GP) as a submucosal injection agent for ESD. The CS/β-GP system with optimal β-GP concentration showed drastic viscosity change near body temperature while other commercial products did not. Additionally, the injectability of the solution was similar to or greater than other commercial products. The solution with low β-GP concentration showed low cytotoxicity similar to other products. An in vivo preclinical study illustrated maintenance of the high cushioning of the thermosensitive solutions. These results indicate that a CS/β-GP system with optimal β-GP concentration might be used as a submucosal injection agent in ESD, and further studies are needed to validate the effectiveness of the solutions in vivo.
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Jeon HJ, Jeong S, Choi HS, Jang SH, Kim SH, Kim SH, Lee JM, Kim ES, Keum B, Jeen YT, Lee HS, Chun HJ, Chung JH, Kim SN. A Comparative Study on Aqueous Chitosan Solution and Various Submucosal Injection Fluids Using a Three-Dimensional Sensor. Gut Liver 2021; 15:217-224. [PMID: 32390408 PMCID: PMC7960965 DOI: 10.5009/gnl19383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 12/13/2022] Open
Abstract
Background/Aims Chitosan, a natural polymer widely used in the biomaterials field, has been proposed as a potential submucosal injection solution. The purpose of this study was to compare the performance and efficacy of aqueous chitosan solution and commercialized submucosal injection fluids using a three-dimensional sensor and to evaluate the efficacy of the measured parameters. Methods Normal saline (0.9% NaCl), as a control, Eleview® (Poloxamer 188), Blue EyeTM (0.4% hyaluronic acid), and aqueous chitosan solution (2.0%) were injected into the submucosa of porcine stomachs ex vivo. The mucosal elevation height, elevated surface area, and angle of the tangent of the submucosal fluid cushion were measured using a three-dimensional sensor. The rates of change for each variable were calculated, and the correlation between parameters was analyzed. Tissue specimens were stained with hematoxylin and eosin. Results All variables exhibited the highest values under chitosan injection. The mucosal elevation height rate of change differed significantly between normal saline and chitosan solution (p=0.024). The elevated surface area rates of change for normal saline and Eleview® were significantly different from those for TS-905 and chitosan solution (p=0.006 and p=0.009, respectively). Further, height, area, and angle showed a positive correlation (p<0.001). A histological examination revealed an even distribution of aqueous chitosan within the submucosa without tissue damage. Conclusions Aqueous chitosan was superior to normal saline and Eleview® and was noninferior to TS-905. A three-dimensional sensor and the measured parameters were effective and useful for evaluating the performance of submucosal fluids.
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Affiliation(s)
- Han Jo Jeon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Jeong
- Department of Biosystems & Biomaterials Science and Engineering, Seoul National University College of Agriculture and Life Science, Seoul, Korea.,Medical Engineering Research Center, The Standard Co. Ltd., Gunpo, Korea
| | - Hyuk Soon Choi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Se Hyun Jang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Hoon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seung Han Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Eun Sun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Bora Keum
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Yoon Tae Jeen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hoon Jai Chun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Hoon Chung
- Department of Biosystems & Biomaterials Science and Engineering, Seoul National University College of Agriculture and Life Science, Seoul, Korea
| | - Seong Nam Kim
- Medical Engineering Research Center, The Standard Co. Ltd., Gunpo, Korea
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Yoshida T, Hirose R, Naito Y, Inoue K, Dohi O, Yoshida N, Kamada K, Uchiyama K, Ishikawa T, Takagi T, Konishi H, Nakaya T, Itoh Y. Viscosity: An important factor in predicting the performance of submucosal injection materials. MATERIALS & DESIGN 2020; 195:109008. [DOI: 10.1016/j.matdes.2020.109008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2023]
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12
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Shafabakhsh R, Yousefi B, Asemi Z, Nikfar B, Mansournia MA, Hallajzadeh J. Chitosan: A compound for drug delivery system in gastric cancer-a review. Carbohydr Polym 2020; 242:116403. [PMID: 32564837 DOI: 10.1016/j.carbpol.2020.116403] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/29/2020] [Accepted: 05/03/2020] [Indexed: 02/07/2023]
Abstract
Gastric cancer is known as the fourth most common cancer and the second main cause of cancer-related deaths. Gastric cancer has some characteristics including high incidence rates of metastasis and mortality as well as low rates of early diagnosis, radical resection and 5-year survival. Radical surgery and following chemotherapy has been done for patients with early gastric cancer leading to 90 % survival rate in 5-year after operation. Besides, in advanced stage some cases don't have the chance of surgery as well as the risk of metastasis is high in these patients overally leading to poor prognosis. In recent years, finding a suitable drug delivery system for chemotherapeutic drugs in gastric cancer is an considerable subject for researchers. Chitosan is known as an appropriate compound for chemo-drug delivery in cancer treatment due to its high biodegradability and biocompatibility. Moreover, trans-mucosal drug delivery is facilitated by chitosan via its mucoadhesive and cationic features enhancing interaction with mucous membrane. In addition, a large amount of experimental evidence has reported the efficacy of chitosan for drug delivery in gastric cancer. Thus, the aim of this article was to review this evidence as well as new chitosan-based drug delivery systems investigated in gastric cancer.
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Affiliation(s)
- Rana Shafabakhsh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran.
| | - Bahman Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran.
| | - Banafsheh Nikfar
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran.
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran.
| | - Jamal Hallajzadeh
- Department of Biochemistry and Nutrition, Research Center for Evidence-Based Health Management, Maragheh University of Medical Sciences, Maragheh, Iran.
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13
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Karakucuk A, Tort S. Preparation, characterization and antimicrobial activity evaluation of electrospun PCL nanofiber composites of resveratrol nanocrystals. Pharm Dev Technol 2020; 25:1216-1225. [DOI: 10.1080/10837450.2020.1805761] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alptug Karakucuk
- Faculty of Pharmacy, Department of Pharmaceutical Technology, Gazi University, Ankara, Turkey
- Fiber Farma Drug Cosmetics Medical Devices and Consulting, Gazi Technopark, Ankara, Turkey
| | - Serdar Tort
- Faculty of Pharmacy, Department of Pharmaceutical Technology, Gazi University, Ankara, Turkey
- Fiber Farma Drug Cosmetics Medical Devices and Consulting, Gazi Technopark, Ankara, Turkey
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14
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Abstract
PURPOSE OF REVIEW To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). RECENT FINDINGS EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed Othman
- Baylor St Luke's Medical Center, Houston, TX, USA.
- Division of Gastroenterology, Baylor College of Medicine, 7200 Cambridge St., 8th Floor, Suite 8B, Houston, TX, 77030, USA.
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15
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Harlow C, Sivananthan A, Ayaru L, Patel K, Darzi A, Patel N. Endoscopic submucosal dissection: an update on tools and accessories. Ther Adv Gastrointest Endosc 2020; 13:2631774520957220. [PMID: 33089213 PMCID: PMC7545765 DOI: 10.1177/2631774520957220] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/08/2020] [Indexed: 12/11/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a minimally invasive therapeutic procedure to remove larger polyps or early non-metastatic lesions. It has long been used in Asia, but is now fast growing in popularity in the West. There are multiple challenges faced by ESD practitioners. While the practice of ESD in gastric lesions is relatively well established, the oesophagus with its narrow lumen and challenging workspace, and the colon with its tortuous course and folds are more challenging frontiers. The nature of performing a procedure endoscopically means that conventional methods offer no mechanism for providing counter-traction while performing dissection, impeding visibility and increasing the rate of complications. There are a multitude of tools available to those performing ESD for the different stages of the procedure. This article reviews the accessories currently used in regular ESD practice including the knives used to cut and dissect lesions, the cap and hood devices used to improve visibility and safety, injection fluids to lift the submucosal plane, haemostatic devices, generators, and finally, emerging traction apparatus. There is some evidence behind the use of these tools, however, ESD remains the domain of a small number of practitioners and the practice relies heavily on expert experience. Evolution of the ESD toolbox will make the procedure more accessible to more endoscopists, which in turn will drive the development of a more substantial evidence base to evaluate efficacy and safety of the multitude of tools.
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Affiliation(s)
| | - Arun Sivananthan
- Imperial College Healthcare NHS Trust, London, UK; Institute of Global Health Innovation, London, UK
| | | | - Kinesh Patel
- Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College Healthcare NHS Trust; Institute of Global Health Innovation, London, UK
| | - Nisha Patel
- Imperial College Healthcare NHS Trust, Institute of Global Health Innovation, St Mary’s Hospital Campus, 10th Floor, QEQM Wing, South Wharf Road, Paddington, London W2 1NY, UK
- Imperial College Healthcare NHS Trust, London, UK
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16
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Pang Y, Liu J, Moussa ZL, Collins JE, McDonnell S, Hayward AM, Jajoo K, Langer R, Traverso G. Endoscopically Injectable Shear-Thinning Hydrogels Facilitating Polyp Removal. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2019; 6:1901041. [PMID: 31592420 PMCID: PMC6774062 DOI: 10.1002/advs.201901041] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/13/2019] [Indexed: 05/17/2023]
Abstract
Submucosal elevation, the process of instilling material in the submucosal space for separation of the surface mucosa and deeper muscularis layer, is a significant aspect of the endoscopic mucosal resection of large lesions performed to facilitate lesion removal and maximize safety. Submucosal injection, when applied, has historically been performed with normal saline, though this is limited by its rapid dissipation; solutions ideally need to be easily injectable, biocompatible, and provide a long-lasting submucosal cushion with a desirable height. Here, reported is a new set of materials, endoscopically injectable shear-thinning hydrogels, meeting these requirements because of their biocompatible components and ability to form a solid hydrogel upon injection. These findings are supported by evaluation in a large animal model and ultimately demonstrate the potential of these shear-thinning hydrogels to serve as efficient submucosal injection fluids for cushion development. Given these unique characteristics, their broad application in mucosal resection techniques is anticipated.
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Affiliation(s)
- Yan Pang
- Department of OphthalmologyNinth People's HospitalShanghai Key Laboratory of Orbital Diseases and Ocular OncologyShanghai Jiao Tong University School of MedicineShanghai200011China
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Jinyao Liu
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
- Institute of Molecular MedicineState Key Laboratory of Oncogenes and Related GenesShanghai Institute of CancerRenji HospitalShanghai Jiao Tong University School of MedicineShanghai200127China
| | - Zaina L. Moussa
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Joy E. Collins
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Shane McDonnell
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Alison M. Hayward
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchDivision of Comparative MedicineMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Kunal Jajoo
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical SchoolBostonMA02115USA
| | - Robert Langer
- Department of Chemical Engineering and Koch Institute for Integrative Cancer ResearchHarvard‐MIT Division of Health Sciences and TechnologyMassachusetts Institute of TechnologyCambridgeMA02139USA
| | - Giovanni Traverso
- Division of GastroenterologyBrigham and Women's HospitalHarvard Medical SchoolBostonMA02115USA
- Department of Mechanical EngineeringMassachusetts Institute of TechnologyCambridgeMA02139USA
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17
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Castro R, Libânio D, Pita I, Dinis-Ribeiro M. Solutions for submucosal injection: What to choose and how to do it. World J Gastroenterol 2019; 25:777-788. [PMID: 30809079 PMCID: PMC6385015 DOI: 10.3748/wjg.v25.i7.777] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/18/2019] [Accepted: 01/26/2019] [Indexed: 02/06/2023] Open
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.
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Affiliation(s)
- Rui Castro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Inês Pita
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
- CIDES/CINTESIS, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
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18
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Kendir OT, Yilmaz HL, Bozdogan S, Bisgin A, Celik T, Surmelioglu O, Doran F. A Two-Month-Old Child with Vascular Ectasia: A Case Report Diagnosed by Molecular Karyotyping. J Pediatr Genet 2019; 8:20-23. [PMID: 30775049 DOI: 10.1055/s-0038-1669385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 07/18/2018] [Indexed: 10/28/2022]
Abstract
Gastrointestinal angiodysplasia can be encountered in cases with aortic stenosis, inflammatory gastrointestinal conditions, von Willebrand disease or vascular damage, and degenerative changes. Predisposing factors have been described in four adults with vascular ectasia located in the stomach, duodenum, and the distal esophagus. Here, we report a 2-month-old infant with vascular ectasia in the proximal esophagus and diagnosed by molecular karyotyping. This is the first case of vascular ectasia in the proximal esophagus in a pediatric patient.
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Affiliation(s)
- Ozlem Tolu Kendir
- Department of Pediatrics, Çukurova Üniversity, Balcali Hospital, Adana, Turkey
| | - Hayri Levent Yilmaz
- Department of Pediatrics, Çukurova Üniversity, Balcali Hospital, Adana, Turkey
| | - Sevcan Bozdogan
- AGENTEM (Adana Genetic Diseases Diagnosis and Treatment Center), Cukurova University, Adana, Turkey.,Medical Genetics Department of Balcali Clinics and Hospital, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Atıl Bisgin
- AGENTEM (Adana Genetic Diseases Diagnosis and Treatment Center), Cukurova University, Adana, Turkey.,Medical Genetics Department of Balcali Clinics and Hospital, Cukurova University Faculty of Medicine, Adana, Turkey
| | - Tugçe Celik
- Department of Pediatrics, Çukurova Üniversity, Balcali Hospital, Adana, Turkey
| | - Ozgur Surmelioglu
- Department of Otorhinolaryngology, Çukurova Üniversity, Balcali Hospital, Adana, Turkey
| | - Figen Doran
- Department of Pathology, Çukurova Üniversity, Balcali Hospital, Adana, Turkey
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19
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Alonci G, Fiorini F, Riva P, Monroy F, López-Montero I, Perretta S, De Cola L. Injectable Hybrid Hydrogels, with Cell-Responsive Degradation, for Tumor Resection. ACS APPLIED BIO MATERIALS 2018; 1:1301-1310. [DOI: 10.1021/acsabm.8b00189] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Giuseppe Alonci
- Institut de Science et d’Ingénierie Supramoléculaires, CNRS, UMR 7006, Université de Strasbourg, 8 rue Gaspard Monge, 67000 Strasbourg, France
| | - Federica Fiorini
- Institut de Science et d’Ingénierie Supramoléculaires, CNRS, UMR 7006, Université de Strasbourg, 8 rue Gaspard Monge, 67000 Strasbourg, France
| | - Pietro Riva
- IHU, Strasbourg 1 place de l’Hôpital, 67000 Strasbourg, France
| | - Francisco Monroy
- Universidad Complutense de Madrid, Avda. Complutense s/n, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Avda. Córdoba s/n, 28041 Madrid, Spain
| | - Ivan López-Montero
- Universidad Complutense de Madrid, Avda. Complutense s/n, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Avda. Córdoba s/n, 28041 Madrid, Spain
| | | | - Luisa De Cola
- Institut de Science et d’Ingénierie Supramoléculaires, CNRS, UMR 7006, Université de Strasbourg, 8 rue Gaspard Monge, 67000 Strasbourg, France
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20
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Mehta N, Strong AT, Franco M, Stevens T, Chahal P, Jang S, Lopez R, Patil D, Abe S, Saito Y, Uraoka T, Vargo J, Bhatt A. Optimal injection solution for endoscopic submucosal dissection: A randomized controlled trial of Western solutions in a porcine model. Dig Endosc 2018; 30:347-353. [PMID: 29181852 DOI: 10.1111/den.12993] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/21/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND AIM When carrying out endoscopic submucosal dissection (ESD), procedural safety increases with greater tissue elevation and efficiency increases with longer-lasting submucosal cushion. Fluids specifically developed for ESD in Asia are not commercially available in the West, leaving endoscopists to use a variety of injectable fluids off-label. To determine the optimal fluid available in the West, we compared commonly used fluids for Western ESD. METHODS All phases were carried out in an ex vivo porcine stomach model. Phase 1 compared tissue elevation and duration of submucosal cushions produced by various standard volumes of various injectable solutions used for ESD. The two best-performing solutions used off-label were tested head-to-head in ESD in Phase 2. Phase 3 compared the best solution from Phase 2 to Eleview® , currently the only submucosal injection fluid approved in the USA. In Phases 2 and 3, five ESD were carried out with each solution. The solutions were randomized and the endoscopist blinded to the solution. RESULTS The best-performing solutions in Phase 1 were 0.4% hyaluronic acid, 6% hydroxyethyl starch (HES), and Eleview® . Phase 2 compared 6% HES and hydroxypropyl methylcellulose (HPMC), showing that ESD with 6% HES was easier (P = 0.007), faster (P = 0.041) and required less injection volume (P = 0.003). In Phase 3, resection speed, ease of ESD and total volume per area resected were comparable between 6% HES and Eleview® . CONCLUSIONS Of the submucosal injection fluids currently available in the West, Eleview® and 6% HES are the best-performing solutions for ESD in a porcine model.
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Affiliation(s)
- Neal Mehta
- Internal Medicine Institute, Cleveland Clinic, Cleveland, USA
| | - Andrew T Strong
- Section of Surgical Endoscopy, Cleveland Clinic, Cleveland, USA
| | - Matheus Franco
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Prabhleen Chahal
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Rocio Lopez
- Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, USA
| | - Deepa Patil
- Department of Pathology, Cleveland Clinic, Cleveland, USA
| | - Seichiiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Yutaka Saito
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Toshio Uraoka
- Department of Gastroenterology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan
| | - John Vargo
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, USA
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21
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Hattori H, Ishihara M. Development of Mucoadhesive Chitosan Derivatives for Use as Submucosal Injections. Polymers (Basel) 2018; 10:polym10040410. [PMID: 30966445 PMCID: PMC6415235 DOI: 10.3390/polym10040410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 04/03/2018] [Accepted: 04/04/2018] [Indexed: 02/07/2023] Open
Abstract
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have been used for surgical treatment of early gastric cancer. These endoscopic techniques require proper submucosal injections beneath the tumor to provide a sufficiently high submucosal fluid cushion (SFC) to facilitate clean dissection and resection of the tumor. Until now, the submucosal injection materials developed for endoscopic techniques such as EMR and ESD of tumors have been composed of macromolecules, proteins, or polysaccharides. We have been investigating the use of chitosan, a product that is obtained by the alkaline deacetylation of chitin, the second-most abundant natural polysaccharide. Specifically, we have been studying a photocrosslinked chitosan hydrogel (PCH) and solubilized chitosan derivatives for use as novel submucosal injections for endoscopic techniques. Notably, chitosan derivatives with lactose moieties linked to the amino groups of its glucosamine units can specifically interact with acidic mucopolysaccharides and mucins in submucosa without the need for the incorporation of harmful photoreactive groups nor potentially mutagenic ultraviolet irradiation.
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Affiliation(s)
- Hidemi Hattori
- Department of Biochemistry and Applied Biosciences, Faculty of Agriculture, University of Miyazaki, 1-1 Gakuenkibanadai-nishi, Miyazaki 889-2192, Japan.
| | - Masayuki Ishihara
- Division of Biomedical Engineering, Research Institute, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan.
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22
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Fujimoto A, Uraoka T, Nishizawa T, Shimoda M, Goto O, Ochiai Y, Maehata T, Akimoto T, Mitsunaga Y, Sasaki M, Yamamoto H, Yahagi N. Rebamipide solution: a novel submucosal injection material to promote healing speed and healing quality of ulcers induced by endoscopic submucosal dissection. Gastrointest Endosc 2018; 87:1114-1120. [PMID: 28993136 DOI: 10.1016/j.gie.2017.09.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/27/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Rebamipide is administered perorally to protect the gastric mucosa. We assessed the efficacy and safety of a novel rebamipide solution as a submucosal injection material for endoscopic submucosal dissection (ESD) using an in vivo porcine model. METHODS An endoscopist blinded to the test agents performed ESDs of hypothetical 30 mm lesions using a 2% rebamipide solution at 2 sites (rebamipide group) and a saline solution at 2 other sites (control group) in the stomachs of 8 pigs. The technical outcomes were compared between the 2 groups. The gastric ulcer stages were evaluated by endoscopy once weekly for 4 weeks after the ESD to determine the healing score (1-6). The pigs were killed at 1 week (n = 2), 2 weeks (n = 2), and 4 weeks (n = 4) after the ESD for pathologic evaluation of ESD-induced ulcers and scarring. RESULTS There were no significant differences in any of the technical outcomes between the 2 groups, and no adverse events related to the ESD in any of the animals. The healing score was significantly higher in the rebamipide group than in the control group at 2 weeks (P = .027), 3 weeks (P = .034), and 4 weeks (P = .012). In the histopathologic assessment, fibrosis was significantly less extensive in the rebamipide group than in the control group at 2 weeks (P = .02) and 4 weeks (P = .04). CONCLUSIONS The rebamipide solution appeared to promote both the speed and quality of healing of ESD-induced ulcers by suppressing fibrosis.
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Affiliation(s)
- Ai Fujimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Toshio Uraoka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan; Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Masayuki Shimoda
- Department of Pathology, Keio University School of Medicine, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yasutoshi Ochiai
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tadateru Maehata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yutaka Mitsunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Hiroyuki Yamamoto
- Department of Hepatology and Gastroenterology, St. Marianna University, School of Medicine, Kanagawa, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
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23
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Facciorusso A, Muscatiello N. Submucosal Injection Solutions for Colon Polypectomy. COLON POLYPECTOMY 2018:89-106. [DOI: 10.1007/978-3-319-59457-6_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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24
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Yang DH, Kwak MS, Park SH, Ye BD, Byeon JS, Myung SJ, Yang SK, Kim HG, Friedland S. Endoscopic Mucosal Resection with Circumferential Mucosal Incision for Colorectal Neoplasms: Comparison with Endoscopic Submucosal Dissection and between Two Endoscopists with Different Experiences. Clin Endosc 2017; 50:379-387. [PMID: 28264251 PMCID: PMC5565045 DOI: 10.5946/ce.2016.058] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 01/22/2017] [Accepted: 01/25/2017] [Indexed: 12/14/2022] Open
Abstract
Background/Aims Endoscopic mucosal resection with circumferential mucosal incision (CMI-EMR) may offer benefits comparable to those of endoscopic submucosal dissection (ESD), while requiring less technical proficiency than ESD. Methods We retrospectively compared the outcomes of CMI-EMR (n=34) and size-matched ESD (n=102), which were performed by a Korean endoscopist for colorectal epithelial lesions of 20–35 mm. Procedural parameters of CMI-EMRs performed by an American ESD novice (n=30) were compared with those performed by the Korean endoscopist. Results The lesion size was 22.3±3.9 mm and 22.9±2.4 mm in the CMI-EMR and size-matched ESD groups, respectively (p=0.730). The resection time was 12.7±7.0 minutes in the CMI-EMR group and 45.6±30.1 minutes in the ESD group (p<0.001). The en bloc resection rate was 94.1% in the CMI-EMR group and 100% in the ESD group (p=0.061). There were no differences in the en bloc resection and complication rates of CMI-EMRs between a Korean and an American endoscopist. Conclusions For the treatment of moderate-size colorectal lesions, CMI-EMR showed a trend toward lower en bloc resection rate, but required shorter procedure time than ESD. CMI-EMR outcomes were similar when performed by a Korean ESD expert and an American ESD novice.
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Affiliation(s)
- Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seob Kwak
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Hyoung Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byong Duk Ye
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Jae Myung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyun Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun Gun Kim
- Institute for Digestive Research, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Shai Friedland
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, Department of Gastroenterology, VA Palo Alto Health Care System, Palo Alto, CA, USA
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25
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Abstract
The transformation of the submucosa into a working space provided a paradigm shift for endolumenal endoscopic intervention. The submucosal space can provide an undermining access to the removal of overlying mucosal disease. This space can also provide a protective mucosal barrier accommodating interventions into the deep layers of the gut wall and body cavities, such as the abdomen and mediastinum.
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Affiliation(s)
- Saurabh S Mukewar
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
| | - Christopher J Gostout
- Division of Gastroenterology & Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Cao L, Li Q, Zhang C, Wu H, Yao L, Xu M, Yu L, Ding J. Safe and Efficient Colonic Endoscopic Submucosal Dissection Using an Injectable Hydrogel. ACS Biomater Sci Eng 2016; 2:393-402. [PMID: 33429543 DOI: 10.1021/acsbiomaterials.5b00516] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic submucosal dissection (ESD) has not yet been widely adopted in the treatment of early colonic cancers due to the greater technical difficulty involved, longer procedure time, and the increased risk of perforation. Adequate mucosal elevation by submucosal injection is crucial for en bloc resection and prevention of perforation during colonic ESD. This study is aimed to evaluate the efficacy of an injectable thermoreversible hydrogel as the colonic submucosal agent for the first time. Triblock copolymer poly(lactic acid-co-glycolic acid)-poly(ethylene glycol)-poly(lactic acid-co-glycolic acid) (PLGA-PEG-PLGA) was synthesized, and its concentrated aqueous solution was injected into the colonic submucosa of living minipig and spontaneously transformed into an in situ hydrogel with adequate mucosal elevation at body temperature. Such a mucosal lifting lasted for a longer time than that created by the control group, glycerol fructose. Colonic ESD was then performed with the administration of hydrogels at various polymer concentrations or glycerol fructose. All colonic lesions were successfully resected en bloc after one single injection of the hydrogel, and repeated injections were not needed. No evidence of major hemorrhage, perforation and tissue damage were observed. Considering the injection pressure, duration of mucosal elevation and efficacy of "autodissection", the hydrogel containing 15 wt % polymer was the optimized system for colonic ESD. Consequently, the thermoreversible hydrogel is an ideal submucosal fluid that provides a durable mucosal lifting and makes colonic ESD accessible to a large extent. In particular, the efficacy of "autodissection" after one single injection of the hydrogel simplifies significantly the procedures while minimizing the complications.
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Affiliation(s)
- Luping Cao
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Quanlin Li
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Chen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Haocheng Wu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Liqing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Meidong Xu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China.,Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Lin Yu
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
| | - Jiandong Ding
- State Key Laboratory of Molecular Engineering of Polymers, Department of Macromolecular Science, Fudan University, Shanghai 200433, China
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27
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Gad SC, Spainhour CB, Shoemake C, Pallman DRS, Stricker-Krongrad A, Downing PA, Seals RE, Eagle LA, Polhamus K, Daly J. Tolerable Levels of Nonclinical Vehicles and Formulations Used in Studies by Multiple Routes in Multiple Species With Notes on Methods to Improve Utility. Int J Toxicol 2016; 35:95-178. [PMID: 26755718 DOI: 10.1177/1091581815622442] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Formulation of nonclinical evaluations is a challenge, with the fundamental need to achieve multiples of the clinical exposure complicated by differences in species and routes of administration-specific tolerances, depending on concentrations, volumes, dosing regimen, duration of each administration, and study duration. Current practice to approach these differences is based on individual experience and scattered literature with no comprehensive data source (the most notable exception being our 2006 publication on this same subject). Lack of formulation tolerance data results in excessive animal use, unplanned delays in the evaluation and development of drugs, and vehicle-dependent results. A consulting firm, a chemical company, and 4 contract research organizations conducted a rigorous data mining operation of vehicle data from studies dating from 1991 to 2015, enhancing the data from this author's 2006 publication (3 of the six 2015 contributors were also 2006 contributors). Additional data were found in the published literature. The results identified 108 single-component vehicles (and 305 combination formulations) used in more than 1,040 studies across multiple species (dog, primate, rat, mouse, rabbit, guinea pig, minipig, pig, chick embryo, and cat) by multiple routes for a wide range of study durations. The tabulated data include maximum tolerated use levels by species, route, duration of study, dose-limiting toxicity where reported, review of the available literature on each vehicle, guidance on syringe selection, volume and pH limits by route with basic guidance on nonclinical formulation development, and guidance on factors to be considered in nonclinical route selection.
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28
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Yamazaki K, Maluf-Filho F, da Costa VAP, Pessorrusso FCS, Hondo FY, Sakai P, de Figueiredo LFP. IMPROVED EXPERIMENTAL MODEL TO EVALUATE SUBMUCOSAL INJECTION SOLUTIONS FOR ENDOSCOPIC SUBMUCOSAL DISSECTION. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2016; 28:262-5. [PMID: 26734797 PMCID: PMC4755179 DOI: 10.1590/s0102-6720201500040011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/30/2015] [Indexed: 11/24/2022]
Abstract
Background : Endoscopic submucosal dissection carries an increased risk of bleeding and
perforation. The creation of a long lasting submucosal cushion is essential for
the safe and complete removal of the lesion. There is not a suitable experimental
model for evaluation of the durability of the cushioning effect of different
solutions. Aim : To describe an improved experimental model to evaluate submucosal injection
solutions. Methods : A total of four domestic pigs were employed to evaluate two different submucosal
fluid solutions in the gastric submucosa. After midline laparotomy, the anterior
gastric wall was incised from the gastric body to the antrum and its mucosal
surface was exposed by flipping inside out the incised gastric wall. Two different
solutions (10% mannitol and normal saline) were injected in the submucosa of the
anterior wall of the distal gastric body. All submucosal cushions were injected
until they reach the same size, standardized as 1.0 cm in height and 2.0 cm in
diameter. A caliper and a ruler were employed to guarantee accuracy of the
measurements. Results : All four animal experiments were completed. All submucosal cushions had the exact
same size measured with caliper and a ruler. By using the mannitol solution, the
mean duration of the submucosal cushion was longer than the saline solution: 20
and 22 min (mean, 21 min) vs 5 and 6 min (mean, 5.5 min) Conclusions : This experimental model is simple and evaluate the duration, size, and effect of
the submucosal cushion, making it more reliable than other models that employ
resected porcine stomachs or endoscopic images in live porcine models.
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Rutter MD, Chattree A, Barbour JA, Thomas-Gibson S, Bhandari P, Saunders BP, Veitch AM, Anderson J, Rembacken BJ, Loughrey MB, Pullan R, Garrett WV, Lewis G, Dolwani S. British Society of Gastroenterology/Association of Coloproctologists of Great Britain and Ireland guidelines for the management of large non-pedunculated colorectal polyps. Gut 2015; 64:1847-73. [PMID: 26104751 PMCID: PMC4680188 DOI: 10.1136/gutjnl-2015-309576] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 05/25/2015] [Accepted: 05/29/2015] [Indexed: 02/07/2023]
Abstract
These guidelines provide an evidence-based framework for the management of patients with large non-pedunculated colorectal polyps (LNPCPs), in addition to identifying key performance indicators (KPIs) that permit the audit of quality outcomes. These are areas not previously covered by British Society of Gastroenterology (BSG) Guidelines.A National Institute of Health and Care Excellence (NICE) compliant BSG guideline development process was used throughout and the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool was used to structure the guideline development process. A systematic review of literature was conducted for English language articles up to May 2014 concerning the assessment and management of LNPCPs. Quality of evaluated studies was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) Methodology Checklist System. Proposed recommendation statements were evaluated by each member of the Guideline Development Group (GDG) on a scale from 1 (strongly agree) to 5 (strongly disagree) with >80% agreement required for consensus to be reached. Where consensus was not reached a modified Delphi process was used to re-evaluate and modify proposed statements until consensus was reached or the statement discarded. A round table meeting was subsequently held to finalise recommendations and to evaluate the strength of evidence discussed. The GRADE tool was used to assess the strength of evidence and strength of recommendation for finalised statements.KPIs, a training framework and potential research questions for the management of LNPCPs were also developed. It is hoped that these guidelines will improve the assessment and management of LNPCPs.
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Affiliation(s)
- Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton on Tees, UK School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Amit Chattree
- School of Medicine, Pharmacy and Health, Durham University, Stockton on Tees, UK
| | - Jamie A Barbour
- Department of Gastroenterology, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | | | - Andrew M Veitch
- Department of Gastroenterology, New Cross Hospital, Wolverhampton, UK
| | - John Anderson
- Department of Gastroenterology, Cheltenham General Hospital, Cheltenham, UK
| | | | | | - Rupert Pullan
- Department of Colorectal Surgery, Torbay Hospital, Torquay, UK
| | - William V Garrett
- Department of Colorectal Surgery, Medway Maritime Hospital, Gillingham, UK
| | - Gethin Lewis
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
| | - Sunil Dolwani
- Department of Gastroenterology, University Hospital Llandough, Cardiff, UK
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30
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Sold M, Kähler G. Improved Techniques for Endoscopic Mucosal Resection (EMR) in Colorectal Adenoma. VISZERALMEDIZIN 2015; 30:33-8. [PMID: 26286120 PMCID: PMC4513797 DOI: 10.1159/000358243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Endoscopic therapy of colorectal adenomas and early cancers is a standard method. Besides oncological criteria, the method is limited by polyp location, size, and texture. Method Based on the current literature, technical modifications and developments in endoscopic mucosal resection are described. Results Numerous approaches exist to improve the conditions of resection, including optimisation of mucosal elevation and modification of techniques, tools, and devices. Conclusion Endoscopic therapy of sessile and flat colorectal polyps remains a challenge. Some of the presented modifications can help to address this challenge.
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Affiliation(s)
- Moritz Sold
- Zentrale Interdisziplinäre Endoskopie ZIE, Universitätsmedizin Mannheim, Germany
| | - Georg Kähler
- Zentrale Interdisziplinäre Endoskopie ZIE, Universitätsmedizin Mannheim, Germany
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31
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Repici A, Pohl H. Revival of a sclerosing agent for prevention of postpolypectomy bleeding. Gastrointest Endosc 2015; 82:359-61. [PMID: 26183495 DOI: 10.1016/j.gie.2015.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 05/01/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milano, Italy
| | - Heiko Pohl
- Section of Gastroenterology, White River Junction VA Medical Center, White River Junction, Vermont, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
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32
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Application of hydrogels as submucosal fluid cushions for endoscopic mucosal resection and submucosal dissection. J Artif Organs 2015; 18:191-8. [DOI: 10.1007/s10047-015-0843-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 05/05/2015] [Indexed: 02/06/2023]
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Efficacy and safety of a novel submucosal lifting gel used for endoscopic submucosal dissection: a study in a porcine model. Surg Endosc 2014; 29:2651-60. [DOI: 10.1007/s00464-014-3985-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 11/04/2014] [Indexed: 12/28/2022]
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Abstract
Endoscopic submucosal dissection (ESD) is a well-established advanced mucosal resection technique used in Japan, where it originated, and some other Asian countries. The technical difficulty and potentially higher rates of significant complications have been obstacles for its dissemination across the United States, on top of the lack of available equipment, candidate lesions in the gastrointestinal tract, and adequate training programs. Yet American physicians are becoming increasingly aware of the benefits of ESD. Simplification of technique, modification of tools and materials, and improved availability of training opportunities are essential in order to accelerate the adoption of ESD in the United States.
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Affiliation(s)
- Norio Fukami
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, B158, Aurora, CO 80045, USA.
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Yu L, Xu W, Shen W, Cao L, Liu Y, Li Z, Ding J. Poly(lactic acid-co-glycolic acid)-poly(ethylene glycol)-poly(lactic acid-co-glycolic acid) thermogel as a novel submucosal cushion for endoscopic submucosal dissection. Acta Biomater 2014; 10:1251-8. [PMID: 24345554 DOI: 10.1016/j.actbio.2013.12.007] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Revised: 11/02/2013] [Accepted: 12/06/2013] [Indexed: 12/21/2022]
Abstract
Endoscopic submucosal dissection (ESD) is a clinical therapy for early stage neoplastic lesions in the gastrointestinal tract. It is, however, faced with a crucial problem: the high occurrence of perforation. The formation of a submucosal fluid cushion (SFC) via a fluid injection is the best way to avoid perforation, and thus an appropriate biomaterial is vital for this minimally invasive endoscopic technique. In this study, we introduced an injectable thermogel as a novel submucosal injection substance in ESD. The hydrogel synthesized by us was composed of poly(lactic acid-co-glycolic acid)-poly(ethylene glycol)-poly(lactic acid-co-glycolic acid) (PLGA-PEG-PLGA) triblock copolymers. The polymer/water system was a low-viscosity fluid at room temperature and thus easily injected, and turned into a non-flowing gel at body temperature after injection. The submucosal injection of the thermogel to create SFCs was performed in both resected porcine stomachs and living minipigs. High mucosal elevation with a clear margin was maintained for a long duration. Accurate en bloc resection was achieved with the assistance of the thermogel. The mean procedure time was strikingly reduced. Meanwhile, no obvious bleeding, perforation and tissue damage were observed. The application of the thermogel not only facilitated the ESD procedure, but also increased the efficacy and safety of ESD. Therefore, the PLGA-PEG-PLGA thermogel provides an excellent submucosal injection system, and has great potential to improve the ESD technique significantly.
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36
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Submucosal injection solutions for endoscopic mucosal resection and endoscopic submucosal dissection of gastrointestinal neoplasms. GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.09.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Abstract
PURPOSE OF REVIEW Standard endoscopic polypectomy is a powerful technique to remove most polyps found in the gastrointestinal tract. However, a small percentage of polyps can be classified as difficult, based on size, location, and/or configuration. Traditionally, these difficult polyps were referred for surgical segmental colectomy. Recently, with advancements in endoscopic techniques and accessories, a majority of these difficult polyps are now able to be completely resected using entirely endoscopic techniques. RECENT FINDINGS Endoscopic techniques and accessories have been evolving during recent years, including increased dissemination of techniques of endoscopic submucosal dissection to the western hemisphere. In addition to refinement of endoscopic techniques, there has been increased interest in developing improved endoscopic accessories, including novel submucosal injectate with auto-dissecting properties, to improve safety and efficiency of endoscopic resection of difficult polyps. SUMMARY This article will review currently available techniques and strategies for successful endoscopic resection for difficult polyps.
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38
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Gostout CJ. Historical notes: The road to peroral endoscopic myotomy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2013.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Alginate hydrogel as a potential alternative to hyaluronic acid as submucosal injection material. Dig Dis Sci 2013; 58:1491-6. [PMID: 23344967 DOI: 10.1007/s10620-012-2555-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2012] [Accepted: 12/24/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sodium alginate is currently used in medical products, including drugs and cosmetic materials. It can also be used as a submucosal injection material due to its excellent water retention ability. Alginate with a high water retention ability is called alginate hydrogel (AH). The aim of this study was to investigate the usefulness of AH as a submucosal injection material. METHODS To investigate the optimal viscosity of AH as a submucosal injection material, we observed the changes in submucosal height from the initial submucosal height in the stomachs of six miniature pigs for each injection material tested (0.3 % AH, 0.5 % hyaluronic acid, glycerol). All submucosal heights were compared serially over time (3, 5, 10, 20, and 30 min). Both immediate and 1-week delayed tissue reactions were investigated endoscopically in the same living pigs. Histological analyses were performed after the animals had been sacrificed. RESULTS In a preliminary study, we determined that 0.3 % sodium alginate mixed with BaCl2 (400 μl) was the optimal viscosity of AH as an injection material. Our comparison of submucosal height changes over time showed that there was a significant decrease in submucosal height just 3 min following the injection of hyaluronic acid and glycerol, but that following the injection of AH a significant decrease in submucosal height was observed only after 10 min (p < 0.05). The histological analyses revealed that there were mild capillary dilations with congestion and mild fibrotic changes with some lymphocytic infiltration at the AH injection site. CONCLUSION Alginate hydrogel demonstrated long-lasting maintenance of submucosal elevation, safety, and cost-effectiveness in a pig model, which makes it a potential alternative to hyaluronic acid.
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Itoi T, Gotoda T, Baron TH, Sofuni A, Itokawa F, Tsuji S, Tsuchiya T, Tanaka R, Tonozuka R, Honjo M, Ryozawa S, Kawai T, Moriyasu F, Isayama H. Creation of simulated papillae for endoscopic sphincterotomy and papillectomy training by using in vivo and ex vivo pig model (with videos). Gastrointest Endosc 2013; 77:793-800. [PMID: 23453186 DOI: 10.1016/j.gie.2012.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND There are few in vivo and ex vivo models for training in endoscopic sphincterotomy (ES) and endoscopic papillectomy (EP). OBJECTIVE We describe in vivo and ex vivo training pig models that use a simulated papilla for hands-on teaching of ES and EP. DESIGN Animal experiment. SETTING A referral center. MATERIALS AND INTERVENTIONS Hyaluronate solution (0.4%) was injected submucosally using a 25-gauge sclerotherapy needle to create a submucosal bleb by using porcine in vivo stomach, ex vivo stomach, and ex vivo rectum. ES and EP were then performed by using a pull-type sphincterotome and snare, respectively. MAIN OUTCOME MEASUREMENT The feasibility of creating a simulated papilla for ES and EP procedures was tested by experienced and nonexperienced ERCP endoscopists. RESULTS Creation of a hemispheroidal bulge was successful in 13 of 17 (76%) areas within an in vivo stomach, 13 of 16 (81%) areas of an ex vivo stomach, and 16 of 16 (100%) areas in an ex vivo rectum. In the in vivo stomach model, ES was successfully and realistically performed on the anterior wall of the stomach rather than in other walls. In the ex vivo stomach model, endoscopists experienced in ERCP and trainees performed ES without difficulty, whereas it was difficult or impossible for nonexperienced trainees to perform ES. In the ex vivo rectum model, all 3 endoscopists were able to complete not only ES but also EP. LIMITATIONS Pilot study. CONCLUSIONS Although further studies are necessary to evaluate the reproducibility and cost-effectiveness, this novel pig model appears useful for ES and EP training.
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Affiliation(s)
- Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.
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Kim HK, Lo SK. Endoscopic approach to the patient with benign or malignant ampullary lesions. Gastrointest Endosc Clin N Am 2013; 23:347-83. [PMID: 23540965 DOI: 10.1016/j.giec.2013.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.
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Affiliation(s)
- Hyung-Keun Kim
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Uijeongbu St. Mary's Hospital, Guemo-dong, Uijeongbu, Republic of Korea
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Lepilliez V, Robles-Medranda C, Ciocirlan M, Lukashok H, Chemali M, Langonnet S, Chesnais S, Hervieu V, Ponchon T. Water-jet dissector for endoscopic submucosal dissection in an animal study: outcomes of the continuous and pulsed modes. Surg Endosc 2013; 27:2921-7. [PMID: 23468330 DOI: 10.1007/s00464-013-2857-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 01/28/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) allows en bloc resection of early neoplastic lesions of gastrointestinal tract. Lesions are lifted by submucosal fluid injection before circumferential incision and dissection. High-pressure fluid injection using water jet (WJ) technology is already used for lifting and dissection in surgery. The study was designed to assess WJ for ESD submucosal lifting and dissection. METHODS An experimental, randomized comparative, "in vivo" nonsurvival animal study on 12 pigs was designed. Stomach mucosal areas were delineated and resected using three ESD techniques: technique A-syringe injection and IT knife dissection; technique B-WJ continuous injection and IT knife dissection; technique C-WJ injection and WJ pulsed dissection. Injection and dissection speeds and complications rates were assessed. RESULTS Water jet continuous injection is faster than syringe injection (B faster than A, p = 0.001 and B nonsignificantly faster than C, p = 0.06). IT knife dissection is significantly faster after WJ continuous injection (B faster than A, p = 0.003). WJ pulsed dissection is significantly slower than IT knife dissection (C slower than A and B, both p < 0.001). The overall procedure speed was significantly higher and the immediate bleedings rate was significantly lower for technique B than A and C (overall procedure speed p = 0.001, immediate bleedings p = 0.032 and 0.038 respectively). There were no perforations with any technique. CONCLUSIONS Water jet fluid continuous injection speeds up ESD, whereas pulsed WJ dissection does not.
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Affiliation(s)
- Vincent Lepilliez
- Digestive Disease Department, "Edouard Herriot" Hospital, 5 Place d'Arsonval, 69437 Lyon Cedex 03, Lyon, France.
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A novel gel provides durable submucosal cushion for endoscopic mucosal resection and endoscopic submucosal dissection. Surg Endosc 2013; 27:3039-42. [PMID: 23392984 DOI: 10.1007/s00464-013-2813-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 01/04/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have transformed the ability to endoscopically remove superficial lesions throughout the gastrointestinal tract. The purpose of this study was to determine the properties and safety of a novel gel designed for the purpose of submucosal injection for EMR and ESD. METHODS Upper endoscopy was performed in six Yorkshire pigs with 5-8 submucosal injections of varying amounts of Cook Medical (Bloomington, IN) gel were delivered in the stomach of each animal. A submucosal bleb of 1-2 ml normal saline was created followed by subsequent injection of 1-5 ml of the gel. Four animals were immediately euthanized and necropsy was performed after gel delivery and in two pigs; repeat endoscopy was performed after 4 weeks followed by necropsy. RESULTS Thirty-nine submucosal injections were performed in six pigs. Every injection resulted in adequate mucosal lifting with a shoulder and defined margin and no cases of gel extravasation. Twenty-seven injections were performed in four pigs followed by immediate necropsy. The submucosal cushion was still present at the time of organ extraction without evidence of perforation, bleeding or tissue damage. Unroofing of the mucosal layer demonstrated a clean submucosal tissue dissection without bleeding or tissue damage. Twelve submucosal injections were performed in two pigs, and repeat endoscopy at 4 weeks demonstrated persistent submucosal cushion without evidence of mucosal ischemia or ulceration. Necropsy demonstrated no evidence of perforation, bleeding, or gel extravasation. Unroofing the mucosa confirmed a clean submucosal dissection. The injectate did not result in mesenteric fibroinflammatory reaction, tissue damage, or adhesion formation after 4 weeks. CONCLUSIONS The gel appears to be a safe injectate that provides a submucosal cushion with a duration that is longer than other available injectates for EMR and ESD. The clean submucosal dissection may decrease the length of these procedures while minimizing complications.
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Endoscopic mucosal resection of giant laterally spreading tumors with submucosal injection of hydroxyethyl starch: comparative study with normal saline solution. Surg Laparosc Endosc Percutan Tech 2012; 22:272-8. [PMID: 22678327 DOI: 10.1097/sle.0b013e318251553c] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Normal saline (NS) plus epinephrine (E) is the traditionally used solution as submucosal fluid cushion for a safe and effective endoscopic mucosal resection (EMR) of sessile colorectal polyps. It was hypothesized that hydroxyethyl starch (HES), an inexpensive and easily available solution might be an ideal solution for prolonged elevation of submucosal cushion for an easy and safe EMR of giant colorectal lateral spreading tumors (LSTs). PATIENTS AND METHODS During a 6-year period, patients suffering from colorectal LSTs with a diameter of ≥ 30 mm were randomized to undergo EMR by using either HES+E (group A) or NS+E (group B) for submucosal fluid cushion. All patients who had undergone a colonoscopy set the diagnosis of LSTs. The LSTs were examined with standard white light and narrow-band imaging to accurately delinate their margins before resection. The initial volume of injected solution, the additional amount to maintain the submucosal cushion, the duration of submucosal elevation and post-EMR-related complications were recorded. After EMR, patients had a standard follow-up at 3, 6, and 12 months and further if it was necessary using total colonoscopy. RESULTS Forty-nine patients suffering from giant LSTs were included in the study. No difference between the 2 groups was observed in patients' characteristics, size of LSTs, and the initial volume of injected solution. However, the additional amount of solution to maintain submucosal elevation was lower in group A (median, 4 mL; range, 2 to 25) than in group B (median, 6 mL; range, 3 to 8; P=0.001). Moreover, submucosal elevation had a statistically longer duration in group A (median, 18.5 min; range, 14.5 to 28.4) than in group B (median, 20.15 min, range, 9.6 to 13.4; P<0.001), and there was a statistical difference on total procedure time in favor of group A [group A, 20.15 min (12 to 32.5) vs. group B, 22.8 min (18 to 34.5)]. One case of macroperforation, 2 cases of postpolypectomy syndrome, and 1 case of EMR-related bleeding were observed in the HES+E group, whereas 6 cases of EMR-related bleeding were observed in the NS+E group. During a median follow-up of 32 and 34 months, for HES+E and NS+E groups, respectively, 5 and 7 recurrences were observed, which were all treated endoscopically. CONCLUSIONS HES+E injection produces a more prolonged submucosal elevation and lowers total procedure time than NS+E; however, the safety of EMR is not influenced.
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Wen W, Shi C, Shi Y, Ji G, Wu P, Fan Z, Zhang F. A pilot animal and clinical study of autologous blood solution compared with normal saline for use as an endoscopic submucosal cushion. Exp Ther Med 2012. [PMID: 23181111 PMCID: PMC3503630 DOI: 10.3892/etm.2012.626] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
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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Affiliation(s)
- Wei Wen
- Institute of Digestive Endoscopy and Medical Center for Digestive Diseases and
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Kumano I, Ishihara M, Nakamura S, Kishimoto S, Fujita M, Hattori H, Horio T, Tanaka Y, Hase K, Maehara T. Endoscopic submucosal dissection for pig esophagus by using photocrosslinkable chitosan hydrogel as submucosal fluid cushion. Gastrointest Endosc 2012; 75:841-8. [PMID: 22301341 DOI: 10.1016/j.gie.2011.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 10/24/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Hypertonic saline solution (HS) as a submucosal fluid cushion (SFC) for endoscopic submucosal dissection (ESD) has several disadvantages, including a short effect duration and increased risk of bleeding and perforation. Photocrosslinkable chitosan hydrogel in DMEM/F12 medium (PCH) can be converted into an insoluble hydrogel by UV irradiation for 30 seconds. OBJECTIVE To evaluate the feasibility, usefulness, and safety of PCH as an SFC for ESD of esophagi, compared with HS and sodium hyaluronate (SH). DESIGN Survival animal study. SETTINGS Research laboratory study of 24 pig models in vivo. INTERVENTIONS Twenty-four pigs were used in the 2 steps: First, ESD of the esophagus was performed with PCH, SH, or HS (each n = 6) as an SFC, and the effects of these agents on wound healing were examined endoscopically and histologically. Second, in vivo degradation of PCH (n = 3) and HS (n = 3) was examined in independent pig esophagi. MAIN OUTCOME MEASUREMENTS Outcome measurements included feasibility and safety of PCH-assisted ESD of esophagus, gross and histologic evidence of the treated esophagus, biodegradation of injected PCH, and clinical tolerance by the animals. RESULT PCH injection led to a longer-lasting elevation with clearer margins compared with SH and HS, thus enabling precise ESD along the margins of the elevated mucosa without complications such as bleeding and perforation. The aspects of wound repair after PCH-assisted ESD were similar to those of SH- and HS-assisted ESDs. Biodegradation of PCH was confirmed to be almost completed within 8 weeks on the basis of endoscopic and histologic observations. LIMITATIONS In vivo animal model study. CONCLUSION PCH permits more reliable ESD of the esophagus without complications than do SH and HS. Furthermore, the applied PCH appeared to be completely biodegraded within 8 weeks. Thus, PCH is a promising agent as an SFC in ESD of the esophagus.
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Affiliation(s)
- Isao Kumano
- Department of Surgery, National Defense Medical College, Tokorozawa, Saitama, Japan
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Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc 2011; 3:241-7. [PMID: 22195233 PMCID: PMC3244941 DOI: 10.4253/wjge.v3.i12.241] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2011] [Accepted: 08/28/2011] [Indexed: 02/05/2023] Open
Abstract
Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.
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Affiliation(s)
- Payam Chini
- Payam Chini, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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Akagi T, Yasuda K, Tajima M, Suzuki K, Inomata M, Shiraishi N, Sato Y, Kitano S. Sodium alginate as an ideal submucosal injection material for endoscopic submucosal resection: preliminary experimental and clinical study. Gastrointest Endosc 2011; 74:1026-32. [PMID: 22032316 DOI: 10.1016/j.gie.2011.07.042] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Accepted: 07/18/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sodium alginate is used clinically in the treatment of peptic ulcer disease. Because of its viscosity, sodium alginate could possibly become a new submucosal injection material for use in endoscopic resection. OBJECTIVE We evaluated the feasibility of endoscopic submucosal dissection (ESD) using sodium alginate. SETTING AND INTERVENTIONS The lesion-lifting properties of sodium alginate were examined in porcine stomachs and were compared with those of normal saline solution and sodium hyaluronate solution. After confirming the proper concentration of sodium alginate, ESD using sodium alginate was performed in 11 patients with gastric mucosal cancer or adenoma. MAIN OUTCOME MEASUREMENT The lesion-lifting properties of sodium alginate and clinical outcomes were assessed. RESULTS The thickness of the submucosal elevation created by 3% sodium alginate in porcine stomach was equivalent to that of sodium hyaluronate. ESD using sodium alginate was completed successfully in all patients without adverse effects except in 1 patient in whom transient shrinkage of the gastric wall disappeared spontaneously after approximately 30 minutes. The mean tumor size was 15.3 mm. En bloc resection and a negative resection margin were obtained in all. Histopathologic examination revealed that all tumors were confined to the mucosal layer except for 1 that was confined to the submucosal layer without lymphovascular invasion, and there were no adverse effects such as tissue damage. No patient required additional treatment, and none showed recurrence during a median follow-up period of 28 months. LIMITATIONS Small sample size. CONCLUSION This preliminary study suggests that sodium alginate might be a novel, safe submucosal injection material for use in endoscopic resection. Further investigation of the properties of sodium alginate is warranted.
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Affiliation(s)
- Tomonori Akagi
- Department of Surgery I, Oita University Faculty of Medicine, Oita, Japan
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Uraoka T, Kawahara Y, Ohara N, Kato J, Hori K, Okada H, Yamamoto K. Carbon dioxide submucosal injection cushion: an innovative technique in endoscopic submucosal dissection. Dig Endosc 2011; 23:5-9. [PMID: 21198910 DOI: 10.1111/j.1443-1661.2010.01038.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM Endoscopic submucosal dissection (ESD) can successfully resect large lesions en bloc, but it requires a satisfactory submucosal (sm) injection agent for proper safety and efficacy. The aim of the present study was to evaluate the effectiveness of carbon dioxide (CO(2) ) as an ESD sm injection agent. METHODS In vitro study using porcine stomachs compared CO(2) with normal saline (NS) and sodium hyaluronic acid (SHA) solution, both of which are currently used to provide long-lasting sm elevation during ESD. Histopathological examination assessed differences between CO(2) and NS sm cushions. ESD were then carried out in vivo in the stomach and rectum of a live pig using CO(2) sm injection. RESULTS CO(2) sm elevation was significantly longer lasting than either NS or SHA (P<0.001). Histopathology revealed no mucosal layer tissue damage, and dissection of honeycomb-like fibrous connective tissue in the CO(2) sm cushion. Creating and maintaining a CO(2) sm cushion of sufficient elevation combined with partial physical dissection of the sm layer was achieved, followed by complete endoscopic dissection of the sm layer with all ESD, resulting in successful en-bloc resections having a mean specimen size of 24.3mm within 15min. CONCLUSION Safety and efficacy of CO(2) as a satisfactory sm injection agent during ESD was successfully demonstrated in these preliminary studies, warranting further investigation of this innovative technique.
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Affiliation(s)
- Toshio Uraoka
- Department of Endoscopy, Okayama University Hospital, Japan.
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Yahagi N, Uraoka T, Ida Y, Hosoe N, Nakamura R, Kitagawa Y, Ogata H, Hibi T. Endoscopic submucosal dissection using the Flex and the Dual knives. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2011; 13:74-78. [DOI: 10.1016/j.tgie.2011.02.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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