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Izumikawa K, Iwamuro M, Inaba T, Ishikawa S, Kuwaki K, Sakakihara I, Yamamoto K, Takahashi S, Tanaka S, Wato M, Okada H. Bleeding in patients who underwent scheduled second-look endoscopy 5 days after endoscopic submucosal dissection for gastric lesions. BMC Gastroenterol 2018; 18:46. [PMID: 29631560 PMCID: PMC5892005 DOI: 10.1186/s12876-018-0774-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 03/28/2018] [Indexed: 02/07/2023] Open
Abstract
Background Bleeding after endoscopic submucosal dissection (ESD) in antithrombotic drug users is still one of the important issues to be solved. We performed scheduled second-look endoscopy (SLE) 5 days after ESD, when the resumption of antithrombotic agents is assumed to have achieved a steady state, rather than on the day after ESD. We investigated bleeding incidence and the status of ulcers. Methods A total of 299 lesions in 299 patients subjected to ESD for gastric neoplasms were enrolled. A double dose of proton pump inhibitors was administered after ESD. SLE was planned 5 days after ESD. Post-ESD bleeding occurring before SLE was defined as early phase post-ESD bleeding, whereas bleeding after SLE was defined as later phase post-ESD bleeding. Forrest IIa and IIb ulcers are defined as high-risk ulcers requiring prophylactic hemostasis. We investigated risk factors for post-ESD bleeding, particularly focusing on the use of antithrombotic agents and the presence of high-risk ulcers requiring prophylactic hemostasis during SLE. Results Under a double dose of proton pump inhibitors, early phase post-ESD bleeding occurred in 2.3% of non-users (5/218) and 6.2% of users of antithrombotic agents (5/81). High-risk ulcers were found in 19.0% of the cases during scheduled SLE (55/289). Later phase bleeding occurred in 5.5% of cases [2.8% of non-users (6/213) and 13.2% of users of antithrombotic agents (10/76)]. Cox regression analysis revealed that the risk factor for post-ESD bleeding was antithrombotic treatment (HR: 3.56; 95% CI: 1.63–8.02, p = 0.002) alone. Among patients with high-risk ulcers, a statistically significant increase in bleeding was observed in the later phase in patients under antithrombotic therapy, compared to those not receiving any antithrombotic agents (p = 0.001). Conclusions Antithrombotic treatment is a risk factor for post-ESD bleeding despite SLE being scheduled 5 days after ESD. Later phase post-ESD bleeding was observed in 13.2% of the patients under antithrombotic treatment even after prophylactic hemostasis for high-risk ulcers. Trial registration This study was registered in the UMIN Clinical Trials Registry System (000023306). Retrospectively registered on 23rd July 2016.
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Affiliation(s)
- Koichi Izumikawa
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan.
| | - Tomoki Inaba
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Shigenao Ishikawa
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Kenji Kuwaki
- Department of Internal Medicine, Fukuyama City Hospital, 5-23-1 Zao-cho, Fukuyama, Hiroshima, 721-8511, Japan
| | - Ichiro Sakakihara
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Kumiko Yamamoto
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Sakuma Takahashi
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Shigetomi Tanaka
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Masaki Wato
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, 1-2-2 Asahi-machi, Takamatsu, Kagawa, 760-8557, Japan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama, Okayama, 700-8558, Japan
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Panos MZ, Koumi A. Argon plasma coagulation in the right and left colon: safety-risk profile of the 60W-1.2 l/min setting. Scand J Gastroenterol 2014; 49:632-41. [PMID: 24694332 DOI: 10.3109/00365521.2014.903510] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND STUDY AIM The 40W-0.8 l/min setting is widely recommended for argon plasma coagulation (APC) in the right colon. Until March 2012, we used the 60W-1.2 l/min setting for all sites of the colon. By auditing our experience, we assessed the safety-risk profile of the 60W-1.2 l/min setting in the right and left colon. PATIENTS AND METHODS All cases treated with APC by a single endoscopist, using the 60W-1.2 l/min setting for all sites of the colon between October 2001 and December 2007 were identified retrospectively and site, type, number of lesions, and complications were recorded. Between January 2008 and March 2012, information was recorded prospectively. RESULTS In the retrospective audit, 290 lesions (101 cecum/ascending, 120 sigmoid/descending, 69 transverse) were treated in 241 patient endoscopies. There were no perforations. In the prospective audit, 156 lesions (83 cecum/ascending, 47 sigmoid/descending, 26 transverse) were treated in 132 patient endoscopies. There was 1/83 (1.2%) perforation in the cecum/ascending colon and none in the transverse or sigmoid/descending (n.s.). Combined, the results yield a cecal/ascending perforation rate of 1/153 (0.6%) patient endoscopies, 1/184 (0.5%) lesions treated and overall perforation rate for all sites of the colon of 1/373 (0.3%) patient endoscopies and 1/446 (0.2%) lesions. Post-polypectomy syndrome and delayed bleeding each occurred in 3/373 (0.8%) patient endoscopies and 3/446 (0.7%) lesions. There were no deaths. CONCLUSION In the cecum and ascending colon, the APC perforation rate at the 60W-1.2 l/min setting was no higher than in the left colon and is similar to that reported in previously published series. Therefore, it appears safe, provided the precautions we describe are strictly followed.
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Affiliation(s)
- Marios Z Panos
- Department of Gastroenterology, Euroclinic of Athens , Athens , Greece
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Ben-Menachem T, Decker GA, Early DS, Evans J, Fanelli RD, Fisher DA, Fisher L, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan KM, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Dominitz JA, Cash BD. Adverse events of upper GI endoscopy. Gastrointest Endosc 2012; 76:707-18. [PMID: 22985638 DOI: 10.1016/j.gie.2012.03.252] [Citation(s) in RCA: 221] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 12/13/2022]
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Endoscopic mucosal ablation: a new argon plasma coagulation/injection technique to assist complete resection of recurrent, fibrotic colon polyps (with video). Gastrointest Endosc 2012; 75:400-4. [PMID: 22154411 DOI: 10.1016/j.gie.2011.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 09/01/2011] [Indexed: 12/13/2022]
Abstract
BACKGROUND Incomplete piecemeal EMR of large, sessile/flat colon polyps results in polyp recurrence, with massive submucosal scarring making subsequent attempts at endoscopic resection problematic. OBJECTIVE We report our experience with a new endoscopic mucosal ablation (EMA) technique that can be used to complement the eradication of recurrent fibrotic colon polyps. DESIGN Single-center, retrospective case series. SETTING Tertiary-care referral academic endoscopy unit. PATIENTS This study involved consecutive patients referred for endoscopic excision of recurrent benign colon polyps with severe submucosal fibrosis (>30% of the entire lesion). INTERVENTION Application of high-power argon plasma coagulation (APC), preceded by injection of a submucosal fluid cushion (normal saline/diluted adrenaline and/or sodium hyaluronate solution) to protect the muscle layer, was performed to augment further piecemeal EMR and polyp eradication. MAIN OUTCOME MEASUREMENTS Technical safety and success, complication and recurrence rates. RESULTS Fourteen patients (mean age 73 years; 9 men, 5 women) with 15 recurrent colon adenomas (mean polyp size 30 mm, 9 proximal/6 distal) were included. EMA with a mean APC power setting of 55 W was applied. Complete polyp eradication was achieved in 9 of 11 patients (82%) at first or second completed follow-up. One patient needed laparoscopic colectomy because of cancer, and 1 underwent transanal endoscopic microsurgery for benign massive recurrence. The other 3 patients with small, easily treatable recurrence (≤3 mm) were followed by 1-year-surveillance. No perforations and no postpolypectomy syndrome were reported. LIMITATIONS Single-center, nonrandomized case series with short duration follow-up. CONCLUSION EMA appears to be a safe and easily applicable technique to assist the complete eradication of recurrent fibrotic colon polyps.
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Muraki Y, Enomoto S, Iguchi M, Fujishiro M, Yahagi N, Ichinose M. Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection. World J Gastrointest Endosc 2012; 4:1-8. [PMID: 22267977 PMCID: PMC3262173 DOI: 10.4253/wjge.v4.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/06/2011] [Accepted: 01/12/2012] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.
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Affiliation(s)
- Yosuke Muraki
- Yosuke Muraki, Shotaro Enomoto, Mikitaka Iguchi, Masao Ichinose, Second Department of Internal Medicine, Wakayama Medical University, Wakayama-city, Wakayama 641-0012, Japan
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Shi Q, Zhong YS, Yao LQ, Zhou PH, Xu MD, Wang P. Endoscopic submucosal dissection for treatment of esophageal submucosal tumors originating from the muscularis propria layer. Gastrointest Endosc 2011; 74:1194-200. [PMID: 21963065 DOI: 10.1016/j.gie.2011.07.039] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 07/20/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND The technique of endoscopic submucosal dissection (ESD), which was developed for en bloc resection of large lesions in the stomach, has been widely accepted for the treatment of early gastric cancer. It is being used for muscularis propria tumors of the digestive tract and has produced positive therapeutic effects. OBJECTIVE To study the feasibility of ESD for the removal of esophageal muscularis propria tumors and to evaluate the efficacy and safety of ESD for this treatment. DESIGN Single-center, retrospective study. SETTING University hospital. PATIENTS Thirty esophageal muscularis propria tumors from 28 patients were treated with ESD between December 2008 and December 2010. We defined esophageal muscularis propria tumors as esophageal submucosal tumors originating from the muscularis propria layer. INTERVENTION ESD. MAIN OUTCOME MEASUREMENTS Tumor characteristics, complications, en bloc resection rate, and local recurrence rate were evaluated. RESULTS Among the 28 patients, 11 were women (39.3%). The median age was 49.32 years (range 22-62 years). Mean (± SD) tumor size was 1.25 ± 0.70 cm (range 0.5-3.0 cm). Except for 2 failed cases (one changed to surgery and the other changed to nylon ligation), 26 cases with 28 tumors (2 cases had 2 tumors) originating from the muscularis propria of the esophagus were successfully resected by ESD. The en bloc resection rate was 93.3% (28/30). The median ESD procedure time was 73.5 minutes (range 30-120 minutes). Perforation occurred in 2 cases during dissection of the lesion, which was closed with metal endoclips. Pneumothorax occurred after the treatment in both cases. Closed thoracic drainages were initiated, and the patients recovered quickly without surgery. Pathological examination confirmed 27 leiomyomas and 1 GI stromal tumor. The curative resection rate was 100% (28/28). There was no recurrence during a 3 to 27-month follow-up period. LIMITATIONS The limitation of the study was its retrospective design. CONCLUSION ESD offers the promise of localized treatment of esophageal muscularis propria tumors with relatively few complications and low mortality. It makes the resection of whole lesions possible and provides precise histologic information.
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Affiliation(s)
- Qiang Shi
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
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Fujishiro M, Abe N, Endo M, Kawahara Y, Shimoda R, Nagata S, Homma K, Morita Y, Uedo N. Retrospective multicenter study concerning electrocautery forceps with soft coagulation for nonmalignant gastroduodenal ulcer bleeding in Japan. Dig Endosc 2010; 22 Suppl 1:S15-8. [PMID: 20590763 DOI: 10.1111/j.1443-1661.2010.00962.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Electrocautery forceps with soft coagulation are actively used for treatment of bleeding and nonbleeding visible vessels during endoscopic submucosal dissection, but the usefulness of gastroduodenal ulcer bleeding has not been elucidated so far. The purpose of this paper is to elucidate the outcomes of electrocautery forceps with soft coagulation for peptic and artificial gastroduodenal ulcer bleeding. A retrospective multicenter study of consecutive case series during one year involved nine departments of high-volume hospitals in Japan. The study included 128 consecutive patients (62 with peptic ulcers and 66 with artificial ulcers) with bleeding nonmalignant gastroduodenal ulcers that were revealed using emergency endoscopy between January 2008 and December 2008. Hemostasis was carried out using electrocautery forceps with soft coagulation. Rates of successful initial hemostasis, rebleeding, transfer to surgery, and death according to peptic and artificial ulcer bleeding were recorded. Successful initial endoscopic hemostasis was obtained in 61 peptic ulcer patients (98.4%) and 66 artificial ulcer patients (100%). Rebleeding was observed in seven peptic ulcer patients (11.5%) and five artificial ulcer patients (7.6%). Rates of successful management with endoscopic methods alone were 96.8% (60/62) and 100% (66/66) in peptic ulcer patients and artificial ulcer patients, respectively. There were no severe complications or deaths related to the management of gastroduodenal ulcer bleeding. The novel endoscopic method using electrocautery forceps with soft coagulation for gastroduodenal ulcer bleeding seems to provide safety and efficacy that is comparable with that of endoscopic hemostasis with other established hemostatic techniques.
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Affiliation(s)
- Mitsuhiro Fujishiro
- Department of Endoscopy and Endoscopic Surgery, The University of Tokyo, Tokyo, Japan.
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Zhou PH, Yao LQ, Qin XY. Endoscopic submucosal dissection for colorectal epithelial neoplasm. Surg Endosc 2009; 23:1546-51. [PMID: 19263116 DOI: 10.1007/s00464-009-0395-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2008] [Revised: 01/06/2009] [Accepted: 01/12/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD), a new widely accepted method for treating early gastric cancer, was developed to increase the en bloc rate, especially for lesions larger than 20 mm in diameter. This study aimed to evaluate the efficacy and safety of ESD for colorectal epithelial neoplasms. METHODS From July 2006 to December 2007, ESD was indicated for patients with colorectal epithelial neoplasms larger than 20 mm in diameter. The rates of curative en bloc resection, the procedure time, and the incidence of complications were investigated. RESULTS A total of 74 colorectal epithelial neoplasms were resected by ESD. The mean diameter of these lesions was 32.6 mm (range, 20-85 mm). The rate of en bloc resection was 93.2% (69/74), and the mean ESD procedure time was 110 min (range, 80-185 min). None of patients had massive hemorrhage during ESD, and only one patient (1.4%) bled 8 days after ESD. Six patients experienced perforation, and all except one recovered after several days of conservative treatment. The patient who did not recover underwent urgent surgery. The perforation rate was 8.1% (6/74). All the patients were followed up. Healing of the artificial ulcer was confirmed, and with no lesion residue or recurrence was found. CONCLUSIONS The findings show ESD to be effective for colorectal epithelial neoplasm, making it possible to resect the whole lesion in one piece and to provide precise histologic information.
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Affiliation(s)
- Ping-Hong Zhou
- Institute of Endsocopy, Zhongshan Hospital, Fudan University, Shanghai, China.
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Fujishiro M, Kodashima S, Ono S, Goto O, Yamamichi N, Yahagi N, Kashimura K, Matsuura T, Iguchi M, Oka M, Ichinose M, Omata M. Submucosal Injection of Normal Saline can Prevent Unexpected Deep Thermal Injury of Argon Plasma Coagulation in the in vivo Porcine Stomach. Gut Liver 2008; 2:95-8. [PMID: 20485617 DOI: 10.5009/gnl.2008.2.2.95] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2008] [Accepted: 06/10/2008] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/AIMS There have been several reports of thermal injury induced by argon plasma coagulation (APC) in animal models, but no follow-up studies have revealed the actual thermal injury. METHODS APC was performed on the stomachs of two living minipigs with and without prior submucosal injection of normal saline. The power and argon gas flow were set to 60 watts and 2 L/min, respectively, and pulse durations of 5, 10, and 20 seconds were used. One of the minipigs was killed immediately thereafter and the other was killed 1 week later. RESULTS The minipig killed immediately showed only subtle differences between noninjected and injected injuries under all the conditions, and the usefulness of prior submucosal injection was not obvious. However, the minipig killed 1 week later had a deep ulcer extending to the deeper muscle layer at the noninjected site where APC had been applied for 20 seconds, whereas tissue injury of the injected site was limited to the submucosal layer. CONCLUSIONS Unexpected tissue damage can occur even using a short-duration APC. Prior submucosal injection for APC might be a safer alternative technique, especially in a thinner and narrower gut wall.
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Affiliation(s)
- Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate School of Medicine, University of Tokyo, Japan
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Abstract
Endoscopic mucosal resection (EMR) is a technique used to locally excise lesions confined to the mucosa. Its main role is the treatment of advanced dysplasia and early gastrointestinal cancers. EMR was originally described as a therapy for early gastric cancer. Recently its use has expanded as a therapeutic option for ampullary masses, colorectal cancer, and large colorectal polyps. In the Western world, the predominant indication for EMR in the upper gastrointestinal tract is the staging and treatment of advance dysplasia and early neoplasia in Barrett’s esophagus. This review will describe the basis, indications, techniques, and complications of EMR, and its role in the management of Barrett’s esophagus.
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Fujishiro M, Yahagi N, Nakamura M, Kakushima N, Kodashima S, Ono S, Kobayashi K, Hashimoto T, Yamamichi N, Tateishi A, Shimizu Y, Oka M, Ichinose M, Omata M. Submucosal injection of normal saline may prevent tissue damage from argon plasma coagulation: an experimental study using resected porcine esophagus, stomach, and colon. Surg Laparosc Endosc Percutan Tech 2007; 16:307-11. [PMID: 17057569 DOI: 10.1097/01.sle.0000213739.85277.3d] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Argon plasma coagulation (APC) is considered to be a safe thermocoagulation technique, but some reports show perforation and deformity during and after APC. In this study, we investigated the usefulness of prior submucosal injection for APC. APC over the mucosa was performed on fresh resected porcine esophagus, stomach, and colon with prior submucosal injection of normal saline (injection group) and without it (control group). The depth of tissue damage increased linearly with pulse duration up to the shallower submucosal layer in both groups. After that, tissue damage in the injection group remained confined to the shallower submucosal layer under any condition, whereas that in the control group continued to extend. The tissue damages of the injection groups were significantly (P<0.05) shallower than those of the control groups that reached the deeper submucosal layer in all the organs. Submucosal injection of normal saline before the application of APC may limit tissue damage and prevent perforation and deformity.
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Affiliation(s)
- Mitsuhiro Fujishiro
- Department of Gastroenterology, Graduate school of Medicine, University of Tokyo, Tokyo, Japan.
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