Impact of including epinephrine in the submucosal injectate for colorectal EMR on postprocedural pain: a randomized controlled trial

Cold Snare Resection in the Colorectum: When to Choose it, When to Avoid it, and How to Do it

Cold snaring is now the preferred resection method for the majority of colorectal polyps encountered during colonoscopy. A key advantage of cold resection over resection utilizing electrocautery is a substantially lower risk of delayed hemorrhage. Cold snare resection is preferred for all lesions ≤10 mm and for nondysplastic sessile serrated lesions of any size but should be avoided when lesions have a significant risk of submucosal invasion or fibrosis. Cold snare resection can be considered for certain lesions 11-19 mm in size and some lateral spreading lesions ≥20 mm. This review discusses tips and techniques to optimize cold snare resection.

Submucosal injection fluid and tattoo agents

BACKGROUND AND AIMS

EMR and endoscopic submucosal dissection (ESD) are minimally invasive endoscopic techniques, developed for the removal of benign and early malignant lesions throughout the GI tract. Submucosal injection of a marking agent can help to identify lesions during surgery. Endoscopic resection frequently involves "lifting" of the lesions by injection of a substance within the submucosal space to create a cushion for safe resection. This review summarizes the current techniques and agents available for endoscopic marking and lifting of GI tract lesions.

METHODS

The MEDLINE database was searched through April 2023 for relevant articles related to the lifting and marking aspect of EMR by using key words such as "endoscopy" or "endoscopic" combined with "marking," "tattoo," and "lifting." The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

RESULTS

This technology review describes the techniques for endoscopic tattoo placement and submucosal lifting, along with currently available agents, safety, and costs.

CONCLUSIONS

Endoscopists performing EMR and ESD have several choices in submucosal injection materials for lifting and marking agents for tattoos. These may be commercially prepared agents or off-the-shelf materials with or without additives to facilitate visualization. A thorough understanding of the indications, techniques, properties of various agents, costs, and adverse events is necessary in choosing the appropriate materials and technique to optimize lesion resection in EMR and ESD.

The effects of tranexamic acid on the histopathology of defect healing in an in vivo porcine model after gastric and colonic endoscopic submucosal dissection

Introduction

There is limited data on the histopathological effects of hemostatic agents (HAs) used during endoscopic submucosal dissection (ESD). We used an in vivo porcine model to compare the tissue effects of tranexamic acid (TXA) and adrenaline (epinephrine) compared to controls.

Methods

Standard ESD, using a 2 mm flash-knife, was performed in three pigs. Four resections were performed in the stomach and rectum of each pig. Injectate contained 4% succinylated gelatin solution and indigo carmine, plus either TXA, adrenaline, or neither. Pigs were euthanized after 7 days and evaluated by two blinded pathologists.

Results

Twenty-four defects were analyzed. Within each animal no significant histopathological changes were noted between the defects, but differences were noted between the animals. In the stomachs of the TXA and adrenaline pigs, pathology revealed a clear ulcer in the mucosa/submucosa with abundant granulation tissue, while the muscular layer was unaffected. In the control pig's stomach, the lesions were deeper, transmurally distributed, with inflammation of the muscular and adventitia layers accompanied by severe inflammation and necrosis. Fewer differences were noted in the rectum.

Conclusion

For ESD, HAs such as TXA and adrenaline may have protective effects on the depth and extent of injury to the underlying tissue.