key: cord-0743930-tdgz0soi
authors: Lisotti, Andrea; Fusaroli, Pietro
title: A dedicated viscous solution for submucosal injection (ORISE Gel) allows rapid and safe endoscopic mucosal resection of a giant (8-cm) cecal laterally spreading tumor (with video)
date: 2021-09-14
journal: Gastroenterol Rep (Oxf)
DOI: 10.1093/gastro/goab024
sha: be71a966ed4665ea9ba92c68a4724fd0f92f8ef0
doc_id: 743930
cord_uid: tdgz0soi

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Endoscopic mucosal resection (EMR) is the technique of choice for large colonic laterally spreading tumors (LSTs) [1] . The use of a dye-containing fluid solution for submucosal injection is necessary for a better depiction of polyp margins, deep wall layers, and possible residual tissue [2] . In recent years, dedicated viscous solutions have been registered for gastrointestinal (GI) endoscopy together with other routinely used non-dedicated viscous solutions, such as hyaluronic acid or Gelofusine, Eleview (Aries Pharmaceutical, CA, USA), and ORISE Gel (Boston Scientific, MA, USA), a viscous solution mixed with a natural dye, which allow rapid and safe resections because of lower fluid diffusion and prolonged persistence of mucosal elevation. A reduction in the number of device changes (needle, snare), specimens, and intervention duration were allowed [3] [4] [5] [6] [7] .

We describe the case of an asymptomatic 61-year-old female patient, referred from a colon-cancer-screening program, after positive fecal occult blood test. Index colonoscopy detected a giant (8-cm) granular-type LST involving the cecum and the ileo-cecal valve (Video 1). The case was discussed by a multidisciplinary team and an endoscopic resection attempt was indicated. The superficial pattern analysis, performed under white light plus narrow-band imaging together with dual-focus, showed features of adenoma with no risk of advanced neoplasia (pattern type 2 A and focal 2B according to JNET classification); therefore, based on the feature and the location, despite the tumor size, we preferred to perform EMR rather than endoscopic submucosal dissection.

Colonoscopy was performed using a pediatric therapeutic colonoscope (PCF-HQ190-TL, EVIS EXERA III, Olympus corp., Japan) because of the scope having a shorter bending section and increased angulation (up to 210 ) that guaranteed a better lesion approach. A disposable transparent hood was attached to the tip of the scope. ORISE Gel (Boston Scientific, MA, USA) was injected using a 23-gauge transparent needle starting from the cecal margin in retroflex position; piecemeal resection was performed using a 15-mm crescent and a 15-mm oval snare; and 20-mL ORISE Gel (two vials, one package) was injected to complete the procedure. A muscular injury (type 2 according to the Sidney classification) was treated with through-the-scope clips (Video 2). The procedure time was 126 minutes. The patient was discharged 4 hours later; she referred to mild self-limiting bleeding. Pathology report showed the presence of a tubular adenoma harboring high-grade dysplasia. Endoscopic follow-up after 6 months showed no endoscopic signs suggestive of recurrence.

This case suggests that a dedicated viscous solution allowed the safe and rapid performance of EMR, even for a giant cecal LST. The balance among the pros and cons of an endoscopic vs surgical approach for that kind of lesion should also take into account the possibility of a procedure carried out in an endoscopic suite in an outpatient setting, with prompt/immediate For commercial re-use, please contact journals.permissions@oup.com recovery and a dramatic reduction in the mean length of stay in hospital. These considerations should be no longer considered as "secondary" outcomes, especially in the COVID-19 pandemic era.

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

Endoscopic mucosal resection of large colonic laterally-spreading tumors using a dedicated viscous solution for submucosal injection (ORISE Gel): a short case series (with video)

Normal saline solution versus other viscous solutions for submucosal injection during endoscopic mucosal resection: a systematic review and metaanalysis

A novel submucosal injection solution for endoscopic resection of large colorectal lesions: a randomized, double-blind trial

Effectiveness and safety of underwater techniques in gastrointestinal endoscopy: a comprehensive review of the literature

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Endoscopic assessment of the giant (8-cm) cecal granular-type laterally spreading tumor

Endoscopic mucosal resection of a giant cecal laterally spreading tumor with endoscopic follow-up

None.

None declared.

A.L. performed the EMR procedure, wrote the manuscript, and created the video; P.F. collected data and edited the video. All authors revised the manuscript for pivotal intellectual content and approved the final version of the manuscript.

The authors received no support or funding for this study.

We declare that we received patients' written informed consent for the intervention procedure, for anonymous review of data, and for publication.