Neil Mitra, MD1, Dasuni Niyagama Gamage, MD1, Xiaohong Yan, PhD1, Jaspreet Sandhu, MD2, Carl Winkler, MD1, Vesna Cekic, RN1, Hmc Shantha Kumara, PhD1, Richard L Whelan, MD1. 1Mount Sinai West Hospital, 2Brookdale University Hospital Medical Center
Endoscopic bowel wall injections are most commonly performed in order to tattoo the location of a lesion or to generate a mucosal lift for ESD and EMR. The sclerotherapy needle is, by far, the most common injection method, however, needleless and punctureless high pressure injection methods are being used more often and offer advantages over needle puncture for lift establishment prior to and during ESD and EMR. The injection physics/mechanics for each method are quite different. The starting point for sclerotherapy needle injections is usually deep in the bowel wall because a firm push of the needle is needed to penetrate the mucosal surface. In contrast, the needleless system is more likely to generate a submucosal lift because there is no puncture; of note, this technique will not generate subserosal tattoos. As regards the sclerotherapy needle, when establishing a submucosal lift (ESD/EMR) or subserosal tattoo the angle of incidence between the needle and the bowel surface should be as tangential as possible so as to facilitate placement of the entire beveled needle tip into the desired layer (vs fully through the wall or in several layers). In contrast, a 90 degree angle of incidence is best when using a punctureless high pressure injection to create a submucosal lift; a tangential angle may result in mucosal injury or a poor lift. The ability to direct the needle or high pressure catheter at the desired angle is heavily influenced by the diameter of the bowel segment in question as well as the type of endoscope being used. Large diameter bowel facilitates right angle injections but makes tangential injection difficult. Likewise, the type of endoscope (upper vs lower, thin vs thick) also impacts the endoscopist’s ability to make a tangential or right angle injection due the fact that the point at which the distal scope shaft bends in response to wheel deflection varies (closer or further from the tip) based on the scope’s diameter. A colonoscope requires a larger bowel diameter in order to attain a 90 degree incidence and is better for making tangential injections. The opposite is the case for upper scopes. This poster will explain how the two bowel injection methods work, differ, and are best used. It will also demonstrate, via pictures and drawings, how the bowel wall diameter together with the endoscope design determine the injection angle options and limitations.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95052
Program Number: P428
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster