Department of Surgery, Brookdale University Hospital & Medical Center, One Brookdale Plaza, Brooklyn, NY, 11212, USA.
Department of Surgery, Mount Sinai West Hospital, New York, NY, USA.
Surg Endosc. 2019 Mar;33(3):949-958. doi: 10.1007/s00464-018-6521-5. Epub 2018 Oct 22.
A mucosal lift is needed for ESD and EMR. Most lifts are made via sclerotherapy needle injection. The firm push needed to penetrate the mucosa often leaves the needle tip in the deep wall. The needle is next withdrawn and fluid injected until a sharp lift (due to submucosal expansion) begins to form; the needle is then held steady and the injection finished. The initial injection may result in a subtle deep lift that resolves quickly. It was the authors' belief that only submucosal expansion could lead to a stable mucosal lift. A colonic ESD case in which a polyp was inadvertently resected via needle knife in an expanded subserosal plane led to a questioning of this position. This study's purpose was to determine if stable deep wall mucosal lifts can be generated via bowel wall injection.
Transmucosal and intramural injections into bovine large bowel were carried out. Stable lifts and lift cross sections were made and examined grossly and histologically to determine the location of the lift fluid. Clinical ESD videos were also reviewed.
Over 200 intact and cross-sectioned lifts were assessed. Gross inspection revealed two types of lifts (superficial and deep), whereas cross sections and histologic analyses revealed examples of stable expansion of the submucosal, muscularis propria, and subserosal layers post injection. Clinical "deep" lifts were also found. Superficial lifts are more focal and taller, whereas deep wall lifts are broader and less prominent.
Stable deep wall mucosal lifts occur and are likely due to the deep starting point of the needle post insertion. If ESD/EMR are attempted with a deep lift, the chances of failure or perforation are high. Lifts must be carefully scrutinized before starting ESD/EMR. Other means of lift establishment should be evaluated and considered.
ESD 和 EMR 需要黏膜提升。大多数提升都是通过硬化治疗针注射来完成的。为了穿透黏膜，需要用力推动针，这往往会导致针尖留在深部壁。然后将针拔出，并注入液体，直到形成明显的提升（由于黏膜下扩张）开始形成；然后将针保持稳定并完成注射。最初的注射可能会导致轻微的深部提升，很快就会消失。作者认为只有黏膜下扩张才能导致稳定的黏膜提升。一个结肠 ESD 病例中，一个息肉在扩张的浆膜下平面通过针刀意外切除，这引发了对这一立场的质疑。本研究的目的是确定是否可以通过肠壁注射产生稳定的深部壁黏膜提升。
对牛大肠进行黏膜下和壁内注射。制作并检查稳定的提升和提升横截面，以大体和组织学检查确定提升液的位置。还回顾了临床 ESD 视频。
评估了超过 200 个完整和横截面提升。肉眼检查显示有两种类型的提升（浅表和深部），而横截面和组织学分析显示注射后黏膜下、固有肌层和浆膜下层的稳定扩张的例子。还发现了临床“深部”提升。浅表提升更集中和更高，而深部壁提升更宽和不太明显。
稳定的深部壁黏膜提升是存在的，可能是由于插入后针的深部起点。如果尝试用深部提升进行 ESD/EMR，则失败或穿孔的可能性很高。在开始 ESD/EMR 之前，必须仔细检查提升。应该评估和考虑其他建立提升的方法。
