Subserosal and Intramuscular Lifts during EMR and ESD: Do they occur?

By Richard Whelan 6 Videos FEATURING Richard Whelan

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January 2, 2019

Purpose/Background: Safe ESD and EMR requires a submucosal lift which increases the distance between the ...
read more ↘ muscularis propria and the mucosal polyp and decreases the chances of perforation when a hot snare or needle knife is used to excise the polyp. In ESD the polyp is detached in the submucosal plane with a needle knife. It is assumed by most endoscopists that when a mucosal lift is obtained that the lift solution is in the submucosal space. During a recent clinical case, after establishing a mucosal lift the mucosa was incised and cap dissection was mistakenly carried out in the subserosal plane that had been expanded by the lift injection inadvertently. This case raised the
possibility that other layers of the bowel wall or potential spaces can be expanded when injected and led to the current study of bowel wall injections and lifts.

Methods/Interventions: Large bowel wall injections in an ex vivo bovine model as well as in human colon specimens was carried as was review of clinical ESD and other endoscopic cases. The breadth and extent of mucosal elevation in response to injection was qualitatively assessed and the distribution of the lift solution in the bowel wall determined by cutting through the final lift with a scalpel and examining the resulting cross section. Direct injections into the cut edge of the bowel into the different layers was also carried out to determine the feasibility of subserosal and intramuscular lifts.

Results/Outcome(s): Many video clips are included in the presentation which well demonstrate the different bowel wall lifts. Both subserosal and intramuscular lifts were demonstrated in both the ex-vivo and clinical settings. Subserosal injections likely account for the great majority of deep wall lifts. Deep wall lifts result in broad and less prominent mucosal elevations than do submucosal lifts which are more bleb like and localized. It was demonstrated that it is possible to make a superficial lift on top of a deep lift and that the lift solution in a deep lift is usually found in the subserosal plane whereas in a superficial lift the solution is in the submucosal layer. A few examples of
intramuscular lifts are also shown.

Conclusions/Discussion: Deep wall mucosal lifts occur and are difficult to distinguish from submucosal lifts. ESD and EMR should be carried out only in the presence of a submucosal lift. Endoscopists need to critically evaluate each lift and recognize deep wall lifts when they occur.
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Subserosal and Intramuscular Lifts during EMR and ESD: Do they occur?

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