Submucosal Saline Injection Research Articles

Solitary fibrous tumor of the stomach

Abstract Introduction/Objective Solitary fibrous tumor (SFT) is an uncommon fibroblastic tumor that originates from the mesenchymal tissue. It has been rarely reported within the stomach. None of these reported tumors have occurred in a background of autoimmune atrophic gastritis as was seen in our patient. Methods/Case Report Case report Results (if a Case Study enter NA) An 85-year-old female with history of anemia and autoimmune atrophic gastritis presented with two-month history of dysphagia and abdominal discomfort. Upper gastrointestinal endoscopy showed a 1 cm subepithelial lesion in the gastric body along the greater curvature. Upper endoscopic ultrasound showed mildly hypoechoic lesion in the submucosa of the stomach with the differential of leiomyoma, neuroendocrine tumor, gastrointestinal stromal tumor, and an atypical looking lipoma. The entire gastric lesion was lifted with submucosal saline injection and then resected using cap endoscopic mucosal resection (EMR) snare cautery. Gross examination showed a well-circumscribed lesion with firm, tan-white cut surface. On microscopy, a bland appearing spindle cell proliferation within a collagenous stroma was seen with alternating hypercellular and hypocellular areas and few dilated vessels. No significant mitosis, nuclear pleomorphism or necrosis was identified. Immunohistochemical stains were performed and the lesional cells were positive for STAT6. Markers for gastrointestinal stromal tumor (CD117, DOG1), smooth muscle tumor (desmin, smooth muscle actin) and schwannoma (S100, SOX10) were negative. Nuclear staining for STAT6 is a sensitive and specific marker for SFTs. This particular SFT was considered to be of low risk and non-malignant considering its small size, lack of mitotic activity and tumor necrosis. The etiology for SFT is not entirely clear but molecular studies have shown that the NAB2::STAT6 translocation in a spindle cell neoplasm is a diagnostic hallmark for SFTs. Conclusion Solitary fibrous tumors have been rarely reported within the stomach. Complete surgical resection with negative margins is the mainstay of treatment as they may recur after an incomplete resection.

Assessment of the protective role of submucosal saline injection of the inferior turbinates prior to submucosal diathermy or coblation techniques

BackgroundInferior turbinate hypertrophy is a common cause of chronic nasal obstruction with many procedures for management including submucosal diathermy and coblation with a variation in their techniques. The aim of this study was to assess the protective role of submucosal saline injection in the inferior turbinates prior to submucosal diathermy or coblation techniques. A prospective cohort study was conducted on 80 patients diagnosed with bilateral hypertrophied inferior turbinates causing persistent nasal obstruction and not responding to medical treatment. The patients were distributed randomly and equally between 2 groups. Group I included 40 patients operated on with coblation of the inferior turbinates. Group II included 40 patients operated on with submucosal diathermy of the inferior turbinates. The right side of the nose of both groups had a saline injection of the inferior turbinates before the procedure and the left side of the nose did not have such injection. Each side of the nose in every patient was assessed for the degree of nasal crusting at 1 week postoperative, the presence of turbinate gangrene at 3 weeks postoperative, and the visual analog scale (VAS) of four symptoms (nasal discomfort, nasal pain, nasal obstruction, and thick nasal discharge) at 1 week postoperative.ResultsIn the coblation group, there was a significant difference between the right and left sides regarding the degree of crusting at 1 week postoperative, and a non-significant difference between the two sides regarding the presence of gangrene at 3 weeks postoperative. In the diathermy group, there was a significant difference between the right and left sides regarding the same parameters. Comparison between the injection and non-injection sides in each group regarding the nasal symptoms showed a highly significant difference between the two sides in each group favoring the injection side.ConclusionSaline injection prior to inferior turbinate coblation or submucosal diathermy had a protective effect against crusting with both techniques and gangrene formation with submucosal diathermy. This was reflected on better postoperative nasal symptoms.

Submucosal Injection Using Epinephrine-Added Saline in Cold Snare Polypectomy for Colorectal Polyps Shortens Time Required for Resection: A Randomized Controlled Study.

Immediate bleeding after cold snare polypectomy (CSP) for colorectal polyps might interfere with confirmation of residuals and prolong the time required for resection. We investigated whether submucosal epinephrine-added saline injection reduces the time required for the CSPprocedure. We conducted a single-center, prospective, randomized controlled trial (clinical trial registration number: UMIN000046770). Patients with colorectal polyps ≤ 10 mm were randomly allocated to either CSP with epinephrine-added submucosal injection (CEMR group) or conventional CSP (CSP group). The primary outcome was the time required for resection defined as the time from the initiation of resection (the first insertion of the snare in the CSP group or the injection needle in the CEMR group) to the end of resection (confirming complete resection endoscopically after recognizing the cessation of immediate bleeding) in each lesion, and the secondary outcome was the time to spontaneous cessation of immediate bleeding after resection defined as the time from ensnaring the lesion to confirming the spontaneous cessation of immediate bleeding. A total of 126 patients were randomly assigned. Finally, 261 lesions in 118 patients (CEMR group, n = 59; CSP group, n = 59) were analyzed. The time required for resection calculated using the least-square mean was significantly shorter in the CEMR group (106.3 s, 95% CI 97.5 to 115.4 s) than in the CSP group (130.9 s, 95% CI 121.2 to 140.7 s) (P < 0.001). The time to spontaneous cessation of immediate bleeding was also significantly shorter in the CEMR group (20.4 s, 95% CI 14.3 to 26.5 s) than in the CSP group (74.2 s, 95% CI 67.6 to 80.7 s) (P < 0.001). Neither group had cases requiringhemostasis, perforation, or delayed bleeding. CEMR shortened the time for resection by shortening the time to cessation of immediate bleeding compared with conventional CSP in colorectal polyps ≤ 10 mm.

Point-of-care ultrasound-guided submucosal paclitaxel injection in tracheal stenosis model.

Transcutaneous point-of-care ultrasound (POCUS) is a good tool to monitor the trachea in many clinical practices. The aim of our study is to verify the feasibility of POCUS-guided submucosal injection as a potential drug delivery method for the treatment of tracheal stenosis. The inner wall of the trachea was monitored via a bronchoscope during the POCUS-guided submucosal injection of methylene blue in fresh ex vivo porcine trachea to evaluate the distribution of methylene blue. The feasibility and eficacy of POCUS-guided submucosal injection were evaluated in a tracheal stenosis rabbit model. Animals were divided into sham group, tracheal stenosis group, and treatment group. Ten days after the scraping of the tracheal mucosa or sham operation, POCUS-guided submucosal injection of paclitaxel or saline was performed. Seven days after the submucosal injection, the trachea was assessed by cervical computed tomography (CT) scan and ultrasound. The distribution of methylene blue in trachea proved the technical feasibility of POCUS-guided submucosal injection. CT evaluation revealed that the tracheal stenosis index and the degree of tracheal stenosis increased significantly in the stenosis group, while POCUS-guided submucosal injection of paclitaxel partially reversed the tracheal stenosis. POCUS-guided submucosal injection of paclitaxel also decreased the lamina propria thickness and collagen deposition in the stenosed trachea. POCUS-guided submucosal paclitaxel injection alleviated tracheal stenosis induced by scraping of the tracheal mucosa. POCUS-guided submucosal injection might be a potential method for the treatment of tracheal stenosis.

Efficacy of submucosal injection of hyaluronidase after mandibular third molar surgery: a randomized controlled trial.

This study aimed to investigate the efficacy of postoperative submucosal injection of hyaluronidase (HUD) for reducing sequelae and quality of life (QOL) after mandibular third molar (M3M) surgery. Participants with bilateral impacted M3M underwent surgical extraction with a split-mouth randomized controlled study design. M3M were removed by the same surgeon in 2 sessions, one a control and the other experimental. Submucosal injection of HUD was performed in the experimental session and submucosal injection of saline in the control session. Mouth opening, facial swelling, and pain intensity were measured before surgery, and then 2 and 7 days after surgery. The QOL of participants following surgery was evaluated by means of a patient-centered outcome questionnaire (PCOQ). A total of 36 patients was included in the final data analysis. There was a significant reduction in the maximal mouth opening and postoperative pain in the experimental side at the 2 and 7 days after surgery (P<0.05), and a remarkable difference in facial swelling was reported on the experimental side 7 days after surgery (P<0.05). The PCOQ demonstrated that participants reported less pain and swelling on the experimental side. The present study provides clinical evidence that submucosal administration of HUD immediately after M3M surgery reduced postoperative discomfort and improved patients' QOL.

Phonation Threshold Pressure as a Unique Outcome Measure of Phonatory Physiology Changes Following Submucosal Saline Injection for Vocal Fold Scarring

Purpose: This study aimed to describe the utility of phonation threshold pressure (PTP) measurement as an additional outcome measure for changes in vocal fold vibration secondary to submucosal saline injection in the case of an individual with idiopathic vocal fold scarring. Method: An 8-week program of voice therapy, followed by submucosal saline infusion, was administered, using multiple outcome measures to assess voice quality, effort, and function in a 38-year-old woman with idiopathic bilateral vocal fold scarring. Transoral rigid video-endoscopy with stroboscopy in conjunction with the Stroboscopy Evaluation Rating Form provided measures of the vibratory characteristics of the vocal folds (amplitude, mucosal wave, nonvibratory portion, edge smoothness, and straightness). Auditory-perceptual measures were obtained using the Consensus Auditory-Perceptual Evaluation of Voice. Acoustic measures included jitter (%local), shimmer (%local), harmonics-to-noise ratio (dB), and Cepstral Spectral Index of Dysphonia. Additionally, PTP was measured 1 day prior to, and 1 month after, saline infusion. Results: Acoustic, auditory-perceptual, and stroboscopic variables suggested minimal change to the vibratory properties of the vocal folds in response to submucosal saline infusion for the treatment of vocal fold scarring. PTP measurements across the patient's frequency range, however, revealed a marked decrease post infusion. This was consistent with the patient's report of improved functioning and her request for repeat saline infusion. Conclusion: These results are consistent with the possibility of using PTP as an independent means of quantifying changes in phonatory physiology across the frequency range in patients with vocal fold scarring. Supplemental Material: https://doi.org/10.23641/asha.21313725

Randomized, controlled, double-blinded clinical trial of effect of bevacizumab injection in management of epistaxis in hereditary hemorrhagic telangiectasia patients undergoing surgical cauterization.

Given its role in the disease pathophysiology, inhibition of vascular endothelial growth factor (VEGF)-mediated angiogenesis has received attention as a potential strategy to reduce epistaxis associated with hereditary hemorrhagic telangiectasia (HHT). In this study we evaluated the efficacy of a submucosal injection of bevacizumab, a VEGF inhibitor, in reducing the severity of epistaxis and improving quality of life when given at the time of operative electrocautery. This randomized, double-blinded, placebo-controlled trial was conducted at a single institution from 2014 to 2019. Patients scheduled to undergo operative bipolar electrocautery of nasal telangiectasias were randomized to receive a submucosal injection of saline or bevacizumab at time of surgery. Surveys to assess epistaxis severity and quality of life (QOL), including the Epistaxis Severity Score (ESS) and the 12-item Short Form (SF-12), were administered preoperatively and at 1, 2, 4, and 6 months postoperatively. The minimal clinically important difference (MCID) of the ESS instrument is reported to be 0.71. Of 39 patients enrolled, 37 (94.9%) completed the study. The saline group demonstrated a reduced ESS vs baseline at 1 (-1.2; p=0.01) and 4 (-1.2; p=0.05) months postprocedure. The bevacizumab group demonstrated a reduced ESS score vs baseline at 1 (-2.3; p<0.001), 2 (-2.3; p<0.001), 4 (-2.0; p=0.003), and 6 (-1.3; p=0.05) months postprocedure. The additive benefit of bevacizumab over saline exceeded the MCID at 1, 2, and 4 months, but the difference was not statistically significant. The addition of a single treatment of submucosal bevacizumab may be associated with additional clinically meaningful benefit for up to 4 months when compared with electrocautery alone.

Injectable Thermogel Generated by the "Block Blend" Strategy as a Biomaterial for Endoscopic Submucosal Dissection.

Endoscopic submucosal dissection is an established method for the removal of early cancers and large lesions from the gastrointestinal tract but is faced with the risk of perforation. To decrease this risk, a submucosal fluid cushion (SFC) is needed clinically by submucosal injection of saline and so on to lift and separate the lesion from the muscular layer. Some materials have been tried as the SFC so far with disadvantages. Here, we proposed a thermogel generated by the "block blend" strategy as an SFC. This system was composed of two amphiphilic block copolymers in water, so it was called a "block blend". We synthesized two non-thermogellable copolymers poly(d,l-lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(d,l-lactide-co-glycolide) and blended them in water to achieve a sol-gel transition upon heating in both pure water and physiological saline. We explored the internal structure of the resultant thermogel with transmission electron microscopy, three-dimensional light scattering, 13C NMR, fluorescence resonance energy transfer, and rheological measurements, which indicated a percolated micelle network. The biosafety of the synthesized copolymer was preliminarily confirmed in vitro. The main necessary functions as an SFC, namely, injectability of a sol and the maintained mucosal elevation as a gel after injection, were verified ex vivo. This study has revealed the internal structure of the block blend thermogel and illustrated its potential application as a biomaterial. This work might be stimulating for investigations and applications of intelligent materials with both injectability and thermogellability of tunable phase-transition temperatures.

Cold or Hot Snare with Endoscopic Mucosal Resection for 6-9 mm Colorectal Polyps: A Propensity Score Matching Analysis.

Objective: To investigate the efficacy and safety of cold snare endoscopic mucosal resection (CS-EMR) and hot snare endoscopic mucosal resection (HS-EMR) for colorectal polyps with diameters of 6-9 mm. Methods: Retrospective analysis was performed on the clinical data of 485 patients with colorectal polyps (6-9 mm in size) who were treated with CS-EMR or HS-EMR in the endoscopy center of Hangzhou Third People's Hospital from January 2017 to December 2019. Colorectal polyps were lifted by submucosal injection of normal saline. The CS-EMR group used a cold snare to remove the lifting polyps, while the HS-EMR group used a hot snare. Propensity score matching analysis with 1:1 matching and the nearest neighbor matching method were performed to ensure well-balanced characteristics of the CS-EMR and HS-EMR groups. Matching factors included age, gender, body mass index, blood routine, coagulation indicators, polyp site, size, number, and morphology. This resulted in a balanced cohort of 128 patients per group. Polyp recovery, complications, clipping for disclosure, and length of hospital stay were compared after matching. t-Tests, χ2 tests, McNemar's tests, and Fisher's exact test were used for comparison between the two groups before and after matching. Results: There were no differences between the two groups of intraoperative and postoperative bleeding (P > .05), but the CS-EMR clipping rate was lower than the HS-EMR group (P < .01). There was a higher incidence of post-polypectomy syndrome (PPS) (P = .03) and longer hospital stays (P < .01) in the HS-EMR group than the CS-EMR group. Conclusions: Compared with HS-EMR, CS-EMR is more convenient to operate, with a low incidence of PPS, clipping rates, and short hospital stays. It is a safe and effective removal method for 6-9 mm colorectal polyps.

Impact of submucosal saline solution injection for cold snare polypectomy of small colorectal polyps: a randomized controlled study

Cold snare polypectomy (CSP) of small colorectal polyps is widely used. However, the technique is still troubled by insufficient resection depth, which may prevent precise pathologic evaluation. In this study, we investigated whether submucosal injection of saline solution helps to achieve deeper resection in CSP. The study was a single-center, prospective, randomized trial. Patients with small (3- to 10-mm diameter) nonpedunculated adenomatous or sessile serrated colorectal polyps were randomly allocated to either conventional CSP (C-CSP) or CSP with submucosal injection (CSP-SI). Primary outcome was the rate of complete muscularis mucosae (MM) resection, defined by the proportion of MM under the tumor more than 80% of the tumor's horizontal dimension. Secondary outcomes were the rates of negative lateral and vertical margins, fragmentation of resected specimens, conversion to hot snare mucosal resection, intraprocedural bleeding, delayed bleeding, and perforation. Two hundred fourteen patients were randomly assigned to the CSP-SI (n= 107) or C-CSP (n= 107) group. The rate of complete MM resection was 43.9% in the CSP-SI group and 53.3% in the C-CSP group, a statistically insignificant difference. The rates of negative lateral margin and vertical margin (42.3% and 56.7%, respectively) in the CSP-SI group were significantly lower than those (58% and 76%) in the C-CSP group (P= .03 and P= .006, respectively). There was no polypectomy-related major bleeding or perforation. Saline solution injection into the submucosa did not improve the resection depth of CSP of small colorectal polyps, and the method resulted in lower rates of negative lateral and vertical margins of resected lesions. (Clinical trial registration number: UMIN000037980.).

Underwater EMR of a colonic adenoma surrounded by diverticula.

An 83-year-old man with positive fecal occult blood test results underwent colonoscopy, which revealed a 15-mm-diameter laterally spreading tumor surrounded by multiple diverticula at the ascending colon (Figs. 1 and 2). The lesion was a nongranular-type laterally spreading tumor, and the Japanese Narrow-Band Imaging Expert Team classification was type 2A, meaning no evidence of invasion; therefore, we performed endoscopic resection instead of surgery.Figure 2Endoscopic image showing the tumor well demarcated with indigo carmine.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Conventional EMR of the tumor surrounded by diverticula with the use of submucosal saline solution injection would have been difficult because the appropriate lifting up by submucosal injection is difficult, and snaring including adjacent diverticula would have resulted in perforations. Furthermore, endoscopic submucosal dissection (ESD) for tumors adjacent to diverticula carries a high risk of perforation, and performing ESD on such lesions demands highly advanced skills, although we have reported success with the use of ESD for colonic polyps involving a diverticulum.1Shichijo S. Matsuno K. Takeuchi Y. et al.Pulley traction-assisted colonic endoscopic submucosal dissection affords good visibility of submucosal layer.VideoGIE. 2018; 3: 358-360Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar,2Shichijo S. Yamasaki Y. Takeuchi Y. Case of colonic adenoma involving a diverticulum resected by a traction-assisted endoscopic submucosal dissection technique.Dig Endosc. 2017; 29: 729-730Crossref PubMed Scopus (17) Google Scholar Underwater EMR was developed and described by Binmoeller et al3Binmoeller K.F. Weilert F. Shah J. et al."Underwater" EMR without submucosal injection for large sessile colorectal polyps (with video).Gastrointest Endosc. 2012; 75: 1086-1091Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar in 2012. We previously reported the usefulness of this procedure with a high en bloc resection rate for intermediate-sized colorectal polyps4Yamashina T. Uedo N. Akasaka T. et al.Comparison of underwater vs conventional endoscopic mucosal resection of intermediate-size colorectal polyps.Gastroenterology. 2019; 157: 451-461.e2Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar; therefore, we performed underwater EMR for this lesion (Video 1, available online at www.VideoGIE.org). We here report the first case, to our knowledge, of a colonic adenoma surrounded by diverticula treated with underwater EMR. We used a magnifying colonoscope (Evis PCF-Q260ZAI; Olympus Medical Systems, Tokyo, Japan). Air was evacuated from the affected segment of the lumen and infused water until the lumen was completely full, after which we performed hot-snare polypectomy without submucosal injection, using a SnareMaster (15 mm; Olympus Medical Systems) (Fig. 3). A high-frequency electrical generator (Vio 300D; Erbe Elektromedizin, Tübingen, Germany) was used with the following settings: endocut Q mode: effect 3, duration 2, interval 4. We resected the lesion en bloc in 2 minutes without perforation and completely closed the mucosal defect with clips (Figs. 4 and 5). No adverse events occurred, and the patient experienced no postoperative abdominal pain or fever requiring antibiotics. On pathologic examination, the lesion was a tubular adenoma, high-grade in part, with negative margins (Fig. 6).Figure 4Endoscopic image showing completed underwater EMR.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Endoscopic image showing complete closure of the defect with clips.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Photograph of the specimen after it was resected en bloc in 2 minutes.View Large Image Figure ViewerDownload Hi-res image Download (PPT) All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJjOWE4NzBhZThjMTAyNjRmNTMyMWUzMThjM2U0OTJhNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4MDA4Njc1fQ.ojSWMYGdEpn8sb_Vue33TsVsQk4sx0xrnjsYhN0e_DMlvnvbvi5PS7yv2mRUWzp3aWHkwZ4DJoK_nBNhCPKTdkB4F-kWgbyJUoHLKX-Wmq3WgmsVAB7rESbsA-KJA1m88IGz7HnhNTBBdva_Y-l26Ngn1miP5yyC9XT5ZVGfCjWvecCVo_hEJW_mHgjtsoOZ7OPrY-u8tb-Xx4tDpXt02RazLx4tDvP4H2nsA00kITkefKFvNuW-xE7zwOvGY82EkSh-eF7LSqwaA-uLhLrVmQb-OqrnZzW2Nxnbn-qa2NBulHuER2Ie6ppmB_x4TSRdEXfxLjxmy7Soh5Bp0OQrOA Download .mp4 (31.25 MB) Help with .mp4 files Video 1Underwater EMR of the colonic adenoma surrounded by diverticula.

Colorectal endoscopic mucosal resection with submucosal injection of epinephrine versus hypertonic saline in patients taking antithrombotic agents: propensity-score-matching analysis

BackgroundEndoscopic mucosal resection (EMR) to remove colon polyps is increasingly common in patients taking antithrombotic agents. The safety of EMR with submucosal saline injection has not been clearly demonstrated in this population.AimsThe present study aimed to evaluate the efficacy and safety of submucosal injection of saline–epinephrine versus hypertonic saline in colorectal EMR of patients taking antithrombotic agents.MethodsThis study enrolled 204 patients taking antithrombotic agents among 995 consecutive patients who underwent colonic EMR from April 2012 to March 2018 at Ureshino Medical Center. Patients were divided into two groups according to the injected solution: saline–epinephrine or hypertonic (10%) saline (n = 102 in each group). Treatment outcomes and adverse events were evaluated in each group and risk factors for immediate and post-EMR bleeding were investigated.ResultsThere were no differences between groups in patient or polyp characteristics. The main antithrombotic agents were low-dose aspirin, warfarin, and clopidogrel. Propensity-score matching created 80 matched pairs. Adjusted comparisons between groups showed similar en bloc resection rates (95.1% with saline–epinephrine vs. 98.0% with hypertonic saline). There were no significant differences in adverse events (immediate EMR bleeding, post-EMR bleeding, perforation, or mortality) between groups. Multivariate analyses revealed that polyp size over 10 mm was associated with an increased risk of immediate EMR bleeding (odds ratio 12.1, 95% confidence interval 2.0–74.0; P = 0.001).ConclusionsTwo tested solutions in colorectal EMR were considered to be both safe and effective in patients taking antithrombotic agents.

1512 A Rare Case of Sigmoid Leiomyoma Disguised as a Polyp

INTRODUCTION: Colonic leiomyomas are smooth muscle tumors which arise from either the muscularis mucosa or the proper muscle layer. Colonic and rectal leiomyomas are rare tumors and represent only about 3% of all gastrointestinal leiomyomas. Most patients are asymptomatic; however, some can have symptoms of abdominal pain, intestinal obstruction, hemorrhage, and perforation when the leiomyoma is of larger size. We present a case of sigmoid leiomyoma encountered on routine colonoscopy. CASE DESCRIPTION/METHODS: A 52-year-old man from Ecuador with a past medical history of hypertension, gastritis, osteoarthritis of the knees, presented to the clinic for evaluation of GERD symptoms. He was also due for repeat colonoscopy for surveillance of colon polyps. He underwent routine EGD and colonoscopy. EGD findings and biopsies of the stomach were unremarkable. The patient underwent a colonoscopy and was found to have an 8 mm sessile polyp seen in the sigmoid colon. The polyp was resected with cold snare and sent to pathology. The bowel preparation was excellent. Pathology revealed colonic mucosa containing smooth muscle proliferation. Immunostain with smooth muscle actin (SMA) supported the diagnosis. DISCUSSION: Leiomyomas have been first described by Virchow in 1854. They are usually considered benign and arise in the uterus, but may also be found in the skin, nipple, scrotum, and labia. Leiomyomas are less frequently encountered in the GI tract, and when found, are primarily seen in the esophagus or stomach. The management of leiomyomas is surgical resection, however, with the evolving field of gastroenterology, endoscopic removal is considered an alternative for resection. Given leiomyomas arise from the muscularis mucosa or the proper muscle layer, endoscopic resection represents a higher risk of perforation. Submucosal injection technique can be used to identify which layer the leiomyoma arises from. If the lesion cannot be lifted using a submucosal injection of saline, the lesion may have deep submucosal invasion or can originate from the proper muscle layer. This risk for perforation is higher when the leiomyoma arises from the proper muscle layer and it is a contraindication to endoscopic removal. We represent a rare case of sigmoid leiomyoma which was removed using endoscopic technique without any complication of perforation or bleeding.

Effect of submucosal injection of normal saline and glycerol fructose on endoscopic polypectomy in patients with colorectal polyps.

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.

Endoscopic submucosal resection using a ligation device without injection for duodenal neuroendocrine tumors.

Duodenal neuroendocrine tumors (NETs) measuring ≤ 10mm in diameter that are confined to the submucosal layer without metastasis are suitable for endoscopic treatment. We previously reported the efficacy and safety of endoscopic submucosal resection with a ligation device (ESMR-L) for duodenal NETs. In order to make the procedure simpler, we attempted ESMR-L without submucosal injection. The aim of this study was to evaluate the efficacy of ESMR-L without injection for duodenal NETs. A total of 12 patients with small (≤ 10mm) sporadic duodenal NETs were treated via endoscopic resection at the National Cancer Center Hospital East between December 2010 and May 2018. All patients were evaluated via endoscopy and endoscopic ultrasound, and abdominal computed tomography was performed to rule out metastatic lesions. The patients' characteristics, clinical courses, and complications, such as perforation and bleeding, were retrospectively assessed. We examined the correlation between ESMR-L with or without submucosal saline injection and clinicopathological parameters. The median procedural time for ESMR-L was 13min. All lesions invaded the submucosal layer, and the histological diagnoses were classified as NET G1 in 11 lesions and NET G2 in one lesion. En bloc resection and complete resection were achieved in 12 and 11 lesions, respectively. The postoperative duration of hospital stay was 4 days. At the median follow-up of 17 months, there was no incidence of local recurrence or distant metastasis. Perforation and intraoperative bleeding were not observed. However, delayed bleeding was found in one patient. ESMR-L without submucosal injection required a significantly shorter procedural time than ESMR-L with submucosal saline injection (10min vs. 15min, respectively; p = 0.007). ESMR-L is safe and effective. Particularly, ESMR-L without submucosal injection could be used to treat these NETs safely within a short period of time.

The effect of platelet-rich plasma injection on post-internal urethrotomy stricture recurrence

Local injection of platelet-rich plasma (PRP) is postulated to work by delivering growth factors and cytokines that recruit healer cells and enhance recovery process at the injection site. As new scar formation leads to stricture recurrence after internal urethrotomy, we proposed to improve post-internal urethrotomy stricture recurrence rate by injecting local submucosal PRP at the time of urethrotomy. From July 2015 to June 2018, 87 male patients with symptomatic bulbar urethral stricture (diagnosed by retrograde urethrography) randomized into two groups of internal urethrotomy and submucosal normal saline injection (control group, 43 patients), and internal urethrotomy with submucosal autologous platelet-rich plasma injection (PRP injection group, 44 patients). According to the endpoint, which happened sooner, each patient was followed at 3-month intervals for 2years after internal urethrotomy or until urethral stricture recurrence. Twelve-month recurrence rates were 26.82 and 9.09% in the control and the PRP injection groups, respectively (p 0.032). After 2years of follow-up, stricture recurrence was identified in 18 (43.90%) and 9 (21.95%) patients in the control and the PRP injection groups, respectively (p 0.34). In our study, submucosal PRP injection at the site of internal urethrotomy decreased the rate of stricture recurrence a year after the intervention. This protective effect lasted for 24months, at least. Submucosal PRP injection at the time of internal urethrotomy also decreased the length of stricture in case of recurrence.

Role of Hybrid Argon-Plasma Coagulation (Hybrid APC) in the Management of Barrettʼs Esophagus: A Case Series Report

Barrett's esophagus (BE) is defined as metaplasia of the esophageal epithelium resulting in the replacement of normal squamous epithelium by columnar epithelium. It is associated with gastroesophageal reflux disease. Patients with BE are at increased risk of developing esophageal adenocarcinoma and require close monitoring. Management of BE has changed remarkably with the introduction of endoscopic thermal ablative therapies that include radiofrequency ablation (RFA) and argon-plasma coagulation (APC).Both therapies are associated with risk of stricture formation and APC increases the risk of buried metaplastic glands under the neosquamous epithelium. To overcome these disadvantages, a novel hybrid ablation method that combines APC and submucosal saline injection called Hybrid APC has been recently developed that has shown to decrease the rate of these complications by creating a submucosal fluid cushion prior to ablation. We present two cases where employment of Hybrid APC resulted in the eradication of BE following endoscopic mucosal resection (EMR) and refractory to multiple RFA therapies. A 67 year old male diagnosed with BE, long segment with high grade dysplasia (HGD) and intramucosal adenocarcinoma status post EMR two years back was closely monitored with surveillance EGD and subsequently underwent RFA four times with satisfactory response but with disease persistence. Patient was deemed to be high risk candidate for surgery. Hybrid APC was employed resulting in significant macroscopic and histologic remission following therapy. Patient continues to be followed up closely with no disease recurrence. A 62 year old male diagnosed with BE, long segment with HGD and intramucosal adenocarcinoma status post EMR four years back was closely monitored with surveillance EGD and subsequently underwent EMR three times, and RFA eight times with disease persistence. Patient was deemed to be a high risk candidate for surgery. Hybrid APC was performed resulting in significant macroscopic and histologic remission following therapy. Patient continues to be followed up closely with no disease recurrence. Hybrid APC is a new novel treatment modality shown to be effective and safe in the management of BE. Manner et.al showed macroscopically complete remission (CR) in 46 of the 48 patients and histologically CR out of 46 patients from BE. Further multicenter prospective trials are required to study this promising new technique compared to other treatment techniques.

Submucosal Saline Injection Followed by Endoscopic Ultrasound versus Endoscopic Ultrasound Only for Distinguishing between T1a and T1b Esophageal Cancer: A Single-Blind, Superiority, Phase 3, Randomized Controlled Trial

Background: Traditional endoscopic ultrasound's (EUS) accuracy in distinguishing between T1a and T1b stage esophageal cancer (EC) is inadequate. As such, we examined whether submucosal saline injection (SSI) can improve its diagnostic accuracy. Methods: We conducted a randomized controlled phase 3 trial at Sun Yat-sen University Cancer Center. A total of 180 patients aged 18-85 years old with T1N0M0 stage EC indicated by prior EUS and radiologic imaging were enrolled and randomly assigned (1:1) to receive either EUS examination after SSI (EUS examination after 3-5 ml submucosal saline injection) or EUS only examination. The randomization sequence was computer-generated and no stratification factor was used. All the patients were referred to thoracic surgeons to receive endoscopic submucosal dissection (ESD) or esophagectomy within one week after EUS examination. Patients, research assistants, thoracic surgeons, pathologists, and statisticians were masked to the allocated examination. Standard EUS criteria were used to preoperatively stage the EC cases, while surgical pathology reports after referral were used to postoperatively stage the cases. The primary endpoint was the diagnostic accuracy of T1a staging (defined as the sum of the true positive [T1a] and true negative [T1b] cases divided by the total number of cases) analyzed in the per-protocol population. Findings: Between February 14, 2012 to October 23, 2017, 180 patients were enrolled and randomly assigned to receive SSI EUS (n=90) or EUS only (n=90) examination. Among the per-protocol population, the SSI EUS group (n=81) was superior to the EUS-only group (n=87) in terms of the diagnostic accuracy for T1a staging (86.4% [95% CI, 79.0-93.9] vs. 66.7% [95% CI, 56.8-76.6]; p=0.003). The specificities with SSI EUS and EUS-only were similar (92.3% [95% CI, 82.1-100.0] vs. 90.5% [95% CI, 81.6-99.4]; p>0.999), whereas the sensitivity of SSI EUS was significantly higher than EUS-only (83.6% [95% CI, 73.9-93.4] vs. 44.4% [95% CI, 29.9-59.0]; p<0.001). Adverse events during examination were recorded in one patient in the SSI EUS group and one in the EUS-only group (grade 1 esophageal hemorrhage for both). Compared with those in the EUS-only group, patients with postoperative T1a disease in the SSI EUS group had more commonly received ESD (38 [69.1%] of 55 patients vs. 16 [35.6%] of 45, p<0.001) and had a lower median total medical cost (4,913.8 vs. 11,717.7 USD, p<0.001) and shorter median hospital stays (13.0 vs. 23.0 days, p=0.003). With a median follow-up time of 40.0 months (range, 8.4-71.2 months) in the SSI EUS group and 35.7 months (range, 8.3-76.0 months) in the EUSonly group, the 3-year overall survival rates were comparable between the SSI EUS and EUS-only groups (91.5% vs. 84.7%, p=0.510) for postoperative T1a stage EC patients. Interpretation: SSI significantly improves the diagnostic accuracy of EUS for T1a staging and might be of great value for optimizing treatment strategies for T1 stage EC patients. Clinical Trial Number: This trial is registered at ClinicalTrials.gov, number NCT01555801. The trial is ongoing but no longer recruiting participants. Funding Statement: The study is supported by the National High Technology Research and Development Program of China (863 Program, 2015AA020103); Science and Technology Plan Projects of Guangdong Province, China (2011B080701015, 2012B061700076, and 2014A020212146); Sun Yat-sen University Cancer Center Clinical Research 308 Program, and Plan Project of Guangdong Esophageal Cancer Institute (2014). The funding agencies will not affect the study results. Declaration of Interests: We declare no competing interests. Ethics Approval Statement: This study was approved by the institutional review board of SYSUCC. This trial was conducted in accordance with the Declaration of Helsinki, the guidelines for Good Clinical Practice, the European Union Clinical Trial Directive, and local regulations. All participants provided written informed consent.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla.

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o’clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

Submucosal injection of pharyngeal ostium of Eustachian tube for diagnosis of patulous Eustachian tube

Objective:To evaluate the clinical value of submucosal injection of pharyngeal ostium of Eustachian tube in diagnosing patulous Eustachian tube(PET).Method:Twenty-six patients(32 sides),whose the symptoms were consistent with PET,were enrolled from March 2014 to May 2016.The symptoms and signs of all patients were evaluated after submucosal injection of saline into the Eustachian tube.Result:Immediately after submucosal injection of saline into the Eustachian tube,the symptoms and signs disappeared in 24 cases(29 sides),and improved in 2 cases(3 sides).The resolution and/or improvement of symptoms and signs lasted for less than 24 hours in 12 patients,for more than 24 hours in 9 patients,and for more than 48 hours in 4 patients.No adverse reactions were observed.Conclusion:Submucosal injection may be a simple and practical method for auxiliary diagnosis of PET,and may be used in preoperative evaluation of Eustachian tuboplasty.