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World J Gastroenterol. Feb 21, 2019; 25(7): 777-788
Published online Feb 21, 2019. doi: 10.3748/wjg.v25.i7.777
Solutions for submucosal injection: What to choose and how to do it
Rui Castro, Diogo Libânio, Inês Pita, Mário Dinis-Ribeiro
Rui Castro, Diogo Libânio, Inês Pita, Mário Dinis-Ribeiro, Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto 4450-590, Portugal
Mário Dinis-Ribeiro, CIDES/CINTESIS, Faculty of Medicine, University of Porto, Porto 4200-319, Portugal
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest. No financial support.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Rui Castro, MD, Doctor, Department of Gastroenterology, Portuguese Oncology Institute of Porto, Rua Dr. António Bernardino de Almeida, Porto 4450-590, Portugal. rui.arrais.castro@gmail.com
Telephone: +351-911592435
Received: November 14, 2018
Peer-review started: November 14, 2018
First decision: January 6, 2019
Revised: January 18, 2019
Accepted: January 26, 2019
Article in press: January 26, 2019
Published online: February 21, 2019
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.

Keywords: Snare polipectomy, Endoscopic mucosal resection, Endoscopic submucosal dissection, Submucosal injection, Submucosal injection solution

Core tip: In this work, we review the importance of submucosal injection and present some of the most commonly used solutions, comparing them taking into account their advantages and disadvantages. Unlike most of the previous papers about this subject, we organized this review in a more practical point of view. For that, we try to answer some essential questions like: what is the need for submucosal injection, when should we use it, what type of solution is more suitable for each endoscopic resection technique and how should we use them.