Submucosal injection materials other than mucosal lift

Submucosal elevation is essential for assisting endoscopic submucosal dissection (ESD) to make it easier and safer. Hence, a submucosal cushion has been a critical issue since the ESD technique came into being. Several agents are available, but it has not yet been proved which agent is preferred over another. Recently, Fujimoto et al1Fujimoto A. Uraoka T. Nishizawa T. et al.Rebamipide solution: a novel submucosal injection material to promote healing speed and healing quality of ulcers induced by endoscopic submucosal dissection.Gastrointest Endosc. 2018; 87: 1114-1120Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar reported rebamipide solution as a modified agent for submucosal injection that could promote wound healing for post-ESD ulcers. There were few reports about the physiologic interaction between cushion agents and post-ESD defects. This research has brought out another potential of submucosal injection materials other than mucosal lift. Other antiulcer drugs might have similar effects. Although that study gives us an inspiration, we still have some concerns. First, 0.5% carboxymethyl cellulose (CMC) was used as a solvent in the experimental group. CMC sheets have been widely proved to reduce postoperative adhesion during surgery.2Vrijland W.W. Tseng L.N. Eijkman H.J. et al.Fewer intraperitoneal adhesions with use of hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial.Ann Surg. 2002; 235: 193-199Crossref PubMed Scopus (223) Google Scholar Some reports show that CMC can promote wound healing3Wong T.W. Ramli N.A. Carboxymethylcellulose film for bacterial wound infection control and healing.Carbohydr Polym. 2014; 112: 367-375Crossref PubMed Scopus (62) Google Scholar and prevent esophageal stricture after extensive ESD.4Lua G.W. Tang J. Liu F. et al.Prevention of esophageal strictures after endoscopic submucosal dissection: a promising therapy using carboxymethyl cellulose sheets.Dig Dis Sci. 2016; 61: 1763-1769Crossref PubMed Scopus (23) Google Scholar, 5Tang J. Ye S. Ji X. et al.Deployment of carboxymethyl cellulose sheets to prevent esophageal stricture after full circumferential endoscopic submucosal dissection: a porcine model.Dig Endosc. 2018; 30: 608-615Crossref PubMed Scopus (16) Google Scholar Instead of saline solution, the 0.5% CMC solution should be considered in the control group to exclude the confounding effect. Second, to promote wound healing, post-ESD patients generally fast for 24 hours and receive proton pump inhibitors for 4 weeks.6Bai Y. Cai J.T. Chen Y.X. et al.Expert consensus on perioperative medications during endoscopic submucosal dissection for gastric lesions (2015, Suzhou, China).J Dig Dis. 2016; 17: 784-789Crossref PubMed Scopus (6) Google Scholar In their article, Fujimoto et al1Fujimoto A. Uraoka T. Nishizawa T. et al.Rebamipide solution: a novel submucosal injection material to promote healing speed and healing quality of ulcers induced by endoscopic submucosal dissection.Gastrointest Endosc. 2018; 87: 1114-1120Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar did not mention whether their subjects fasted. These issues raise the question: Will rebamipide solution be superior with or without proton pump inhibitor intervention? Finally, in ESD practice, the submucosal injection solution leaks into the adjacent interstitial space through the procedure. The rebamipide remaining after operation might be minimal. Would it be better to administer oral rebamipide for ulcer recovery? We thank the authors and encourage similar efforts to advance the clinical benefit of ESD. All authors disclosed no financial relationships relevant to this publication. Rebamipide solution: a novel submucosal injection material to promote healing speed and healing quality of ulcers induced by endoscopic submucosal dissectionGastrointestinal EndoscopyVol. 87Issue 4PreviewRebamipide is administered perorally to protect the gastric mucosa. We assessed the efficacy and safety of a novel rebamipide solution as a submucosal injection material for endoscopic submucosal dissection (ESD) using an in vivo porcine model. Full-Text PDF Response:Gastrointestinal EndoscopyVol. 89Issue 3PreviewWe appreciate the insightful advice on our article1 from Dr Dong and colleagues.2 The reviewers point out that 0.5% carboxymethyl cellulose (CMC), the solvent used in the rebamipide solution, may have promoted wound healing. That is, the favorable effect on ulcer healing might have been bestowed by the CMC rather than by the rebamipide treatment. When we conducted a similar experiment using CMC as a control in an earlier study, the ulcers healed more quickly in the rebamipide group than in the CMC group. Full-Text PDF