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      Aspectos galénicos de las soluciones de inyección submucosa para su utilización en polipectomía endoscópica Translated title: Galenic aspects of submucosal injection solutions for use in endoscopic polypectomy

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          Abstract

          Resumen La disección submucosa endoscópica submucosa (DSE) y la resección mucosa endoscópica mucosa (RME) o mucosectomía son las principales técnicas empleadas en la extirpación endoscópica de pólipos del tubo digestivo. En ambas técnicas se inyecta una solución submucosa para crear un habón debajo de la lesión que separe la mucosa de la capa muscular propia. Esto permite una mejor delimitación de la lesión y facilita su resección. En la práctica clínica, se han probado diferentes soluciones para este uso, utilizándose en la mayoría de los casos fuera de indicación en ficha técnica y sin control galénico, fisicoquímico ni microbiológico, a pesar de ser soluciones de administración parenteral. El objetivo de este trabajo es llevar a cabo una revisión de las principales soluciones utilizadas, así como de sus limitaciones y de los principales avances realizados en este ámbito.

          Translated abstract

          Summary Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) are the main techniques used in the removal of intestinal polyps. In both techniques a submucosal solution is injected to create a hub under the lesion that separates the mucosa from the muscular layer itself. This allows a better delimitation of the lesion and facilitates its resection. In clinical practice, many solutions have been tested for this use, being used in most cases out off-label and without galenic, physicochemical or microbiological control, despite being parenteral administration solutions. The objective of this study is to carry out a review of the main solutions used, as well as their limitations and the main advances made in this area.

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          Most cited references89

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          Colorectal polypectomy and endoscopic mucosal resection (EMR): European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline.

          1  ESGE recommends cold snare polypectomy (CSP) as the preferred technique for removal of diminutive polyps (size ≤ 5 mm). This technique has high rates of complete resection, adequate tissue sampling for histology, and low complication rates. (High quality evidence, strong recommendation.)2 ESGE suggests CSP for sessile polyps 6 - 9 mm in size because of its superior safety profile, although evidence comparing efficacy with hot snare polypectomy (HSP) is lacking. (Moderate quality evidence, weak recommendation.)3 ESGE suggests HSP (with or without submucosal injection) for removal of sessile polyps 10 - 19 mm in size. In most cases deep thermal injury is a potential risk and thus submucosal injection prior to HSP should be considered. (Low quality evidence, strong recommendation.)4 ESGE recommends HSP for pedunculated polyps. To prevent bleeding in pedunculated colorectal polyps with head ≥ 20 mm or a stalk ≥ 10 mm in diameter, ESGE recommends pretreatment of the stalk with injection of dilute adrenaline and/or mechanical hemostasis. (Moderate quality evidence, strong recommendation.)5 ESGE recommends that the goals of endoscopic mucosal resection (EMR) are to achieve a completely snare-resected lesion in the safest minimum number of pieces, with adequate margins and without need for adjunctive ablative techniques. (Low quality evidence; strong recommendation.)6 ESGE recommends careful lesion assessment prior to EMR to identify features suggestive of poor outcome. Features associated with incomplete resection or recurrence include lesion size > 40 mm, ileocecal valve location, prior failed attempts at resection, and size, morphology, site, and access (SMSA) level 4. (Moderate quality evidence; strong recommendation.)7 For intraprocedural bleeding, ESGE recommends endoscopic coagulation (snare-tip soft coagulation or coagulating forceps) or mechanical therapy, with or without the combined use of dilute adrenaline injection. (Low quality evidence, strong recommendation.)An algorithm of polypectomy recommendations according to shape and size of polyps is given (Fig. 1).
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            Terminology, Molecular Features, Epidemiology, and Management of Serrated Colorectal Neoplasia

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              Endoscopic submucosal dissection.

              ESD is an established effective treatment modality for premalignant and early-stage malignant lesions of the stomach, esophagus, and colorectum. Compared with EMR, ESD is generally associated with higher rates of en bloc, R0, and curative resections and a lower rate of local recurrence. Oncologic outcomes with ESD compare favorably with competing surgical interventions, and ESD also serves as an excellent T-staging tool to identify noncurative resections that will require further treatment. ESD is technically demanding and has a higher rate of adverse events than most endoscopic procedures including EMR. As such,sufficient training is critical to ensure safe conduct and high-quality resections. A standardized training model for Western endoscopists has not been clearly established,but will be self-directed and include courses, animal model training, and optimally an observership at an expert center.Numerous dedicated ESD devices are now available in the United States from different manufacturers. Although the use of ESD in the United States is increasing, issues related to technical difficulty, limited training opportunities and mentors, risk of adverse events, long procedure duration,and suboptimal reimbursement may limit ESD adoption in the United States to a modest number of academic referral centers for the foreseeable future.
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                Author and article information

                Journal
                ofil
                Revista de la OFIL
                Rev. OFIL·ILAPHAR
                Organización de Farmacéuticos Ibero-Latinoamericanos (Madrid, Madrid, Spain )
                1131-9429
                1699-714X
                2020
                : 30
                : 2
                : 131-139
                Affiliations
                [2] Santiago de Compostela orgnameInstituto de Investigación Sanitaria (IDIS-ISCIII) orgdiv1Grupo de Farmacología Clínica España
                [3] Santiago de Compostela orgnameXerencia de Xestión Integrada de Santiago de Compostela (SERGAS) orgdiv1Servicio de Aparato Digestivo España
                [5] Santiago de Compostela Galicia orgnameUniversidad de Santiago de Compostela orgdiv1Facultad de Farmacia orgdiv2Departamento de Farmacia y Tecnología Farmacéutica Spain
                [4] Alicante orgnameHospital General de Alicante orgdiv1Servicio de Farmacia España
                [1] Santiago de Compostela orgnameXerencia de Xestión Integrada de Santiago de Compostela (SERGAS) orgdiv1Servicio de Farmacia España
                Article
                S1699-714X2020000200131 S1699-714X(20)03000200131
                10.4321/s1699-714x2020000200013
                75db07b8-763b-41e3-8337-d63e308e9a40

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                History
                : 19 February 2020
                : 21 February 2020
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 92, Pages: 9
                Product

                SciELO Spain

                Categories
                Revisión

                solución de inyección,injection solution,polypectomy,endoscópica,Submucosa,polipectomía,endoscopic

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