Addition of dilute epinephrine to commercially available submucosal lifting agents for cold snare EMR

Graphical Abstract

Introduction

The European Society of Gastrointestinal Endoscopy recommends that duodenal adenomas be considered for management with EMR.¹ In recent years, there has been an increase in use of cold snare EMR (cs-EMR) for removal of colon polyps and nonampullary duodenal polyps.² cs-EMR avoids the use of electrocautery for resecting polyps, and therefore leads to reduced risk of delayed bleeding and perforation.³ Several experts suggest adding dilute epinephrine to the submucosal injectate solution to reduce intraprocedural oozing, which improves visualization during resection.

The addition of dilute epinephrine while performing EMR has been well-described due to its benefit of reducing intraprocedural oozing and helping visualization during resection; however, data around its use are limited, and the addition of epinephrine to commercially available lifting solutions has not been well characterized.4, 5, 6 One meta-analysis found that use of viscous and hypertonic lifting solutions leads to higher rates of en bloc resection and lower rates of residual lesion compared with use of normal saline as a lifting solution for EMR.⁷ In this video, we detail the case of a patient referred for endoscopic resection of a duodenal adenoma. Here, we describe the preparation and clinical application of a commercially available lifting solution mixed with dilute epinephrine to aid in the successful cs-EMR of a duodenal adenoma (Video 1, available online at www.videogie.org).

Technique

Required supplies including a commercially available lifting agent, 0.1 mg/mL epinephrine syringe (epinephrine 1:10,000), a 25-gauge needle, 10 mL of normal saline, and a 3-way stopcock were gathered (Fig. 1A).

Figure 1.

A, Required supplies for creation of dilute epinephrine lifting solution injectate. B, Final mixing of the submucosal injectate using 3-way stopcock prior to use during endoscopy.

First, a 25-gauge needle was attached to the epinephrine 1:10,000 syringe. Next, 1 mL from the normal saline syringe was wasted. Then, 1 mL of epinephrine 1:10,000 was added to the normal saline flush to replace the 1 mL of saline that had been wasted. A total of 1 mL of the commercially available lifting agent was then wasted. A total of 1 mL of the dilute epinephrine solution was then added to the commercially available lifting agent to replace the 1 mL that had been wasted. An empty flush was then attached to the combined lifting agent and dilute epinephrine before being mixed using a 3-way stopcock (Fig. 1B).

Case Presentation

A 73-year-old man was referred after identification of a duodenal adenoma on EGD for abdominal pain. EGD was performed, and the duodenal adenoma was identified (Fig. 2A). During EGD, the prepared submucosal injectate solution was used to lift the duodenal adenoma in preparation for cs-EMR (Fig. 2B).

Figure 2.

A, Duodenal adenoma (arrow) visualized on EGD. B, Duodenal adenoma (arrow) being lifted using the prepared submucosal injectate with dilute epinephrine mixture.

Piecemeal resection of the duodenal adenoma was then performed using cs-EMR. Despite the highly vascularized nature of the duodenum, there was minimal bleeding due to the addition of epinephrine to the commercially available lifting agent (Fig. 3A). The area of defect was subsequently examined using water immersion without evidence of residual adenoma or bleeding (Fig. 3B). The defect was not closed in line with our institutional practice pattern, as it has not been shown to provide significant benefit in preventing delayed bleeding in cs-EMR for non-ampullary duodenal adenomas.⁸ Defect closure following cs-EMR in the duodenum is only performed in our practice if there is significant intraprocedure bleeding.

Figure 3.

A, Minimal bleeding observed following cold snare EMR (cs-EMR) of duodenal adenoma. B, Water immersion inspection of the area of defect following cs-EMR without evidence of residual adenoma or bleeding.

Discussion

Use of submucosal lifting solutions in EMR is effective in separating the lesion from the underlying muscularis propria. We conservatively estimate the duration of effect of the dilute epinephrine lifting solution to be 15 minutes. The addition of epinephrine in a submucosal lifting agent mixture is typically safe and well tolerated.⁴ There is a risk of ischemia induced by addition of epinephrine to the submucosal injectate, which has been previously described.⁹ This is related to the risk of increased postprocedural pain with use of epinephrine.¹⁰ This risk is likely mitigated by using a dilute concentration of epinephrine in the submucosal injectate.

Additionally, there is a theoretical risk of myocardial infarction while using large quantities of lifting agents containing epinephrine in patients with underlying cardiac risk factors.¹¹ Although these reports are rare, these are important considerations for endoscopists to be aware of while using dilute epinephrine in submucosal lifting agents. This described technique has been used at our institution to successfully perform cs-EMR while minimizing intraprocedural oozing and aiding in effective visualization and complete resection of lesions.

Disclosure

The authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Preparation and application of dilute epinephrine combined with commercially available lifting solution for cold snare endoscopic mucosal resection of duodenal adenoma.