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Wang P, Li R, Ma J, Zhang W, Shen H, Ren Y, Zhang X, Li S, Chi B. Facilitating safe and sustained submucosal lift through an endoscopically injectable shear-thinning carboxymethyl starch sodium hydrogel. Carbohydr Polym 2024; 336:122128. [PMID: 38670759 DOI: 10.1016/j.carbpol.2024.122128] [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: 01/30/2024] [Revised: 03/04/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024]
Abstract
Traditional submucosal filling materials frequently show insufficient lifting height and duration during clinical procedures. Here, the anionic polysaccharide polymer sodium carboxymethyl starch and cationic Laponite to prepare a hydrogel with excellent shear-thinning ability through physical cross-linking, so that it can achieve continuous improvement of the mucosal cushion through endoscopic injection. The results showed that the hydrogel (56.54 kPa) had a lower injection pressure compared to MucoUp (68.56 kPa). The height of submucosal lifting height produced by hydrogel was higher than MucoUp, and the height maintenance ability after 2 h was 3.20 times that of MucoUp. At the same time, the hydrogel also showed satisfactory degradability and biosafety, completely degrading within 200 h. The hemolysis rate is as low as 0.76 %, and the cell survival rate > 80 %. Subcutaneous implantation experiments confirmed that the hydrogel showed no obvious systemic toxicity. Animal experiments clearly demonstrated the in vivo feasibility of using hydrogels for submucosal uplift. Furthermore, successful endoscopic submucosal dissection was executed on a live pig stomach, affirming the capacity of hydrogel to safely and effectively facilitate submucosal dissection and mitigate adverse events, such as bleeding. These results indicate that shear-thinning hydrogels have a wide range applications as submucosal injection materials.
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Affiliation(s)
- Penghui Wang
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Ruixue Li
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Juping Ma
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Wenjie Zhang
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Haifeng Shen
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Yanhan Ren
- University of Massachusetts Chan Medical School, Worcester, MA 01655, USA
| | - Xun Zhang
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Shuang Li
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China
| | - Bo Chi
- State Key Laboratory of Materials-Oriented Chemical Engineering, College of Biotechnology and Pharmaceutical Engineering, College of Food Science and Light Industry, Nanjing Tech University, Nanjing 211816, China; National Synergetic Innovation Center for Advanced Materials, Nanjing Tech University, Nanjing 211816, China.
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Adoor D, Chak A. Submucosal Lifting Agents: An Updated Review. Am J Gastroenterol 2024:00000434-990000000-01212. [PMID: 39092711 DOI: 10.14309/ajg.0000000000002916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/17/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Dayyan Adoor
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Disease, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio, USA
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Gao L, Bai J, Liu K, Wang L, Zhu S, Zhao X, Han Y, Liu Z. Hypertonic solution as an optimal submucosal injection solution for endoscopic resection of gastrointestinal mucosal lesions: Systematic review and network meta-analysis. Dig Endosc 2024; 36:657-669. [PMID: 37767724 DOI: 10.1111/den.14692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/24/2023] [Indexed: 09/29/2023]
Abstract
OBJECTIVES Based on different physicochemical properties, common submucosal injection solutions could be classified into three categories: normal saline solution (NS), hypertonic solution (HS), and viscous solution (VS). We compared the efficacy and safety of various categories of solutions in this network meta-analysis of randomized controlled trials (RCTs) to identify the optimal submucosal injection fluid. METHODS PubMed, Embase, Web of Science, and the Cochrane Library were searched for RCTs that compared the efficacy and safety of NS, HS, and VS during endoscopic resection for gastrointestinal (GI) mucosal lesions. Pairwise and network analyses were conducted to determine the ranking of different fluids. RESULTS Thirteen RCTs were included in the final analysis with 1637 patients (1639 lesions). HS outperformed NS in rates of en bloc (pooled relative risk [RR] 1.50; 95% confidence interval [CI] 1.10-1.90), overall bleeding (pooled odds ratio [OR] 0.33; 95% CI 0.10-0.88; lesions >10 mm OR 4.65 × 10-2; 95% CI 1.10 × 10-3-0.46), and intraoperative bleeding (lesions >10 mm OR 7.10 × 10-6; 95% CI 4.30 × 10-18-0.26). HS showed the highest probability of ranking first in each outcome except for the volume of injection. Although VS was superior to NS in rates of en bloc, overall, and intraoperative bleeding in the lesions >10 mm subgroup, and required less fluid in pooled analysis, it ranked last in cost of submucosal injection solution. CONCLUSIONS Both HS and VS were superior to NS in comparisons of efficacy and safety. Considering the better performance and potentially low cost, HS might be an optimal choice during gastrointestinal endoscopic resection, especially for colorectal endoscopic mucosal resection.
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Affiliation(s)
- Li Gao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Jiawei Bai
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
- School of Medicine, Yan'an University, Yan'an, China
| | - Kai Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Lulu Wang
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Shaohua Zhu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Xin Zhao
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Ying Han
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Zhiguo Liu
- Xijing Hospital of Digestive Diseases, Air Force Medical University (Fourth Military Medical University), Xi'an, China
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Jung KU, Lee YJ, Jang JY, Cho JY. Efficacy and safety of a submucosal injection solution of sodium alginate for endoscopic resection in a porcine model. Sci Rep 2024; 14:4592. [PMID: 38409310 PMCID: PMC10897473 DOI: 10.1038/s41598-024-55226-y] [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: 09/25/2023] [Accepted: 02/21/2024] [Indexed: 02/28/2024] Open
Abstract
Endoscopic resection techniques require the use of submucosal injection. Normal saline and sodium hyaluronate solutions are mainly used for this purpose, but an ideal solution has not yet been developed. The aim of this study was to assess a new solution, MC-003-a novel submucosal injection solution developed with sodium alginate as the main ingredient. Normal saline, a commercial sodium hyaluronate solution (Endo-Ease), and MC-003 were examined. A total of 18 gastric submucosal cushions were created in the stomachs of six pigs. The height of mucosal elevation was measured sequentially using endoscopic sonography. After euthanizing the animals either 2 h or 5 days after the procedure, pathologic examination was performed for each injection site. Although not statistically significant over the entire study period, MC-003 showed a superior result to normal saline and an equivalent result to Endo-Ease in the submucosal cushion height and its rate of decrease. There were no adverse outcomes after injection of the three solutions and there was no pathologically identified detrimental change in the resected specimens. MC-003 creates a sufficient submucosal fluid cushion without apparent tissue damage. It can be considered as an effective submucosal injection material.
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Affiliation(s)
- Kyung Uk Jung
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, 29 Saemunan-ro, Jongno-gu, Seoul, 03181, Republic of Korea.
| | - Yeon Jae Lee
- Research and Development Center of Mcnulty Pharma Co., Ltd., Seoul, Republic of Korea
| | - Jae-Young Jang
- Departments of Gastroenterology, Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Republic of Korea
| | - Joo Young Cho
- Departments of Gastroenterology, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul, Republic of Korea
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He XJ, Wang XL, Jiang CS, Hong DG, Lin HL, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Luo BX, Li DL, Li DZ, Wang W. Novel beagle model of gastric local fibrotic target lesions for the evaluation and training of endoscopic techniques. BMC Gastroenterol 2023; 23:412. [PMID: 38012582 PMCID: PMC10683295 DOI: 10.1186/s12876-023-03055-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 11/18/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Novel endoscopic techniques used in the treatment of gastric lesions with local submucosal fibrosis need preclinical evaluation and training due to safety limitations. Therefore, the purpose of our study was to establish an animal model of gastric local fibrotic target lesions and assess its feasibility in the evaluation and training of endoscopic techniques. METHODS In six experimental beagles, a 50% glucose solution was injected into three submucosal areas of the fundus, body, and antrum of the stomach to create gastric local fibrotic target lesions (experimental group). On post-injection day (PID) 7, the injection sites were assessed endoscopically to confirm the presence of submucosal fibrosis formation, and the dental floss clip traction assisted endoscopic submucosal dissection (DFC-ESD) procedure was performed on the gastric local fibrotic target lesions to confirm its feasibility after endoscopic observation. The normal gastric mucosa of six control beagles underwent the same procedure (control group). All the resected specimens were evaluated by histological examination. RESULTS All 12 beagles survived without postoperative adverse events. On PID 7, 16 ulcer changes were observed at the injection sites (16/18) under the endoscope, and endoscopic ultrasonography confirmed the local submucosal fibrosis formation in all ulcer lesions. The subsequent DFC-ESD was successfully performed on the 32 gastric target lesions, and the mean submucosal dissection time in the ulcer lesions was greater than that in the normal gastric mucosa (15.3 ± 5.6 vs. 6.8 ± 0.8 min; P < 0.001). There was no difference in rates of en bloc resection, severe hemorrhage, or perforation between the two groups. Histological analysis of the ulcer lesions showed the absence of epithelial or muscularis mucosae and extensive submucosal fibrous tissue proliferations compared with normal gastric mucosa. Overall, endoscopists had high satisfaction with the realism and feasibility of the animal model. CONCLUSION We developed a novel animal model of gastric local fibrotic target lesions to simulate difficult clinical situations, which strongly appeared to be suitable for the preclinical evaluation and learning of advanced endoscopic techniques.
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Affiliation(s)
- Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Hai-Lan Lin
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Bao-Xiang Luo
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China
| | - Dong-Liang Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Hepatobiliary Disease, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China.
- Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, 156 North Road of West No.2 Ring, Fuzhou, 350025, 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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Wang XL, He XJ, Jiang CS, Hong DG, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Li DZ, Wang W. Magnetic ring-assisted endoscopic submucosal dissection for gastric lesions with submucosal fibrosis: A preliminary study in beagle model. Asian J Surg 2023; 46:3673-3679. [PMID: 37120374 DOI: 10.1016/j.asjsur.2023.04.035] [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: 11/02/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND During endoscopic submucosal dissection (ESD) for gastric lesions with fibrosis, appropriate traction could provide clear submucosal dissection visualization to improve safety and efficiency of procedures. Therefore, the aim of this study was to evaluate the feasibility of magnetic ring-assisted ESD (MRA-ESD) for gastric fibrotic lesions. METHOD In the eight healthy beagles, 2-3 mL of 50% glucose solution was injected into submucosal layer of the stomach to induce gastric fibrotic lesions. A week after submucosal injection, two endoscopists at different levels performed MRA-ESD or standard ESD (S-ESD) for gastric simulated lesions, respectively. The magnetic traction system consisted of external handheld magnet and internal magnetic ring. The feasibility and procedure outcomes of the magnetic traction system were mainly evaluated. RESULTS Forty-eight gastric simulated lesions with ulceration were confirmed to have submucosal fibrosis formation by preoperative endoscopic ultrasonography. The magnetic traction system could be easily established, only took 1.57 min, and allowed excellent submucosal visualization. The total procedure time was significantly shorter in the MRA-ESD group than in the S-ESD group for both endoscopists (mean: 46.83 vs. 25.09 min, p < 0.001), and this difference was accentuated in non-skilled endoscopist. There was significant difference between two groups in bleeding and perforation rates. Histological analysis showed the depth of resected specimens was a little deeper around the fibrotic portion in the S-ESD group (p < 0.001). CONCLUSION The magnetic ring-assisted ESD technique may be an effective and safe treatment for gastric fibrotic lesions and may shorten the endoscopic learning curve for non-skilled endoscopists.
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Affiliation(s)
- Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
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Zhang L, Li X, Yue G, Guo L, Hu Y, Cui Q, Wang J, Tang J, Liu H. Nanodrugs systems for therapy and diagnosis of esophageal cancer. Front Bioeng Biotechnol 2023; 11:1233476. [PMID: 37520291 PMCID: PMC10373894 DOI: 10.3389/fbioe.2023.1233476] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 06/29/2023] [Indexed: 08/01/2023] Open
Abstract
With the increasing incidence of esophageal cancer, its diagnosis and treatment have become one of the key issues in medical research today. However, the current diagnostic and treatment methods face many unresolved issues, such as low accuracy of early diagnosis, painful treatment process for patients, and high recurrence rate after recovery. Therefore, new methods for the diagnosis and treatment of esophageal cancer need to be further explored, and the rapid development of nanomaterials has brought new ideas for solving this problem. Nanomaterials used as drugs or drug delivery systems possess several advantages, such as high drug capacity, adjustably specific targeting capability, and stable structure, which endow nanomaterials great application potential in cancer therapy. However, even though the nanomaterials have been widely used in cancer therapy, there are still few reviews on their application in esophageal cancer, and systematical overview and analysis are deficient. Herein, we overviewed the application of nanodrug systems in therapy and diagnosis of esophageal cancer and summarized some representative case of their application in diagnosis, chemotherapy, targeted drug, radiotherapy, immunity, surgery and new therapeutic method of esophageal cancer. In addition, the nanomaterials used for therapy of esophageal cancer complications, esophageal stenosis or obstruction and oesophagitis, are also listed here. Finally, the challenge and the future of nanomaterials used in cancer therapy were discussed.
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Affiliation(s)
- Lihan Zhang
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Xing Li
- Department of General Surgery, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Guangxing Yue
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Lihao Guo
- Interdisciplinary Research Center of Smart Sensors, School of Advanced Materials and Nanotechnology, Xidian University, Xi’an, China
| | - Yanhui Hu
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Qingli Cui
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Jia Wang
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Jingwen Tang
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
| | - Huaimin Liu
- Department of Integrated Chinese and Western Medicine, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, China
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Chen Z, Ding J, Wu C, Wei D, Sun J, Fan H, Guo Z. A review of hydrogels used in endoscopic submucosal dissection for intraoperative submucosal cushions and postoperative management. Regen Biomater 2023; 10:rbad064. [PMID: 37501677 PMCID: PMC10368804 DOI: 10.1093/rb/rbad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/02/2023] [Accepted: 06/14/2023] [Indexed: 07/29/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been clinically proved to have prominent advantages in the treatment of early gastrointestinal cancers over traditional surgery, including less trauma, fewer complications, a quicker recovery and lower costs. During the procedure of ESD, appropriate and multifunctional submucosal injected materials (SIMs) as submucosal cushions play an important role, however, even with many advances in design strategies of SIMs over the past decades, the performance of the submucosal cushions with postoperative management function seems to be still unsatisfactory. In this review, we gave a brief historical recount about the clinical development of SIMs, then some common applications of hydrogels used as SIMs in ESD were summarized, while an account of the universal challenges during ESD procedure was also outlined. Going one step further, some cutting-edge functional strategies of hydrogels for novel applications in ESD were exhibited. Finally, we concluded the advantages of hydrogels as SIMs for ESD as well as the treatment dilemma clinicians faced when it comes to deeply infiltrated lesions, some technical perspectives about linking the clinical demand with commercial supply were also proposed. Encompassing the basic elements of SIMs used in ESD surgery and the corresponding postoperative management requirements, this review could be a good reference for relevant practitioners in expanding the research horizon and improving the well-being index of patients.
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Affiliation(s)
| | | | - Chengheng Wu
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, Sichuan 610064, China
- Institute of Regulatory Science for Medical Devices, Sichuan University, Chengdu, Sichuan 610064, China
| | - Dan Wei
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, Sichuan 610064, China
| | - Jing Sun
- National Engineering Research Center for Biomaterials, College of Biomedical Engineering, Sichuan University, Chengdu, Sichuan 610064, China
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10
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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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11
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He MJ, Liu XY, Xu JX, Xu XY, Li QL, Chen WF, Zhou PH. Endoscopic submucosal dissection for gastric adenocarcinoma of the fundic gland type (chief cell predominate type): Four years' experience from a tertiary hospital. J Dig Dis 2022; 23:620-627. [PMID: 36546620 DOI: 10.1111/1751-2980.13149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 08/25/2022] [Accepted: 12/20/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To summarize the endoscopic and clinicopathological features of gastric adenocarcinoma of the fundic gland type (GA-FG), and to evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for the treatment of GA-FGs. METHODS From September 2017 to August 2021, patients treated with ESD who were pathologically confirmed to have GA-FGs were included. Those with lymphovascular and distal metastasis were excluded before ESD. The medical records were retrospectively reviewed to obtain information regarding patient demographics, clinicopathological characteristics, tumor features, complete resection rate, and complications, etc. All patients underwent follow-up for at least 12 months to evaluate any local recurrence or distant metastasis. RESULTS A total of 15 patients with an average age of 56.9 ± 10.7 years were recruited, including 11 men and 4 women. Lesions were found at the upper third (13 [86.7%]) or middle third (2 [13.3%]) of the stomach. The average lesion size was 9.1 ± 4.8 mm. Macroscopically, lesions presented as a flat elevated type with reddish or erosion on top (n = 7, 46.7%), depressed type with pale color (n = 5, 33.3%), or submucosal tumor (SMT)-like appearance type (n = 3, 20.0%). En bloc resection, complete resection and curative resection were achieved in 14 (93.3%), 13 (86.7%), and 11 (73.3%) patients, respectively. Nine (60.0%) of the lesions had submucosal invasion. One patient underwent additional surgery. No local recurrence or metastasis was detected during the follow-up duration. CONCLUSIONS GA-FGs present with various endoscopic features. ESD appears to be effective and safe for treating early-stage GA-FGs.
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Affiliation(s)
- Meng Jiang He
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xin Yang Liu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jia Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Xiao Yue Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China.,Endoscopy Center, Zhongshan Hospital, Fudan University (Xiamen Branch), Xiamen, Fujian Province, China
| | - Ping Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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12
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Moles-Aranda C, Pérez-González N, Calpena-Campmany AC, Martín-Villena MJ, Otero-Espinar FJ, Severino P, Souto EB, Morales-Molina JA, Clares-Naveros B. Preparation and ex vivo investigation of an injectable microparticulate formulation for gastrointestinal mucosa polyp resection. Eur J Pharm Biopharm 2022; 178:25-34. [PMID: 35905803 DOI: 10.1016/j.ejpb.2022.07.012] [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: 06/10/2022] [Revised: 07/18/2022] [Accepted: 07/24/2022] [Indexed: 11/04/2022]
Abstract
Endoscopic submucosal dissection (ESD) and endoscopic submucosal resection (EMR) are non-invasive endoscopic techniques. They allow an early excised gastrointestinal (GI) mucosal precancerous lessions. For their application is necessary use of a submucosal injection that lift area to excise. The main objective of this study was the preparation of microparticulate-based fluid for injection in the GI submucosa. Alginate microparticles (MPs) were developed by the solvent displacement technique and characterized by particle size, surface electrical properties, swelling, degradation, rheology, adhesion and leakage, syringeablity and stability. Furthermore, their potential to form a submucosal cushion was assayed in porcine stomach mucosa and porcine colon mucosa. Results showed MPs sizes below 160 μm, negative surface charge around -50 mV at pH=6, high rates of swelling and good adhesion. The microparticulate-based fluid exhibited pseudoplastic behavior following the Ostwald-de Waele rheological model. A brief force is sufficient for its injection through a syringe. Finally, formulations were able to provide a submucosa elevation of 1.70 cm for more than 90 min and 120 min in the porcine stomach and colon, respectively.
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Affiliation(s)
- Cristina Moles-Aranda
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain
| | - Noelia Pérez-González
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain
| | - Ana C Calpena-Campmany
- Department of Pharmacy and Pharmaceutical Technology and Physical Chemistry, Faculty of Pharmacy and Food Sciences, University of Barcelona, 08028 Barcelona, Spain
| | - María J Martín-Villena
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain
| | - Francisco J Otero-Espinar
- Department of Pharmacology, Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Santiago de Compostela, 15872 Santiago de Compostela, Spain
| | - Patricia Severino
- Institute of Technology and Research, University of Tiradentes, 49010-390 Aracaju, Brazil
| | - Eliana B Souto
- Department of Pharmaceutical Technology, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal; REQUIMTE/UCIBIO, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal
| | | | - Beatriz Clares-Naveros
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, University of Granada, 18071 Granada, Spain.
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13
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Application of Hemocoagulase Bothrops Atrox in the submucosal injection for endoscopic submucosal dissection: a preliminary trial. Eur J Gastroenterol Hepatol 2021; 33:e681-e685. [PMID: 34034279 PMCID: PMC8734620 DOI: 10.1097/meg.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE This study aimed to evaluate the efficacy and safety of using Hemocoagulase Bothrops Atrox in the submucosal injection solution for endoscopic submucosal dissection (ESD). METHODS A total of 120 patients with superficial neoplastic lesions of the esophagus, stomach, and colon receiving ESD were randomly divided into two groups: The epinephrine group used epinephrine-containing submucosal fluid cushion for ESD, while the hemocoagulase group used Hemocoagulase Bothrops Atrox-containing submucosal fluid cushion for ESD. The preoperative, intraoperative, and postoperative clinical parameters and postoperative adverse events of the two groups were recorded, and comparative analysis within and between groups was performed. RESULTS There was no significant difference in the demographic and clinical characteristics between the hemocoagulase and epinephrine group (all P > 0.05). ESD surgery was completed in all patients. The hemocoagulase group had significantly shorter surgery time (P = 0.003) and less number of intraoperative bleeding (P = 0.010) than the epinephrine group. However, there was no significant difference in the incidences of postoperative delayed hemorrhage, and adverse events between the two groups (all P > 0.05). Multivariate linear regression demonstrated that the epinephrine group had significantly more number of intraoperative bleeding (B: 0.98, 95% confidence interval: 0.04-1.93) as compared with the hemocoagulase group. CONCLUSION Compared with epinephrine, using Hemocoagulase Bothrops Atrox in the submucosal injection for ESD surgery can significantly reduce the number of intraoperative bleeding, shorten the operation time, and did not elevate the incidence of adverse events.
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14
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Tang Y, Hu M, Tang F, Huang R, Wang H, Wu D, Lan P. Easily-injectable shear-thinning hydrogel provides long-lasting submucosal barrier for gastrointestinal endoscopic surgery. Bioact Mater 2021; 15:44-52. [PMID: 35386335 PMCID: PMC8940951 DOI: 10.1016/j.bioactmat.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/22/2022] Open
Abstract
Submucosal injection material has shown protective effect against gastrointestinal injury during endoscopic surgery in clinic. However, the protective ability of existing submucosal injection material is strictly limited by their difficult injectability and short barrier time. Herein, we report a shear-thinning gellan gum hydrogel that simultaneously has easy injectability and long-lasting barrier function, together with good hemostatic property and biocompatibility. Shear-thinning property endows our gellan gum hydrogel with excellent endoscopic injection performance, and the injection pressure of our gellan gum hydrogel is much lower than that of the small molecule solution (50 wt% dextrose) when injected through the endoscopic needle. More importantly, our gellan gum hydrogel shows much stronger barrier retention ability than normal saline and sodium hyaluronate solution in the ex vivo and in vivo models. Furthermore, our epinephrine-containing gellan gum hydrogel has a satisfactory hemostatic effect in the mucosal lesion resection model of pig. These results indicate an appealing application prospect for gellan gum hydrogel utilizing as a submucosal injection material in endoscopic surgery. Submucosal injection materials are widely used in endoscopic surgery to protect against gastrointestinal injury. Gellan gum hydrogel with shear-thinning character is a novel submucosal injection material. Gellan gum hydrogel simultaneously has easy injectability and long-lasting barrier performance in vivo. Epinephrine-containing gellan gum hydrogel has a satisfactory hemostatic effect.
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15
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Ni P, Li R, Ye S, Shan J, Yuan T, Liang J, Fan Y, Zhang X. Lactobionic acid-modified chitosan thermosensitive hydrogels that lift lesions and promote repair in endoscopic submucosal dissection. Carbohydr Polym 2021; 263:118001. [PMID: 33858584 DOI: 10.1016/j.carbpol.2021.118001] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 03/05/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023]
Abstract
To develop a biomaterial to lift the lesion and promote wound healing in endoscopic submucosal dissection (ESD), we used lactobionic acid (LA) to improve the water solubility of chitosan (CS) and prepared a new three-phase hydrogel system with lactobionic acid-modified chitosan/chitosan/β-glycerophosphate (CSLA/CS/GP). The results indicated that the hydrogel retains temperature-sensitive properties, and CSLA obviously improved the low-temperature fluidity of the hydrogel precursor solution, enabling injection of the hydrogel by endoscopic needle. The mechanical strength and bio-adhesion of the hydrogels were also improved by the addition of CSLA and the hydrogels could be maintained in acidic environment for a few days and exhibit greater protection of cells. The CSLA/CS/GP hydrogels show good cytocompatibility. The heights of cushions elevated by CSLA/CS/GP hydrogels remained ∼ 60 % 2 h post-injection in porcine stomach models. Given the unique characteristics of these materials, the CSLA/CS/GP thermo-sensitive hydrogel is a promising intraoperative biomaterial in ESD.
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Affiliation(s)
- Panxianzhi Ni
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China
| | - Renpeng Li
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China
| | - Sheng Ye
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China
| | - Jing Shan
- Department of Gastroenterology, the 3rd People's Hospital of Chengdu, The Second Affiliated Hospital of Chengdu, Chongqing Medical University, 82# Qinglong Street, Qingyang District, Chengdu, Sichuan, China
| | - Tun Yuan
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China.
| | - Jie Liang
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China.
| | - Yujiang Fan
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China
| | - Xingdong Zhang
- National Engineering Research Center for Biomaterials, Sichuan University, 29 Wangjiang Road, Chengdu, Sichuan, China
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16
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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: 0.7] [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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17
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Hirose R, Nakaya T, Naito Y, Yoshida T, Bandou R, Daidoji T, Inoue K, Dohi O, Yoshida N, Itoh Y. An innovative next-generation endoscopic submucosal injection material with a 2-step injection system (with video). Gastrointest Endosc 2021; 93:503-513.e5. [PMID: 32565186 DOI: 10.1016/j.gie.2020.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 06/05/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Next-generation submucosal injection materials (SIMs) with higher performance and flexibility than the current SIMs (eg, 0.4% sodium hyaluronate solution [HA]) are expected to improve the outcomes of endoscopic submucosal dissection (ESD) but are difficult to develop. We developed a next-generation SIM by devising a 2-solution-type SIM comprising 2.0% calcium chloride solution (Ca) and 0.4% sodium alginate solution (SA) and evaluated its performance. METHODS Viscoelasticity, submucosal elevation height, and injection pressure of HA, SA, and the next-generation SIM were measured. Outcomes of ESDs on pseudo-lesions in ex vivo porcine stomach/colon models were compared. RESULTS The dramatic increase in SA viscoelasticity with the addition of Ca facilitated the formation of highly viscous submucosal cushions that can be controlled by endoscopists. The submucosal elevation height of the next-generation SIM was significantly higher than that of HA or SA with the same injection pressure. The ESD procedure time using the next-generation SIM was significantly shorter than that using HA or SA (14.2 ± 6.1 vs 29.2 ± 9.1 minutes, P = .0004, or 14.2 ± 6.1 vs 29.1 ± 5.9 minutes, P <.0001). Furthermore, the total injection volume for the next-generation SIM was considerably lower than that for HA or SA (7.0 ± 0.9 vs 17.2 ± 3.4 mL, P <.0001, or 7.0 ± 0.9 vs 16.2 ± 2.9 mL, P <.0001). CONCLUSIONS We developed an ideal next-generation SIM that achieved high performance and high flexibility in ex vivo models. Our findings warrant further investigations in a patient population.
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Affiliation(s)
- Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takaaki Nakaya
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takuma Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Risa Bandou
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomo Daidoji
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ken Inoue
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Viscosity and degradation controlled injectable hydrogel for esophageal endoscopic submucosal dissection. Bioact Mater 2020; 6:1150-1162. [PMID: 33134608 PMCID: PMC7588753 DOI: 10.1016/j.bioactmat.2020.09.028] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/26/2020] [Accepted: 09/27/2020] [Indexed: 12/16/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a common procedure to treat early and precancerous gastrointestinal lesions. Via submucosal injection, a liquid cushion is created to lift and separate the lesion and malignant part from the muscular layer where the formed indispensable space is convenient for endoscopic incision. Saline is a most common submucosal injection liquid, but the formed liquid pad lasts only a short time, and thus repeated injections increase the potential risk of adverse events. Hydrogels with high osmotic pressure and high viscosity are used as an alternate; however, with some drawbacks such as tissue damage, excessive injection resistance, and high cost. Here, we reported a nature derived hydrogel of gelatin-oxidized alginate (G-OALG). Based on the rheological analysis and compare to commercial endoscopic mucosal resection (EMR) solution (0.25% hyaluronic acid, HA), a designed G-OALG hydrogel of desired concentration and composition showed higher performances in controllable gelation and injectability, higher viscosity and more stable structures. The G-OALG gel also showed lower propulsion resistance than 0.25% HA in the injection force assessment under standard endoscopic instruments, which eased the surgical operation. In addition, the G-OALG hydrogel showed good in vivo degradability biocompatibility. By comparing the results acquired via ESD to normal saline, the G-OALG shows great histocompatibility and excellent endoscopic injectability, and enables create a longer-lasting submucosal cushion. All the features have been confirmed in the living both pig and rat models. The G-OALG could be a promising submucosal injection agent for esophageal ESD. Injectable gel with controlled viscosity. Injectable gel with controlled degradation. Making esophageal submucosal liquid cushion. Potential treatment for early esophageal cancer. Big animal in-situ imaging.
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19
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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: 57] [Impact Index Per Article: 14.3] [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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20
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Review on colorectal endoscopic submucosal dissection focusing on the technical aspect. Surg Endosc 2020; 34:3766-3787. [PMID: 32342217 DOI: 10.1007/s00464-020-07599-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 04/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) enables removal of broad-based colorectal polyps or lateral spreading tumors with a higher rate of en bloc resection and a lower risk of local recurrence. However, it is technically demanding. Over the past 20 years, various equipment and innovative techniques have been developed to reduce the difficulty of ESD. The information in the literature is scattered. Our aim is to provide a comprehensive review on the setup and technical aspects of colorectal ESD. METHODS We searched the PubMed database and systemically reviewed all original and review articles related to colorectal ESD. Further manual search according to reference lists of identified articles were done. The selected articles were categorized and reviewed. Original figures were created to help readers understand some of the ESD techniques. RESULTS A total of 216 articles were identified, in which 25 of them were review articles and 191 of them were original articles. They were categorized and reviewed. An in-depth appraisal of the setting, equipment, and technical aspects of colorectal ESD was performed. CONCLUSIONS Although ESD is a technically demanding procedure that requires expert endoscopic skills, it can be mastered. With good peri-procedural preparation, sufficient knowledge of the equipment, and thorough understanding of the useful endoscopic tricks and maneuvers, colorectal ESD can be performed smoothly and safely.
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21
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Moles-Aranda C, González-Pérez R, Gallego-Rojo FJ, Martínez-Augustin O, Clares-Naveros B, Sánchez de Medina F, Morales-Molina JA. Efficacy and Safety of a Novel Submucosal Injection Solution for Resection of Gastrointestinal Lesions. J Clin Med 2020; 9:jcm9041162. [PMID: 32325745 PMCID: PMC7230585 DOI: 10.3390/jcm9041162] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/29/2020] [Accepted: 04/14/2020] [Indexed: 01/08/2023] Open
Abstract
Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are minimally invasive and efficient techniques for the removal of gastrointestinal (GI) mucosal polyps. In both techniques, submucosal injection solutions are necessary for complete effectiveness and safety during the intervention to be obtained. The main objective of this study was to evaluate the efficacy and safety of a new sterile submucosal injection solution for EMR/ESD used within a clinical protocol in patients with intestinal polyps. We carried out a prospective study between 2016 and 2017 with patients who attended the Endoscopy Consultation—Digestive Department of Primary Hospital. Patients were selected for EMR/ESD after the application of clinical protocols. Thirty-six patients were selected (≥ 66 years with comorbidities and risk factors). Lesions were located mainly in the colon. Our solution presented an intestinal lift ≥ 60 min in EMR/ESD and a high expansion of tissue, optimum viscosity, and subsequent complete resorption. The genes S100A9 and TP53 presented an expression increase in the distal regions. TP53 and PCNA were the only genes whose expression was increased in polyp specimens vs. the surrounding tissue at the mRNA level. In EMR/ESD, our solution presented a prolonged effect at the intestinal level during all times of the intervention. Thus, our solution seems be an effective and safe alternative in cases of flat lesions in both techniques.
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Affiliation(s)
- Cristina Moles-Aranda
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain; (C.M.-A.); (B.C.-N.)
| | - Raquel González-Pérez
- Department of Pharmacology, CIBERehd, Instituto de Investigación Biosanitaria ibs.GRANADA, School of Pharmacy, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, 18071 Granada, Spain; (O.M.-A.); (J.A.M.-M.)
| | | | - Olga Martínez-Augustin
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, 18071 Granada, Spain; (O.M.-A.); (J.A.M.-M.)
- Department of Biochemical and Molecular Biology II, CIBERehd, Instituto de Investigación Biosanitaria ibs.GRANADA, School of Pharmacy, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain
| | - Beatriz Clares-Naveros
- Department of Pharmacy and Pharmaceutical Technology, School of Pharmacy, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain; (C.M.-A.); (B.C.-N.)
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, 18071 Granada, Spain; (O.M.-A.); (J.A.M.-M.)
- Nanoscience and Nanotechnology Institute (IN2UB), University of Barcelona, 08193 Barcelona, Spain
| | - Fermín Sánchez de Medina
- Department of Pharmacology, CIBERehd, Instituto de Investigación Biosanitaria ibs.GRANADA, School of Pharmacy, University of Granada, Campus Universitario de Cartuja, 18071 Granada, Spain;
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, 18071 Granada, Spain; (O.M.-A.); (J.A.M.-M.)
- Correspondence:
| | - José Antonio Morales-Molina
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, 18071 Granada, Spain; (O.M.-A.); (J.A.M.-M.)
- Department of Pharmacy, H.U. Torrecárdenas, C/ Hermandad de Donantes de Sangre, 04009 Almería, Spain
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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: 2.0] [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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EndoClot ®SIS Polysaccharide Injection as a Submucosal Fluid Cushion for Endoscopic Mucosal Therapies: Results of Ex Vivo and In Vivo Studies. Dig Dis Sci 2019; 64:2955-2964. [PMID: 31165380 DOI: 10.1007/s10620-019-05686-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 05/25/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND There are many studies on submucosal injection materials, but their clinical use is restricted for various reasons. The objective of this study was to compare the feasibility and safety of injected EndoClot®SIS polysaccharide as a submucosal injection material (SFC) in ESD in the pig stomach to that of injected sigMAVisc™ or Eleview™. METHODS Four pig stomachs were used for the ex vivo study. Eighteen pigs were used for the in vivo study. In the ex vivo study, four injections were made in the gastric submucosa to induce submucosal uplift and extend its duration. Tissue change was observed. The in vivo study was performed in 2 steps. First, 3 injections were made in the esophageal mucosa to induce submucosal uplift and extend its duration. Histological change was observed. Second, ESD was performed in the stomach by injecting EndoClot®SIS polysaccharide, sigMAVisc™, or Eleview™ (each, n = 6) as an SFC. The effects of these agents on wound healing were examined. We evaluated the efficacy and safety of endoscopic surgery after EndoClot®SIS polysaccharide injection. RESULTS EndoClot®SIS polysaccharide produced a longer-lasting elevation with clearer margins than was achieved by sigMAVisc™, Eleview™, or 0.9% NaCl and thereby enabled precise ESD without complications, such as bleeding and perforation. No obvious histopathological damage was observed at the injection site on endoscopy and histology. CONCLUSION Submucosally injected EndoClot®SIS polysaccharide increased the effective separation of the mucosa and submucosa and reduced surgical complications. Hence, EndoClot®SIS polysaccharide injection is a safe and effective submucosal injection material.
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Uemura N, Oda I, Saito Y, Ono H, Fujisaki J, Matsuhashi N, Ohata K, Yahagi N, Yada T, Satoh M, Tajiri H, Inomata M, Kitano S. Efficacy and safety of 0.6% sodium alginate solution in endoscopic submucosal dissection for esophageal and gastric neoplastic lesion: A randomized controlled study. Dig Endosc 2019; 31:396-404. [PMID: 30667557 PMCID: PMC6850280 DOI: 10.1111/den.13352] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Sodium alginate (SA) solution has characteristic viscoelasticity. We aimed to determine efficacy and safety of 0.6% SA for submucosal injection during endoscopic submucosal dissection (ESD) in patients with localized neoplastic lesion in the esophageal and gastric mucosa. METHODS We conducted a randomized controlled study at six major hospitals in Japan including 130 patients with endoscopically localized neoplastic lesion in the esophageal and gastric mucosa and eligible for ESD. Patients were randomly assigned to SA or 0.4% sodium hyaluronate (SH) group (control); ESD was performed using a submucosal injection of SA/SH. As a primary outcome measure, non-inferiority of SA against SH was investigated using en bloc complete resection in ESD and formation and maintenance of mucosal elevation upon injection as an efficacy index. Adverse events during the study were evaluated as safety outcome measures. This study was registered with Pharmaceuticals and Medical Devices Agency (clinical trial no. 28-277/2016-18; clinical trial identification no. KP2013-009_C001). RESULTS Efficacy rate of submucosal injection during ESD was 91.7% (55/60) and 88.7% (55/62) in the SA and SH groups, respectively, demonstrating non-inferiority of SA against SH. Adverse events for which a causal relationship with submucosal injection solution could not be eliminated were noted in 8.2% (5/61) and 4.7% (3/64) in the SA and SH groups, respectively, but symptoms disappeared without treatment/after drug administration in both groups. CONCLUSIONS In Japan, 0.4% SH is the only commercially approved formulation for submucosal injection during ESD. The study results may expand submucosal injection solution options in clinical practice.
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Affiliation(s)
- Naomi Uemura
- Kohnodai HospitalNational Center for Global Health and MedicineChibaJapan
| | - Ichiro Oda
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| | - Yutaka Saito
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| | - Hiroyuki Ono
- Division of EndoscopyShizuoka Cancer CenterShizuokaJapan
| | - Junko Fujisaki
- Department of GastroenterologyCancer Institute Hospital AriakeTokyoJapan
| | | | - Ken Ohata
- Department of GastroenterologyNTT Medical Center TokyoTokyoJapan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive TreatmentCancer CenterKeio University School of MedicineTokyoJapan
| | - Tomoyuki Yada
- Department of Gastroenterology and HepatologyKohnodai HospitalNational Center for Global Health and MedicineChibaJapan
| | - Masahiro Satoh
- Department of Research and DevelopmentKaigen Pharma Co. LtdHokkaidoJapan
| | - Hisao Tajiri
- Department of Innovative Interventional Endoscopy ResearchThe Jikei University School of MedicineTokyoJapan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric SurgeryOita UniversityFaculty of MedicineOitaJapan
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Bon I, Bartolí R, Cano-Sarabia M, de la Ossa N, de Vega VM, Marín I, Boix J, Lorenzo-Zúñiga V. Comparative study of electrical and rheological properties of different solutions used in endoscopic mucosal resection. Dig Endosc 2019; 31:276-282. [PMID: 30430648 DOI: 10.1111/den.13297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM The study of electrical and rheological properties of solutions to carry out endoscopic resection procedures could determinate the best candidate. An ex vivo study with porcine stomachs was conducted to analyze electrical resistivity (R) and rheological properties (temperature, viscosity, height and lasting of the cushion) of different substances used in these techniques. METHODS Tested solutions were: 0.9% saline (S), platelet-rich plasma (PRP), Gliceol (GC), hyaluronic acid 2% (HA), Pluronic-F127 20% (PL), saline with 10% glucose (GS), Gelaspan (GP), Covergel-BiBio (TB) and PRP with TB (PRP+TB). Measurements of electrical and rheological properties were done at 0, 15, 30, 45 and 60 min after submucosal injection. RESULTS Solutions showed a wide variability of transepithelial R after submucosal injection. Substances able to maintain the highest R 60 min postinjection were TB (7 × 104 Ω), HA (7 × 104 Ω) and PL (7 × 104 Ω). Protective solutions against deep thermal injury (Tª lower than 60°C) were PL (47.6°C), TB (55°C) and HA (56.63°C). Shortest time to carry out resections were observed with GC (17.66″), PRP (20.3″) and GS (23.45″). Solutions with less cushion decrease (<25%) after 60 min were TB (11.74%), PL (18.63%) and PRP (22.12%). CONCLUSIONS Covergel-BiBio, PL and HA were the best solutions with long-term protective effects (transepithelial R, lower thermal injury and less cushion decrease). Solutions with quicker resection time were GC, PRP and GS.
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Affiliation(s)
- Ignacio Bon
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Ramón Bartolí
- Network Biomedical Research Center of Hepathic and Digestive Diseases (CIBERehd), CSIC and The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Mary Cano-Sarabia
- Catalan Institute of Nanoscience and Nanotechnology, CSIC and The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Napoleón de la Ossa
- Department of Pathology, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | | | - Ingrid Marín
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Jaume Boix
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Network Biomedical Research Center of Hepathic and Digestive Diseases (CIBERehd), CSIC and The Barcelona Institute of Science and Technology, Barcelona, Spain
| | - Vicente Lorenzo-Zúñiga
- Endoscopy Unit, Germans Trias i Pujol University Hospital, Barcelona, Spain.,Network Biomedical Research Center of Hepathic and Digestive Diseases (CIBERehd), CSIC and The Barcelona Institute of Science and Technology, Barcelona, Spain
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Wang H, Wang S. Effect of submucosal injection of normal saline and glycerol fructose on endoscopic polypectomy in patients with colorectal polyps. Oncol Lett 2019; 17:4449-4454. [PMID: 30944637 PMCID: PMC6444498 DOI: 10.3892/ol.2019.10120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 02/25/2019] [Indexed: 11/05/2022] Open
Abstract
Effect of submucosal injection of normal saline and glycerol fructose on endoscopic polypectomy in patients with colorectal polyps was investigated. A total of 275 patients with colorectal polyps were enrolled in this study and underwent endoscopic gastrointestinal polypectomy in Qingdao Chengyang People's Hospital from March 2013 to December 2016. Among them, 150 patients who underwent submucosal injection of glycerol fructose were set as the experimental group, and 125 patients who underwent submucosal injection of normal saline were set as the control group. The surgery conditions, complications and recurrence rates were compared between the two groups. The time of processing polyps and the total surgery time in the experimental group were shorter than those in the control group (P<0.05). The number of repeated injections in the experimental group was less than that in the control group, and the difference was statistically significant (P<0.05). The amount of fluid and propofol injected in patients of the experimental group was significantly lower than that of the control group, and the difference was statistically significant (P<0.05). The en bloc resection rate (EBRR) and complete resection rate (CRR) in the experimental group were 68.0 and 48.0%, respectively. EBRR and CRR in the control group were 49.6 and 27.2%, respectively. EBRR and CRR in the experimental group were significantly higher than those in the control group (P<0.05). After follow-up of the patients for 3 months, there was no significant difference in the recurrence rate between the two groups (P>0.05). The results indicated that endoscopic colorectal polypectomy with glycerol fructose as a submucosal injection can shorten the time of surgery, reduce the number of repeated injections, reduce the amount of fluid and propofol, and also improve EBRR and CRR.
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Affiliation(s)
- Haowen Wang
- Department of Gastroenterology, Qingdao Chengyang People's Hospital, Qingdao, Shandong 266109, P.R. China
| | - Shuangshuang Wang
- Department of Gastroenterology, Qingdao Chengyang People's Hospital, Qingdao, Shandong 266109, P.R. China
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Córdova H, Cuatrecasas M, García-Rodríguez A, Montenegro A, Melo J, Rodríguez-de Miguel C, Martínez-Pallí G, Garcés-Durán R, Llach J, Fernández-Esparrach G. Successful outcomes of a new combined solution of hyaluronic acid, chondroitin sulfate and poloxamer 407 for submucosal injection: animal survival study. Endosc Int Open 2019; 7:E576-E582. [PMID: 30994113 PMCID: PMC6461554 DOI: 10.1055/a-0869-7757] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 01/07/2019] [Indexed: 12/13/2022] Open
Abstract
Background and study aims Endoscopic resection requires use of submucosal injection. This study was conducted to assess efficacy and impact on early healing of hyaluronic acid combined with chondroitin sulfate and poloxamer 407 (Ziverel) when used as a solution for submucosal injection. Materials and methods Prospective and comparative study of gastric endoscopic mucosal resection (EMR) with three groups of two Yorkshire pigs. Six submucosal cushions were created in each animal by injecting 2 mL of Ziverel (Group 1) or succinylated gelatin (SG) (Group 2), enabling 12 EMR in each group. Submucosal cushions were created with Ziverel in Group 3, without resection. Electrosurgery unit settings were the same in all cases. EMR defects and injection sites were marked with clips. The animals were sacrificed 7 days later. EMR specimen size and duration of procedure were recorded. EMR specimens and EMR scars and injection sites were evaluated by a blinded pathologist. Results We successfully performed 24 EMR (15 en-bloc and 9 piecemeal, without differences between groups 1 and 2). Mean EMR specimen dimensions were significantly larger in Group 1 (median 19 mm, range 6 - 40 vs 16.6 mm, range 5‑25; P = 0.019), without changing the electrocautery unit settings. Blinded histopathologist assessment of EMR specimens showed less fibrosis in the submucosa and a trend to fewer cautery artifacts with Ziverel and did not identify any significant differences in early healing of resection sites. Conclusion The combination of Ziverel enables EMR and does not negatively affect early healing.
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Affiliation(s)
- Henry Córdova
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Miriam Cuatrecasas
- Pathology Department, CDB, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Banc de Tumors Biobanc Clinic-IDIBAPS, Barcelona, Spain
| | - Ana García-Rodríguez
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Andrea Montenegro
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Jordana Melo
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Cristina Rodríguez-de Miguel
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | | | - Rodrigo Garcés-Durán
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Josep Llach
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Gloria Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain,Corresponding author G. Fernández-Esparrach Villarroel 17008036 BarcelonaSpain+34 932279387
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Pioche M, Jacques J. Endoscopic submucosal dissection: macromolecules or high-pressure injection or both? Endosc Int Open 2019; 7:E583-E584. [PMID: 30994112 PMCID: PMC6461545 DOI: 10.1055/a-0838-5508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mathieu Pioche
- Hepatogastroenterology division, Edouard Herriot Hospital, Lyon, France
| | - Jérémie Jacques
- Hepatogastroenterology division, Dupuytren Hospital, Limoges, France
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Fukunaga S, Nagami Y, Shiba M, Sakai T, Maruyama H, Ominami M, Otani K, Hosomi S, Tanaka F, Taira K, Tanigawa T, Yamagami H, Watanabe T, Fujiwara Y. Impact of preoperative biopsy sampling on severe submucosal fibrosis on endoscopic submucosal dissection for colorectal laterally spreading tumors: a propensity score analysis. Gastrointest Endosc 2019; 89:470-478. [PMID: 30201398 DOI: 10.1016/j.gie.2018.08.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 08/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS It is believed that preoperative biopsy sampling for superficial-type colorectal tumors should be avoided because submucosal fibrosis caused by biopsy sampling makes EMR impossible. However, few studies have reported the influence of biopsy sampling on colorectal endoscopic submucosal dissection (ESD). This study aimed to examine the effect of biopsy sampling on submucosal fibrosis and treatment outcomes of ESD for laterally spreading tumors (LSTs). METHODS Between April 2005 and September 2015, 441 consecutive patients underwent colorectal ESD in Osaka City University Hospital. Using propensity score matching and inverse probability of treatment weighting (IPTW), we retrospectively evaluated risk factors for severe submucosal fibrosis and treatment outcomes for patients with LSTs, with or without preoperative biopsy sampling. RESULTS A total of 428 LSTs resected using ESD were enrolled. After matching, there were 136 matched pairs of lesions that did or did not undergo biopsy sampling. Preoperative biopsy sampling increased severe fibrosis compared with that in the non-biopsy sampling group (20.6% vs 11.0%; P = .03) and was significantly associated with severe fibrosis after matching (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.07-4.10; P = .03). After adjustment with IPTW, biopsy sampling also increased the risk of severe fibrosis (OR, 2.33; 95% CI, 1.17-4.63; P = .02). However, no significant differences were observed between the 2 groups in treatment outcomes. CONCLUSIONS Preoperative biopsy sampling for colorectal LSTs might cause severe submucosal fibrosis but has no adverse influence on clinical outcomes of ESD.
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Affiliation(s)
- Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Taishi Sakai
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koji Otani
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Hosomi
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Koichi Taira
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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30
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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: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [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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Zhu Y, Xu JX, Cheng J, Zhang Z, Zhu BQ, Chen TY, Xu XY, Wang Y, Cai MY, Zhou PH. A novel injectable thermo-sensitive binary hydrogels system for facilitating endoscopic submucosal dissection procedure. United European Gastroenterol J 2019; 7:782-789. [PMID: 31316782 DOI: 10.1177/2050640619825968] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/31/2018] [Indexed: 02/06/2023] Open
Abstract
Background and aims Making an optimal and lasting submucosal cushion is critical for endoscopic submucosal dissection. The thermo-sensitive binary hydrogels system composed of poloxamer 407 and poloxamer 188 might be an excellent submucosal injection solution considering the unique feature that it remains liquid at room temperature and becomes gelatinous after being injected in the submucosa of the digestive tract. The present study focuses on preparing the thermo-sensitive binary hydrogels system and testing its capacity in mucosal lifting and its role in the endoscopic submucosal dissection procedure. Methods Various concentrations of poloxamer 407 and poloxamer 188 were added to normal saline. The gelation temperature viscosity of the thermo-sensitive binary hydrogels system was measured to choose the best formula. The thermo-sensitive binary hydrogels system and normal saline were first compared in extracted porcine stomach. For in vivo study, the thermo-sensitive binary hydrogels system and normal saline were compared for facilitating the endoscopic submucosal dissection procedure. Results Among the 46 kinds of thermo-sensitive binary hydrogels system, gelation temperatures of the thermo-sensitive binary hydrogels system I (poloxamer 407/poloxamer 188, 17%/0.5%, w/w) and the thermo-sensitive binary hydrogels system II (poloxamer 407/poloxamer 188, 18%/2%, w/w) were among the ideal range of gelation temperature. The injecting pressure in vitro study of thermo-sensitive binary hydrogels system II was significantly higher than that of thermo-sensitive binary hydrogels system I and normal saline (p < 0.001). Sixteen gastric endoscopic submucosal dissection procedures were performed in a porcine model. The initial volume of normal saline injection (13.88 ± 3.91 ml vs 5.88 ± 3.44 ml, p = 0.001) was significantly larger than the thermo-sensitive binary hydrogels system group. The postoperative wound showed a significant difference in the two groups (p = 0.023) indicating that the thermo-sensitive binary hydrogels system can create a cleaner wound. Conclusions Considering the gelation temperature, viscosity, injection pressure, and the height of the mucosal elevation, the thermo-sensitive binary hydrogels system I was the better submucosal injection solution.
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Affiliation(s)
- Yan Zhu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Jia-Xin Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Jing Cheng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Zhen Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Bo-Qun Zhu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Tian-Yin Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Xiao-Yue Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Yun Wang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Shanghai, China
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Wedi E, Ho CN, Conrad G, Weiland T, Freidinger S, Wehrmann M, Meining A, Ellenrieder V, Gottwald T, Schurr MO, Hochberger J. Preclinical evaluation of a novel thermally sensitive co-polymer (LiftUp) for endoscopic resection. MINIM INVASIV THER 2019; 28:277-284. [PMID: 30663522 DOI: 10.1080/13645706.2018.1535440] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Endoscopic resection techniques can successfully resect large lesions either in "en bloc" fashion or in "piece-meal" technique by using a submucosal injection solution. The aim of this study was to evaluate the safety of a novel injectable, containing thermally sensitive co-polymer from ethylenoxide and propylenoxide (LiftUp) used as submucosal injection solution.Material and methods: We conducted an in vivo animal trial in the porcine model to evaluate the LiftUp gel in a preclinical setting and to study the effectiveness of mucosal lifting and the safety of the new injectable. In seven animals a total of 63 injections and endoscopic resections were carried out in different anatomical locations (esophagus, stomach and rectum). The resection sites were controlled endoscopically one and four weeks after resection and a histopathological evaluation of the resection sites was performed after four weeks.Results: The application of LiftUp was safe and there were no negative effects on wound healing after injection and resection. A major procedural complication rate (defined as perforation and major haemorrhage) of 3.2% was registered, which undercuts the anticipated mean complication rate of 4-8%. Furthermore, there was no necessity of reinjection after the initial submucosal injection in 90.5% and no procedural complications in 98.8%. The histopathological examination of the tissue samples indicated normal wound healing with granulation tissue and epithelialisation.Conclusion: The use of LiftUp as submucosal injection solution was feasible for different endoscopic resection techniques, with high and long-lasting elevation and fewer procedural adverse events than expected at trial planning. The new injectable is a practical advancement over the current state-of-the-art of submucosal injection and could fasten up the resection procedure and make endoscopic 'en bloc' resection safer.
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Affiliation(s)
- Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Timo Weiland
- Novineon CRO & Consulting Ltd, Tuebingen, Germany
| | | | | | - Alexander Meining
- Interventional and Experimental Endoscopy (InExEn), Medizinische Klinik I, University Medical Centre Ulm, Germany
| | - Volker Ellenrieder
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre, Goettingen, Germany
| | | | | | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, Berlin, Germany
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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: 2.3] [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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Hirose R, Nakaya T, Naito Y, Daidoji T, Dohi O, Yoshida N, Yasuda H, Konishi H, Itoh Y. Identification of the critical viscoelastic factor in the performance of submucosal injection materials. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2018; 94:909-919. [PMID: 30423779 DOI: 10.1016/j.msec.2018.10.051] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/17/2022]
Abstract
High-performance submucosal injection materials (SIMs) contribute to the success of endoscopic therapy for early-stage gastrointestinal neoplasms. This study aimed to identify the most important factor (viscoelastic parameter) that determines SIM performance and the ease of injection. To determine the ideal viscoelastic parameters of SIMs, submucosal elevation heights (SEHs) and the ease of submucosal injection [characterized by injection pressures (IPs)] were evaluated using a newly developed ex vivo model, in which a constant tension was applied to the studied specimen. The strongest positive correlation was observed between the loss modulus determined at an oscillation frequency of 0.1 rad/s and SEH (correlation coefficient > 0.9) and between the loss modulus at 10 rad/s and IP (correlation coefficient > 0.9). SIMs with high loss moduli (0.1 rad/s) also contributed to maintenance of the submucosal elevation. Moreover, the SEHs of pseudoplastic fluid SIMs (whose loss moduli increased slightly with increasing angular frequency) were greater than those of Newtonian fluid SIMs (whose loss modulus increased drastically with increasing angular frequency). In this study, the ideal viscoelastic SIM parameters were clarified. The loss modulus (0.1 rad/s) was the most important viscoelastic factor affecting SIM performance. Additionally, the development of pseudoplastic fluid SIMs may lead to the creation of next-generation SIMs, with a performance superior to that of sodium hyaluronate, which is currently used widely in endoscopic treatments.
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Affiliation(s)
- Ryohei Hirose
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan; Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Takaaki Nakaya
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yuji Naito
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomo Daidoji
- Department of Infectious Diseases, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Osamu Dohi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohisa Yoshida
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hiroaki Yasuda
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideyuki Konishi
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yoshito Itoh
- Department of Molecular Gastroenterology and Hepatology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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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: 34] [Impact Index Per Article: 5.7] [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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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: 0.7] [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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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: 8] [Impact Index Per Article: 1.3] [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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Liu W, Wang M, Zhao L, Wang M, Wang X, Fan Z, Liu L. Thermo-sensitive isopentane aerification for mucosal lift during endoscopic resection in animal models (with video). Gastrointest Endosc 2017; 86:1168-1175.e3. [PMID: 28288842 DOI: 10.1016/j.gie.2017.02.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 02/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Mucosal lift is critical for successful endoscopic treatment. Normal saline (NS) solution is widely used as the submucosal filler, but its short persistency restricts clinical endoscopic submucosal dissection (ESD). In this study, thermo-sensitive isopentane was introduced for submucosal injection. With a boiling point at 27.8°C, liquid isopentane can be easily applied, and gasification inflation can provide great support for submucosal lifting at body temperature. The feasibility and efficiency of isopentane were evaluated in this study. METHODS Porcine stomachs were used for in vitro evaluation. A 37°C water bath was used to mimic body temperature. Compared with NS, isopentane was studied for its lifting performance, including injection dosage, persistence of lifting strength, and efficacy for assisting submucosal dissection. The changes in submucosal tissue were also compared. For in vivo evaluation, rats were used to further compare the differences between isopentane and NS, including lifting efficacy, pathologic effect, and safety. RESULTS Compared with NS, the maximum lifting height was achieved with less isopentane (2% NS volume). Longer persistency and faster operation for submucosal dissection were also recorded for isopentane during the in vitro study. Aerification resulted in vacuolization of submucosal connective tissue, which facilitates EMR and postoperative recovery. The same results were confirmed in the rat model. With the same dosage, isopentane produced better mucosal elevation and larger range than NS. According to the histologic examination, no tissue injury was observed with isopentane application. CONCLUSIONS As a submucosal injection agent, the feasibility, efficacy, and safety of isopentane has been demonstrated. Thermo-sensitive aerification may be a promising approach to facilitate ESD.
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Affiliation(s)
- Wenjie Liu
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Min Wang
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Lili Zhao
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Min Wang
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Xiang Wang
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Zhining Fan
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Li Liu
- Digestive Endoscopy Center, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
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Fernández-Esparrach G, Cuatrecasas M, Rodríguez de Miguel C, Sánchez-Montes C, Córdova H. Efficacy and safety of a combination of hyaluronic acid, chondroitin sulfate, and poloxamer 407 as a submucosal injection solution for endoscopic resection: pilot study on a swine model. Endosc Int Open 2017; 5:E450-E454. [PMID: 28573177 PMCID: PMC5451276 DOI: 10.1055/s-0043-107614] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 01/13/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS Endoscopic resection techniques require use of submucosal injection. The aim of this study was to assess a new solution that combines hyaluronic acid, chondroitin sulfate, and poloxamer 407 for submucosal injection. METHODS A total of 48 gastric submucosal cushions were created in fresh porcine stomachs using gelafundin (n = 16) or the new solution diluted at 50 % (n = 16), or 80 % (n = 16). The duration of mucosal elevation was measured. In an in vivo model, 10 gastric submucosal cushions were created by injecting 2 mL of the new solution at 80 % and the animal was euthanized 30 minutes after the last injection. RESULTS Submucosal cushions with the new solution at 80 % and 50 % concentration lasted longer than with gelafundin (23.13 ± 15.57, 13.1 ± 6.6, 3.94 ± 1.53 minutes, respectively; P = 0.000). In the in vivo study, no damage or necrosis was observed in the mucosa or muscularis propria. CONCLUSION The combination of hyaluronic acid, chondroitin sulfate, and poloxamer 407 produces a long-lasting submucosal cushion and does not seem to induce acute damage in the tissue making it suitable for submucosal injection.
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Affiliation(s)
- G. Fernández-Esparrach
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain,Corresponding author Gloria Fernández-Esparrach, MD PhD Villarroel 17008036 BarcelonaSpain+34-932-279387
| | - M. Cuatrecasas
- Pathology Department, CDB, Hospital Clínic, IDIBAPS, Universitat de Barcelona, Banc de Tumors Biobanc Clinic-IDIBAPS, Barcelona, Spain
| | - C. Rodríguez de Miguel
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - C. Sánchez-Montes
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - H. Córdova
- Endoscopy Unit, Gastroenterology Department, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Ning B, Abdelfatah MM, Othman MO. Endoscopic submucosal dissection and endoscopic mucosal resection for early stage esophageal cancer. Ann Cardiothorac Surg 2017; 6:88-98. [PMID: 28446997 DOI: 10.21037/acs.2017.03.15] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Mortality from esophageal cancer remains high despite advances in medical therapy. Although the incidence of squamous cell carcinoma of the esophagus remains unchanged, the incidence of the esophageal adenocarcinoma has increased over time. Gastroesophageal reflux disease (GERD and obesity are contributing factors to the development of Barrett's esophagus and subsequent development of adenocarcinoma. Early recognition of the disease can lead to resection of esophageal cancer prior to the development of lymphovascular invasion. Various modalities have been implemented to aid identification of precancerous lesions and early esophageal cancer. Chromoendoscopy, narrowband imaging and endoscopic ultrasound examination are typically used for evaluating early esophageal lesions. Recently, confocal laser endomicroscopy (CLE) and volumetric laser scanning were implemented with promising results. Endoscopic management of early esophageal cancer may be done using endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Both techniques allow resection of the mucosa (and possibly a portion of the submucosa) containing the early tumor without interruption of deeper layers. A submucosal injection creating a cushion coupled with snare resection or cap assisted mucosal suction followed by ligation and snare resection are the most common techniques of EMR. EMR can remove lesions less than 2 cm in size en bloc. Larger lesions may require resection in piecemeal fashion. This may limit assessment of the margins of the lesion and orienting the lesion's border. ESD offers en bloc dissection of the lesion regardless of its size. ESD is performed with specialized needle knives, which allow incision followed by careful dissection of the lesion within the submucosal layer. Tumor recurrence after ESD is rare but the technique is labor intensive and has an increased risk of perforation. Esophageal stenosis remains a concern after extensive EMR or ESD. Dilation with balloon or stent placement is usually sufficient to treat post-resection stenosis.
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Affiliation(s)
- Bo Ning
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, China
| | - Mohamed M Abdelfatah
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX, USA
| | - Mohamed O Othman
- Division of Gastroenterology, Department of Internal Medicine, East Carolina University, Greenville, NC, USA
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Xu JF, Yang L, Jin P, Sheng JQ. Endoscopic Approach for Superficial Colorectal Neoplasms. Gastrointest Tumors 2016; 3:69-80. [PMID: 27904859 DOI: 10.1159/000447128] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Colorectal cancer (CRC) is the third most commonly diagnosed cancer in males and the second in females, with an estimated 1.4 million cases and 693,900 deaths in 2012. Colonoscopy is the cornerstone for the detection and prevention of CRC. In addition, endoscopic treatment for CRC at an early stage can effectively improve patients' quality of life and cure rate. SUMMARY This review focuses on endoscopic approaches, including white light endoscopy, chromoendoscopy, magnifying endoscopy and therapeutic endoscopy, for the evaluation and treatment of superficial colorectal neoplasms. KEY MESSAGE Understanding the preoperative evaluation, indications and techniques of endoscopic mucosal resection/endoscopic submucosal dissection as well as postoperative surveillance for superficial colorectal neoplasms is critical for providing appropriate management to the patients. PRACTICAL IMPLICATIONS Endoscopic therapy, a method preserving organ function and improving quality of life, is a widely applied microinvasive treatment for superficial colorectal neoplasms. This review describes the basics and developments of endoscopic approaches and may facilitate daily practice for superficial colorectal neoplasms.
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Affiliation(s)
- Jun-Feng Xu
- People's Liberation Army General Hospital, Beijing, China
| | - Lang Yang
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
| | - Peng Jin
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
| | - Jian-Qiu Sheng
- Department of Gastroenterology, PLA Army General Hospital, Beijing, China
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Saunders BP, Tsiamoulos ZP. Endoscopic mucosal resection and endoscopic submucosal dissection of large colonic polyps. Nat Rev Gastroenterol Hepatol 2016; 13:486-96. [PMID: 27353401 DOI: 10.1038/nrgastro.2016.96] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Almost all large and complex colorectal polyps can now be resected endoscopically. Piecemeal endoscopic mucosal resection (PEMR) is an established technique with fairly low complication risk and good short-term and medium-term outcomes. Several modifications to the basic injection and snare technique have been developed contributing to safer and more complete resections. Delayed bleeding requiring reintervention is the most troublesome complication in 2-7% of patients, particularly in those with comorbidities and large, right-sided polyps. Endoscopic submucosal dissection (ESD) has become popular in Japan and has theoretical advantages over PEMR in providing a complete, en bloc excision for accurate histological staging and reduced local recurrence. These advantages come at the cost of a more complex, expensive and time-consuming procedure with a higher risk of perforation, particularly early in the procedure learning curve. These factors have contributed to the slow adoption of ESD in the West and the challenge to develop new devices and endoscopic platforms that will make ESD easier and safer. Currently, ESD indications are limited to large rectal lesions, in which procedural complications are easily managed, and for colorectal polyps with a high risk of containing tiny foci of early submucosally invasive cancer, whereby ESD may be curative compared with PEMR.
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Affiliation(s)
- Brian P Saunders
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
| | - Zacharias P Tsiamoulos
- Imperial College, London, Wolfson Unit for Endoscopy, St Mark's Academic Institute, Watford Road, Harrow HA1 3UJ, UK
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Hikichi T, Yamasaki M, Watanabe K, Nakamura J, Sato M, Takagi T, Suzuki R, Sugimoto M, Kikuchi H, Konno N, Waragai Y, Asama H, Takasumi M, Ejiri Y, Watanabe H, Ohira H, Obara K. Gastric endoscopic submucosal dissection using sodium carboxymethylcellulose as a new injection substance. Fukushima J Med Sci 2016; 62:43-50. [PMID: 27020144 PMCID: PMC5131580 DOI: 10.5387/fms.2015-27] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 02/23/2016] [Indexed: 12/12/2022] Open
Abstract
AIM To investigate the feasibility of endoscopic submucosal dissection (ESD) using sodium carboxymethylcellulose (SCMC) for gastric cancer. METHODS During October 2011 through April 2013, 98 lesions from 98 patients who underwent ESD using SCMC (ESD-SCMC) for early gastric cancer were enrolled in this study. Two endoscopists, who had each performed fewer than 30 ESD procedures (less-experienced ESD physicians), performed ESD-SCMC under the supervision of two experts. The primary outcome was the en bloc resection rate. Secondary outcomes included the complete resection rate, the procedural time, the bleeding rate after SCMC injection, and complications. Patient characteristics, time necessary for hemostasis after SCMC injection, rate of treatment completion by less-experienced ESD physicians alone, and the effects of SCMC during ESD and on resected specimens were also evaluated. RESULTS The en bloc resection rate was 100%. Among these resections, 87.8% of the cases were completed by a less-experienced ESD physician alone. The complete resection rate was 98.0%. The mean total procedural time was 75.4 min. The mean incidence of intraoperative bleeding following SCMC local injection was 1.7 times. No bleeding was observed after SCMC injection in 29.6% of cases (29/98). Five complications occurred: one case of microperforation (1.0%) and four cases of postoperative bleeding (4.0%). SCMC remained in the submucosa. The submucosa was readily manipulated when the deep submucosa was dissected, even after placing the specimen on a slide. CONCLUSION ESD-SCMC is feasible for the resection of early gastric cancer.
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Affiliation(s)
- Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital
| | - Masahiro Yamasaki
- Third Department of Internal Medicine, University of Occupational and Environmental Health
- Division of Gastroenterology, Fukushima Rosai Hospital
| | - Ko Watanabe
- Department of Endoscopy, Fukushima Medical University Hospital
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Jun Nakamura
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Masaki Sato
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Tadayuki Takagi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Rei Suzuki
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Mitsuru Sugimoto
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hitomi Kikuchi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Naoki Konno
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Yuichi Waragai
- Department of Endoscopy, Fukushima Medical University Hospital
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hiroyuki Asama
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Mika Takasumi
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Yutaka Ejiri
- Division of Gastroenterology, Fukushima Rosai Hospital
| | - Hiroshi Watanabe
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Hiromasa Ohira
- Department of Gastroenterology and Rheumatology, Fukushima Medical University School of Medicine
| | - Katsutoshi Obara
- Department of Advanced Gastroenterological Endoscopy, Fukushima Medical University
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Large Colorectal Lesions: Evaluation and Management. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 23:197-207. [PMID: 28868460 PMCID: PMC5580011 DOI: 10.1016/j.jpge.2016.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 01/04/2016] [Indexed: 02/07/2023]
Abstract
In the last years, a distinctive interest has been raised on large polypoid and non-polypoid colorectal tumors, and specially on flat neoplastic lesions ≥20 mm tending to grow laterally, the so called laterally spreading tumors (LST). Real or virtual chromoendoscopy, endoscopic ultrasound or magnetic resonance should be considered for the estimation of submucosal invasion of these neoplasms. Lesions suitable for endoscopic resection are those confined to the mucosa or selected cases with submucosal invasion ≤1000 μm. Polypectomy or endoscopic mucosal resection remain a first-line therapy for large colorectal neoplasms, whereas endoscopic submucosal dissection in high-volume centers or surgery should be considered for large LSTs for which en bloc resection is mandatory.
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Abstract
ESD is an established effective treatment modality for premalignant and early-stage malignant lesions of the stomach, esophagus, and colorectum. Compared with EMR, ESD is generally associated with higher rates of en bloc, R0, and curative resections and a lower rate of local recurrence. Oncologic outcomes with ESD compare favorably with competing surgical interventions, and ESD also serves as an excellent T-staging tool to identify noncurative resections that will require further treatment. ESD is technically demanding and has a higher rate of adverse events than most endoscopic procedures including EMR. As such,sufficient training is critical to ensure safe conduct and high-quality resections. A standardized training model for Western endoscopists has not been clearly established,but will be self-directed and include courses, animal model training, and optimally an observership at an expert center.Numerous dedicated ESD devices are now available in the United States from different manufacturers. Although the use of ESD in the United States is increasing, issues related to technical difficulty, limited training opportunities and mentors, risk of adverse events, long procedure duration,and suboptimal reimbursement may limit ESD adoption in the United States to a modest number of academic referral centers for the foreseeable future.
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Ferreira AO, Moleiro J, Torres J, Dinis-Ribeiro M. Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis. Endosc Int Open 2016; 4:E1-E16. [PMID: 26793777 PMCID: PMC4713187 DOI: 10.1055/s-0034-1393079] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 08/11/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND AND AIMS Submucosal injection is standard practice in endoscopic mucosal resection of gastrointestinal lesions. Several solutions are used. Our aim was to systematically review their efficacy and safety. PATIENTS AND METHODS We performed a systematic review and meta-analysis using a random effects model of randomized controlled trials (RCTs) from MEDLINE. Studies in animal models were qualitatively assessed for efficacy and safety. RESULTS In total, 54 studies were qualitatively assessed. Eleven RCTs were analyzed, two of which were on endoscopic submucosal dissection (ESD). The quantitative synthesis included nine RCTs on endoscopic mucosal resection (EMR), comprising 792 subjects and 793 lesions. Mean lesion size was 20.9 mm (range 8.5 - 46 mm). A total of 209 lesions were randomized to sodium hyaluronate (SH) vs normal saline (NS), 72 to 50 % dextrose (D50) vs NS, 82 to D50 vs SH, 43 to succinylated gelatin, 25 to hydroxyethyl starch and 36 to fibrinogen. In total, 385 were randomized to NS as controls. NS and SH are the best studied solutions and seem to be equally effective in achieving complete resection (OR 1.09; 95 %CI 0.82, 1.45). No solution was proven to be superior in complete resection rate, post-polypectomy bleeding or coagulation syndrome/perforation incidence. Many solutions have been tested in animal studies and most seem more effective for mucosal elevation than NS. CONCLUSIONS There are several solutions in clinical use and many more under research, but most are poorly studied. SH seems to be clinically equivalent to NS. There are no significant differences in post-polypectomy complications. Larger RCTs are needed to determine any small differences that may exist between solutions.
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Affiliation(s)
- Alexandre Oliveira Ferreira
- Department of Gastroenterology, Hospital Beatriz Ângelo, Lisboa, Portugal
- Corresponding author Alexandre Oliveira Ferreira, MD Hospital Beatriz ÂngeloDepartment of GastroenterologyAvenida Carlos Teixeira 32674-514 LouresPortugal+351-21-9847209
| | - Joana Moleiro
- Department of Gastroenterology, Instituto Português do Oncologia de Lisboa, Lisboa, Portugal
| | - Joana Torres
- Department of Gastroenterology, Hospital Beatriz Ângelo, Lisboa, Portugal
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Instituto Português do Oncologia do Porto, Porto, Portugal
- CIDES/CINTESIS, Faculty of Medicine – University of Porto, Porto, Portugal
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Oda I, Suzuki H, Yoshinaga S. Endoscopic Submucosal Dissection for Early Gastric Cancer: Getting It Right! ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 908:317-30. [PMID: 27573778 DOI: 10.1007/978-3-319-41388-4_15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Endoscopic resection is a widely accepted less-invasive treatment technique for local resection of early gastric cancer (EGC) lesions with a negligible risk of lymph node metastasis. Remarkable progress has been made during the last decade in this field, both in terms of expansion of the indications (to larger lesions and to lesions with ulceration) and in terms of technical improvements from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Previously, larger lesions and lesions with ulceration were resected surgically because of the difficulty in effectively using EMR in this context. ESD however allows a high rate of en bloc resections, regardless of tumor location, tumor size, or the presence of ulceration. Nonetheless, ESD also has drawbacks: the procedure time is increased, ESD is more technically challenging compared to EMR, and, finally, ESD is associated with a slightly higher risk of complications. In order to overcome these limitations and minimize complications, a step-by-step process is important for learning ESD techniques. This chapter addresses the indications, results, some technical tips, and complications of ESD for EGC.
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Affiliation(s)
- Ichiro Oda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Harushisa Suzuki
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shigetaka Yoshinaga
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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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: 151] [Impact Index Per Article: 16.8] [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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HybridKnife high-pressure glycerol jet injection for endoscopic submucosal dissection increases procedural ease and speed: a randomised study in pigs and a human case series. Surg Endosc 2015; 30:3152-9. [DOI: 10.1007/s00464-015-4554-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 09/03/2015] [Indexed: 02/07/2023]
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50
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Hwang JH, Konda V, Abu Dayyeh BK, Chauhan SS, Enestvedt BK, Fujii-Lau LL, Komanduri S, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82:215-26. [PMID: 26077453 DOI: 10.1016/j.gie.2015.05.001] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/01/2015] [Indexed: 02/06/2023]
Abstract
EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.
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