Post written by William Hirsch, MD, from the Division of Internal Medicine, Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA, and Mohammad Bilal, MD, from the Division of Gastroenterology & Hepatology, Minneapolis VA Medical Center, University of Minnesota.

Our video case details the process of adding dilute epinephrine to commercially available submucosa lifting agents.

After describing the technique for preparation, we detail the application in aiding in successful cold snare EMR (cs-EMR) of a duodenal adenoma. The use of the combined lifting agent with dilute epinephrine helps with separating the duodenal adenoma from the underlying muscularis propria.

We felt it was important to share this video of our process of preparing the lifting solution combined with dilute epinephrine at our facility because it has been used consistently to aid in performing cs-EMR. Commercially available lifting agents are now widely used for EMR, and the addition to the injectate during EMR, especially during cs-EMR in the duodenum, allows for less intraprocedural oozing and better visualization during resection.

However, there is limited information regarding the addition of dilute epinephrine to these lifting agents. We knew it was crucial to provide step-by-step instruction on its preparation and an example of the application of this lifting solution to highlight its efficacy. We felt that this case would be of particular interest because of cs-EMR performed in the duodenum, a particularly highly vascularized area.

Generally, the addition of dilute epinephrine to commercially available lifting agents to improve cs-EMR is very safe and well tolerated, but endoscopists should be aware of potential associated risks. The use of dilute epinephrine to aid in resection naturally increases the risk of local ischemia, which may be associated with a higher risk of postprocedural pain.

In addition, endoscopists should be aware of the very rare risk of myocardial infarction with the use of large quantities of lifting agents with dilute epinephrine, especially in patients with underlying cardiac risk factors. Given this, we use a very dilute formulation of 1:100,000 or 1:200,000 in the majority of cases.

We thank the Editors and reviewers of VideoGIE for the opportunity to share our work.

Duodenal adenoma being lifted using the prepared submucosal injectate with dilute epinephrine mixture.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.