Is blood the ideal submucosal cushioning agent? A comparative study in a porcine model

Background and study aims: Creation of a submucosal cushion before endoscopic mucosal resection (EMR) significantly reduces perforation risk. We evaluated six solutions as cushioning agents in live pigs.
Material and methods: 5 ml of normal saline, normal saline plus epinephrine, albumin 12.5 %, albumin 25 %, hydroxypropyl methylcellulose, and the pig’s own whole blood were endoscopically injected into the porcine esophageal submucosa. Blood was obtained from a peripheral vein immediately before injection. Injections were made every 4 cm from the gastroesophageal junction. The time from completion of the injection to disappearance of the cushion was recorded. Endoscopy was repeated at 48 hours post injection. Two EMRs were performed after blood injection. Statistical analysis employed one-way analysis of variance followed by pairwise t test comparisons using the Bonferroni correction.
Results: Five animal experiments were completed. The mean time to dissipation of the submucosal cushion was shortest for saline plus epinephrine sites (2.87 minutes, SD 2.21) followed by the saline (4.8 minutes, SD 1.56), albumin 12.5 % (5.68 minutes, SD 3.48), albumin 25 % (7.83 minutes, SD 2.02), hydroxypropyl methylcellulose (9.77 minutes, SD 1.55), and blood sites (38.6 minutes, SD 6.07). Injection of blood resulted in significantly longer mucosal elevation than any other solution (P < 0.0007). Blood from the cushion did not hamper visualization and facilitated EMR.
Conclusion: Blood produces the most durable cushion compared with standard agents, also having the advantages of being readily available and without cost. Albumin 25 % provides as durable a cushion as hydroxypropyl methylcellulose.

References

• 1 Rosch T, Sarbia M, Schumacher B. et al . Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series.  Endoscopy. 2004;  36 788-801
• 2 Roukos D H. Current advances and changes in treatment strategy may improve survival and quality of life in patients with potentially curable gastric cancer.  Ann Surg Oncol. 1999;  6 46-56
• 3 Soetikno R M, Inoue H, Chang K J. Endoscopic mucosal resection. Current concepts.  Gastrointest Endosc Clin N Am. 2000;  10 595-617
• 4 Uraoka T, Fujii T, Saito Y. et al . Effectiveness of glycerol as a submucosal injection for EMR.  Gastrointest Endosc. 2005;  61 736-740
• 5 Fujishiro M, Yahagi N, Kashimura K. et al . Comparison of various submucosal injection solutions for maintaining mucosal elevation during endoscopic mucosal resection.  Endoscopy. 2004;  36 579-583
• 6 Yamamoto H, Yube T, Isoda N, Sato Y. et al . A novel method of endoscopic mucosal resection using sodium hyaluronate.  Gastrointest Endosc. 1999;  50 251-256
• 7 Feitoza A B, Gostout C J, Burgart L J. et al . Hydroxypropyl methylcellulose: a better submucosal fluid cushion for endoscopic mucosal resection.  Gastrointest Endosc. 2003;  57 41-47
• 8 Matsui Y, Inomata M, Izumi K. et al . Hyaluronic acid stimulates tumor-cell proliferation at wound sites.  Gastrointest Endosc. 2004;  60 539-543
• 9 Tan B, Wang J H, Wu Q D. et al . Sodium hyaluronate enhances colorectal tumour cell metastatic potential in vitro and in vivo.  Br J Surg. 2001;  88 246-250
• 10 Rosenberg N. Submucosal saline wheal as a safety factor in fulguration of rectal and sigmoid polyps.  Arch Surg. 1955;  70 120-123
• 11 Obara S, Muto H, Shigeno H, Yoshida A. et al . A three-month repeated oral administration study of a low viscosity grade of hydroxypropyl methylcellulose in rats.  J Toxicol Sci. 1999;  24 33-43
• 12 Fujishiro M, Yahagi N, Kashimura K. et al . Tissue damage of different submucosal injection solutions for EMR.  Gastrointest Endosc. 2005;  62 933-942
• 13 Wilkes M M, Navickis R J. Patient survival after human albumin administration. A meta-analysis of randomized, controlled trials.  Ann Intern Med. 2001;  135 149-164