Carl Winkler, MD1, Jaspreet Sandhu, MD2, Xiaohong Yan, PhD1, Neil Mitra, MD1, Dasuni Niyagama Gamage1, Vesna Cekic, RN1, Hmc Shantha Kumara, PhD1, Richard L Whelan, MD1. 1Mount Sinai West Hospital, 2Brookdale University Hospital Medical Center
Introduction: A mucosal “lift”, generated by injecting fluid into the submucosal layer, needs to be established prior to endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR). Lifts are most often generated with a sclerotherapy catheter/needle. Although the muscularis propria or subersosal bowel wall layers may be inadvertently injected it is assumed that only submucosal injection can result in a “stable” lift. Recently, it was noted that stable “deep wall lifts” can result from injection into the muscularis propria or subserosal layers. This ex vivo bovine study was carried out to histologically assess needle injection generated bowel wall lifts to determine how often deep wall lifts occur.
Methods: Ex vivo bovine colorectal specimens were injected: 1) via colonoscope and sclerotherapy needle into an intact colon or 2) via a syringe and needle into the wall of an opened colon specimen. After visually grading each lift (superficial or deep) a full thickness piece of the bowel wall (including the lift) was harvested and placed in formalin. Days later, after dehydration in alcohol, the specimens were paraffin embedded and then cut into sections that were H & E stained. A pathologist assessed each slide to determine which layer(s) had actually expanded.
Results: A total of 5 bovine large bowel specimens were utilized and 83 stable lifts generated that were visually and histologically assessed (46 via scope and sclerotherapy needle into closed colon; 37 via direct syringe injection into opened colon). As per visual inspection, the location of the lifts was judged to be submucosal in 25 (30%), deep in 16 (19%), and mixed (submucosal & intramuscular) in 42 (51%). As per the histologic evaluation of “readable” slides (74/83), the lift location(s) were; submucosal in 12 (16%), deep in 31 (42%), and mixed in 31 (42 %). The deep lift location breakdown was muscularis propria in 25 (34%) and subserosal in 6 (18%).
Conclusions: A pure submucosal lift was obtained only 16% of the time with needle injection into ex vivo bovine colon; mixed (42%) and deep lifts (42%) where more common. Ex vivo models increase the odds of deep wall lifts because the tissue is non vital and easily damaged, however, deep wall lifts do occur in the clinical setting. Safe ESD is not possible with a deep lift. Lifts must be carefully assessed before starting ESD and a more superficial layer sought if a deep lift is suspected.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93783
Program Number: P371
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster