Dextrose 50 % solution as a submucosal fluid cushion in the resection of sessile colorectal polyps

We read with considerable interest the paper by Hurlstone et al. [1], which compared dextrose 50 % (D₅₀) with sodium hyaluronic acid (SHA) for the development of long-lasting submucosal elevation to improve the technical feasibility of en bloc endoscopic mucosal resection (EMR) of sessile colorectal polyps with a diameter of < 30 mm. They found no difference in the rates of complete resection (D₅₀ 59/82 vs. SHA 56/81), recurrence, and complications between the two groups.

We want to underscore that the purpose of using high-viscosity solutions to develop a long-lasting submucosal cushion is to reduce additional submucosal injections, thus enabling the endoscopist to achieve complete resection of the lesion quickly and without complications. Moreover, it is known that the rate of complete resection is higher when the lesions are resected en bloc rather than piecemeal [2]. The en bloc resection is achieved more easily when lesions measure < 30 mm, especially if using polypectomy snares with a diameter of 40 or 50 mm, and when the polyps are not located in difficult sites such as behind an angle.

In this respect, we conducted a prospective, double-blind randomized study [3] comparing D₅₀ with normal saline (NS) solutions for EMR of large sessile rectosigmoid polyps (> 10 mm). The primary endpoint was to evaluate the duration of the submucosal elevation. We observed no difference in the complete resection between the two groups (D₅₀ 36/36 vs. NS 34/35) concerning resection of polyps measuring 10 – 39 mm. A positive trend in favor of the D₅₀ group (D₅₀ 6/8 vs. NS 7/12) was observed in giant sessile polyps (> 40 mm). Moreover, an interesting finding in our study was six cases of postpolypectomy syndrome in the D₅₀ group and only one similar case in the normal saline group.

Therefore, because resection of medium-size sessile polyps (< 20 mm or even < 30 mm using larger snares of 40 – 50 mm) can usually be performed en bloc within a few minutes, the type of injected solution to create submucosal elevation does not seem to contribute to an easier, safer or more complete resection. We believe that a study comparing D₅₀ (an inexpensive solution that is available in all hospitals) with other, more expensive and difficult-to-find cushioning agents with high viscosity (SHA, glycerol, hydroxypropylmethylcellulose) in giant sessile colorectal polyps (> 40 mm) would be of greater interest in order to conclude that the role of D₅₀ is equally significant in the development of long-lasting elevation compared with other high-viscosity solutions. Because the duration of elevation is rather inaccurate in clinical studies with simultaneous resection of polyps, it should rather be evaluated in an animal model where the elevation is observed for a long time without resection. Finally, because postcoagulation (postpolypectomy) syndrome caused by the transmural thermal injury leading to serosal inflammation is characterized by localized abdominal pain, leucocytosis, and occasionally fever, it would be interesting to know if the authors considered this syndrome, particularly in their two cases of the dextrose group reported with postresection abdominal pain.

Competing interests: None

References

• 1 Hurlstone D P, Fu K I, Brown S R. et al . EMR using dextrose solution versus sodium hyaluronate for colorectal Paris type I and O – II lesions: a randomized endoscopists-blinded study.  Endoscopy. 2008;  40 110-114
• 2 Soetkino R M, Gotoda T, Nakanishi Y. et al . Endoscopy mucosal resection.  Gastrointest Endosc. 2003;  57 567-579
• 3 Katsinelos P, Kountouras I, Paroutoglou G. et al . A comparative study 50 % dextrose and normal saline solution on ability to create submucosal fluid cushions for endoscopic resections of sessile rectosigmoid polyps.  Gastrointest Endosc. 2008;  in press