Solutions for submucosal injection: What to choose and how to do it

Abstract

During the past decades, endoscopic resection techniques have gradually improved and gained more importance for the management of premalignant lesions and early cancers. These endoscopic resection techniques can be divided in 3 major groups: snare polipectomy, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). The use of submucosal injection is essential for the majority of EMR techniques and is an integral part of ESD, whereas during polipectomy it is not crucial in most cases except to prevent bleeding in large polyps and/or those with large stalks as an alternative to mechanical methods. Injection provides a lifting up effect of the lesion separating it from the muscular layer, thereby reducing thermal injury and the risk of perforation and bleeding while also facilitating en-bloc resection by improving technical feasibility. With this work, we aim to review the most common endoscopic resection techniques and the importance of submucosal injection in each one of them. For that, we present some of the most commonly used submucosal injection solutions, taking into account their advantages and disadvantages. We also discuss, based on current recommendations and our own experience, how and when to preform submucosal injection, depending on lesions features and endoscopic resection technique that´s being used, to assure complete resection and to prevent associated adverse events. Finally, we also present and discuss some new proposed submucosal injection solutions, endoscopic resection techniques and devices that may have a major impact on the future of therapeutic endoscopy.

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

Figure 1

Decision algorithm. ¹Without deep submucosal invasion features; ²In most cases, especially in the right colon, deep thermal injury with hot snare polipectomy is a potential risk; ³Clip placement can be an alternative to submucosal injection; ⁴Hyaluronic acid should be avoided in piecemeal resection; ⁵Endoscopic submucosal resection enables en-bloc resection of larger lesions; ⁶May be considered in Paris 0-IIa gastric Lesions < 15 mm. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; NS: Normal saline; LST: Lateral spreading tumour.

Figure 2

Submucosal injection for en-bloc resection of a colonic flat lesion.

Figure 3

Submucosal injection for a piecemeal resection of a colonic flat lesion.

Figure 4

How to inject: Pratical tips. EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal resection.