Carbon dioxide submucosal injection cushion: an innovative technique in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) can successfully resect large lesions en bloc, but it requires a satisfactory submucosal (sm) injection agent for proper safety and efficacy. The aim of the present study was to evaluate the effectiveness of carbon dioxide (CO(2) ) as an ESD sm injection agent.

In vitro study using porcine stomachs compared CO(2) with normal saline (NS) and sodium hyaluronic acid (SHA) solution, both of which are currently used to provide long-lasting sm elevation during ESD. Histopathological examination assessed differences between CO(2) and NS sm cushions. ESD were then carried out in vivo in the stomach and rectum of a live pig using CO(2) sm injection.

CO(2) sm elevation was significantly longer lasting than either NS or SHA (P<0.001). Histopathology revealed no mucosal layer tissue damage, and dissection of honeycomb-like fibrous connective tissue in the CO(2) sm cushion. Creating and maintaining a CO(2) sm cushion of sufficient elevation combined with partial physical dissection of the sm layer was achieved, followed by complete endoscopic dissection of the sm layer with all ESD, resulting in successful en-bloc resections having a mean specimen size of 24.3mm within 15min.

Safety and efficacy of CO(2) as a satisfactory sm injection agent during ESD was successfully demonstrated in these preliminary studies, warranting further investigation of this innovative technique.