Post written by Hiroki Hayashi, MD, from the Division of Gastroenterology, Department of Medicine, Jichi Medical University, Shimotsuke, Japan.

EMR and endoscopic submucosal dissection are widely used for treating intramucosal gastric neoplasms. However, securing a clear visual field in a stomach with residue is challenging. In this article, we present 2 cases in which tumors were endoscopically resected by securing the visual field using the gel immersion method in remnant stomachs after proximal gastrectomy with residue.

Underwater EMR and underwater endoscopic submucosal dissection are effective methods. Yet, these techniques can cause problems such as difficulty retaining water, blurred vision because of cloudy water containing food residue, bile, intestinal fluid, and feces, as well as loss of vision because of intraprocedural bleeding.

In addition, because these techniques use a saline solution, monopolar hemostatic forceps are ineffective because of electrical dissipation. These issues can be resolved by using the gel immersion method with the electrolyte-free gel VISCOCLEAR (Otsuka Pharmaceutical Factory, Tokushima, Japan). This video clearly demonstrates the usefulness of the gel immersion method.

To effectively use the gel immersion method, it is essential to remove residual gas and deflate the lumen before injecting the gel. Attaching a cylindrical hood or a small-caliber-tip transparent hood to the endoscope’s tip makes it easier to hold the gel in front of the scope. The biopsy valve, which is equipped with an irrigation tube BioShield irrigator (US Endoscopy, Mentor, Ohio, USA), allows for additional gel to be injected after the device is inserted into the channel.

Unfortunately, the dedicated gel VISCOCLEAR is only available in the Japanese market. We hope it will become available worldwide and benefit many patients and endoscopists.

Underwater, the visual field was poor as the result of floating residue, obscuring the incision line; however, the application of the gel effectively displaced the residue, thereby improving visualization.

Read the full article online.

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