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Bhatt A, Bucobo JC, Abdi M, Akshintala VS, Chen D, Chen YI, Copland AP, Das KK, Desilets DJ, Girotra M, Han S, Kahn A, Krishnan K, Leung G, Lichtenstein DR, Mishra G, Muthusamy VR, Obando JV, Onyimba FU, Pawa S, Rustagi T, Sakaria SS, Saumoy M, Shahnavaz N, Trikudanathan G, Trindade AJ, Vinsard DG, Yang J, Law R. Submucosal injection fluid and tattoo agents. Gastrointest Endosc 2024:S0016-5107(24)03347-9. [PMID: 39269377 DOI: 10.1016/j.gie.2024.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND AND AIMS EMR and endoscopic submucosal dissection (ESD) are minimally invasive endoscopic techniques, developed for the removal of benign and early malignant lesions throughout the GI tract. Submucosal injection of a marking agent can help to identify lesions during surgery. Endoscopic resection frequently involves "lifting" of the lesions by injection of a substance within the submucosal space to create a cushion for safe resection. This review summarizes the current techniques and agents available for endoscopic marking and lifting of GI tract lesions. METHODS The MEDLINE database was searched through April 2023 for relevant articles related to the lifting and marking aspect of EMR by using key words such as "endoscopy" or "endoscopic" combined with "marking," "tattoo," and "lifting." The report was drafted, reviewed, and edited by the American Society for Gastrointestinal Endoscopy Technology Committee and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy. RESULTS This technology review describes the techniques for endoscopic tattoo placement and submucosal lifting, along with currently available agents, safety, and costs. CONCLUSIONS Endoscopists performing EMR and ESD have several choices in submucosal injection materials for lifting and marking agents for tattoos. These may be commercially prepared agents or off-the-shelf materials with or without additives to facilitate visualization. A thorough understanding of the indications, techniques, properties of various agents, costs, and adverse events is necessary in choosing the appropriate materials and technique to optimize lesion resection in EMR and ESD.
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Affiliation(s)
- Amit Bhatt
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Carlos Bucobo
- Gastroenterology Services, Northwell Health Gastroenterology Institute, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Maaza Abdi
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Dennis Chen
- Digestive Diseases Center, University of Chicago, Chicago, Illinois, USA
| | - Yen-I Chen
- Division of Gastroenterology & Hepatology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Andrew P Copland
- Division of Gastroenterology and Hepatology, University of Virginia Health Systems, Charlottesville, Virginia, USA
| | - Koushik K Das
- Division of Gastroenterology, Washington University School of Medicine, St Louis, Missouri, USA
| | - David J Desilets
- Division of Gastroenterology, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Mohit Girotra
- Department of Gastroenterology, Swedish Medical Center, Issaquah, Washington, USA
| | - Samuel Han
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Allon Kahn
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Kumar Krishnan
- Division of Gastroenterology, Department of Internal Medicine, Harvard Medical School and Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Galen Leung
- Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David R Lichtenstein
- Division of Gastroenterology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Girish Mishra
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - V Raman Muthusamy
- Division of Digestive Diseases, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Jorge V Obando
- Division of Gastroenterology, Duke University Health System, Raleigh, North Carolina, USA
| | - Frances U Onyimba
- Department of Gastroenterology, WellSpan Digestive Health, York, Pennsylvania, USA
| | - Swati Pawa
- Department of Gastroenterology, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Tarun Rustagi
- Department of Gastroenterology, Kern Medical Center, Bakersfield, California, USA
| | - Sonali S Sakaria
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, USA
| | - Monica Saumoy
- Department of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nikrad Shahnavaz
- Division of Digestive Diseases, Emory University, Atlanta, Georgia, USA
| | - Guru Trikudanathan
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Arvind J Trindade
- Department of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | | | - Julie Yang
- Division of Gastroenterology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Ryan Law
- Department of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Alipouriani A, Elsoukkary SS, Erozkan K, Sommovilla J, Bhatt A, Valente MA, Steele SR, Gorgun E. Adverse Tissue Reactions to Orise Gel During Endoscopic Mucosal Resection and Dissection. J Gastrointest Surg 2024:S1091-255X(24)00603-6. [PMID: 39243809 DOI: 10.1016/j.gassur.2024.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Revised: 08/19/2024] [Accepted: 09/03/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND To facilitate endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), submucosal injection of lifting agents (LAs) is frequently used. ORISE™ gel, approved in 2018 by the US Food and Drug Administration (FDA), has been commonly utilized until recently. Its use grew rapidly due to its practical pre-filled syringe, prolonged lift effect, and ideal coloration. However, it has been noted to cause unexpected tissue reactions, described as "giant cell reaction" (GCR), which can obscure both macroscopic and microscopic views, potentially interfering with pathological evaluation. This study aims to describe the adverse effects of ORISE™ gel. METHODS This retrospective study analyzed pathology specimens from all consecutive patients who received ORISE™ injections for attempted polyp removal and subsequently underwent segmental colon resection at our center between 2019 and 2022. Descriptive analysis was performed. RESULTS A total of 45 patients were included, with 38% (n=17) being female and a median age of 66 years. The indications for surgery included adenocarcinoma in 14 patients (31%), suspected malignancy in 3 patients (7%) who had benign GCR-induced masses, and other indications in 28 patients, such as large polyps or recurrent polyps after initial endoscopic treatment. Surgical procedures included right hemicolectomy (44%), low anterior resection (13%), left colectomy (11%), sigmoidectomy (7%), and abdominoperineal resection (4%). Histologic evidence of prior LA injection was seen in 31 patients (69%), with 24 of these exhibiting GCR. At final pathology, no residual neoplasm was found in 9 patients (18%), while 14 patients (31%) had adenocarcinoma [T1 (7), T2 (3), T3 (3), T4 (1)]. CONCLUSION ORISE™ Gel interacts with various tissue layers of the colon, frequently resulting in GCR. This reaction and the potential subsequent mass effect formation can impact decision-making in the management of complex colorectal lesions. Further study into the cause and consequences of LA tissue reactions is warranted.
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Affiliation(s)
- Ali Alipouriani
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sarah S Elsoukkary
- Department of Pathology, Pathology & Laboratory Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kamil Erozkan
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joshua Sommovilla
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amit Bhatt
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Michael A Valente
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Scott R Steele
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Emre Gorgun
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH, USA.
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Dhorajiya P, Mahmood S, Fabrizio A, Deshpande V, Vyas M. Gone but not forgotten: expanding the spectrum of ORISE (submucosal lifting agent) associated diagnostic pitfalls and complications. J Clin Pathol 2024:jcp-2024-209419. [PMID: 39025488 DOI: 10.1136/jcp-2024-209419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 06/25/2024] [Indexed: 07/20/2024]
Abstract
AIMS A synthetic lifting agent, ORISE, used for endoscopic mucosal resections, has been recalled from the market since November 2022 due to clinical complications. Despite this, the impact of ORISE-associated complications is expected to persist in the foreseeable future. We present a large single institutional series of therapeutic resections from patients for whom ORISE was used for initial endoscopic procedures, highlighting the pitfalls and complications associated with its use. METHODS All specimens showing lifting agent granulomata (LAGs) associated with the use of ORISE were identified. The H&E slides were reviewed to define the morphological characteristics and extent of LAG in the intestinal wall and other organs. The clinical impression and gross findings were compared with the final pathological diagnosis. RESULTS 34 cases (28 resections and 6 repeat endoscopic mucosal resection specimens) showed LAG. On microscopy, 20.5% showed no residual disease, 64.7% also showed residual precursor lesion and 14.7% also showed malignancy. In 64.2% of cases, a mass lesion was seen grossly but no malignancy was identified microscopically. ORISE was present in vascular spaces (n=9), lymph nodes (n=2), other organs such as appendix (n=1) and omentum/peritoneum (n=1). The major discordance between clinical impression (mass/neoplasm) and final pathology (no residual malignancy) was seen in 4/34 (11.8%) cases. LAGs were seen up to 10 months after the use of ORISE in the prior endoscopic procedure. CONCLUSION ORISE deposits may mimic residual/disseminated neoplasm and prompt inadvertent changes in surgical decisions. Awareness of this pitfall is essential to prevent unwarranted surgical resections in patients undergoing follow-up for endoscopically resected lesions.
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Affiliation(s)
- Pooja Dhorajiya
- Department of Pathology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Sultan Mahmood
- Department of Gastroenterology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Anne Fabrizio
- Department of Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Vikram Deshpande
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Monika Vyas
- Department of Pathology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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Denesh D, Mundre P, Rembacken BJ, Maleki N. Lifting agents in endoscopic resection: a cause for histological disquietude? Frontline Gastroenterol 2023; 14:444. [PMID: 37581178 PMCID: PMC10423605 DOI: 10.1136/flgastro-2022-102367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 01/11/2023] [Indexed: 01/25/2023] Open
Affiliation(s)
- Deepa Denesh
- Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Pradeep Mundre
- Gastroenterology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | | | - Nima Maleki
- Histopathology, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Shah RH, Amin S. Building the Toolbox of Devices to Optimize a Practice in Submucosal Endoscopy. Gastrointest Endosc Clin N Am 2023; 33:15-28. [PMID: 36375879 DOI: 10.1016/j.giec.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic submucosal dissection (ESD) is a technically complex and still evolving procedure. As a result, there are many advances in the technology and tools available to assist the endoscopist. This article delves into the various tools developed for ESD including electrosurgical knives, caps, injection agents, and traction devices. The authors discuss tools available as well as their respective pros, cons, and technical considerations for use. Overall, the choice of tools depends on a multitude of factors from availability, cost, lesion characteristics, and the endoscopist's familiarity and proficiency.
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Affiliation(s)
- Rahil H Shah
- Department of Medicine, University of Miami/Jackson Memorial Hospital, 1611 Northwest 12th Avenue, C-600D, Miami, FL 33136, USA
| | - Sunil Amin
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, Miller School of Medicine at the University of Miami, 1120 Northwest 14th Street, Clinical Research Building, Suite 11145 (D-49), Miami, FL 33136, USA.
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Assessment of submucosal distortion and mass effect seen at follow-up after colorectal EMR with ORISE (with video). Gastrointest Endosc 2022; 96:679-682. [PMID: 35550794 DOI: 10.1016/j.gie.2022.04.1344] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/30/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ORISE (Boston Scientific, Marlborough, Mass, USA) is a viscous gel used for submucosal injection. We noted anecdotally that ORISE is associated with submucosal distortion of EMR scars at follow-up. METHODS We blindly reviewed photographs of 30 consecutive EMR scars at follow-up after resections using ORISE and 30 resections using other agents. Distortion was scored on a scale of 0 (no submucosal distortion) to 5 (overt submucosal distortion). RESULTS The median submucosal distortion score at follow-up in ORISE cases was 3 (range, 0-5) versus 0 (range, 0-2) with other fluids (P < .001, Mann-Whitney U test) by 1 reviewer and 3 (range, 0-5) versus 2 (range, 0-5), respectively, by a second reviewer (P = .018). The kappa value for agreement in the submucosal distortion scores between the 2 experts was .148 for all photographs and .214 for the ORISE cases (overall minimal agreement). CONCLUSIONS ORISE can cause submucosal distortion in the region of EMR scars when they are viewed at follow-up. Such distortions must not be mistaken for submucosal tumor growth.
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Romutis S, McGrath K. Edge of uncertainty: won't get fooled again. Gastrointest Endosc 2022; 96:683-684. [PMID: 35970604 DOI: 10.1016/j.gie.2022.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/18/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Stephanie Romutis
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Kevin McGrath
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Bulking agents in gastrointestinal endoscopy: present applications and future advances. Curr Opin Gastroenterol 2022; 38:472-480. [PMID: 35881970 DOI: 10.1097/mog.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW Bulking agents are inert materials injected into an organ to affect the physical properties of the organ for a therapeutic purpose. Various agents have been developed to aid in the treatment of diseases like gastroesophageal reflux disease (GERD), fecal incontinence, obesity, malignancy, hemostasis, and tissue dissection. Here, we review the state of the art in bulking agents in gastrointestinal endoscopy, past failures, current limitations, and where we see the field heading in the future. RECENT FINDINGS Though bulking agents have been trialed for various different gastrointestinal diseases, there are currently limited uses in gastrointestinal endoscopy. Though various agents have been trialed for GERD, numerous complications and adverse events have limited its current use. However, for the treatment of fecal incontinence endoscopic bulking agent therapy is a reasonable option. Though in early stages of exploration, bulking agent therapy for enteric protection from radiotherapy may be a promising tool to improve treatment of pancreatic cancer. Bulking agents for tissue dissection have substantially improved lifting agents and complex polyp removal. Bulking agent therapy has not really been explored for endoscopic bariatric therapy or hemostasis but may be a fruitful area for exploration in the future. SUMMARY Bulking agent therapy has been trialed for various gastrointestinal diseases with mixed success. There is currently a therapeutic roll in the endoscopic management of fecal incontinence and tissue dissection. A future role in the treatment of GERD, obesity, malignancy, and hemostasis seem feasible.
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Rau S, Cummings D. Giant cell reaction subsequent to ORISE gel lifting agent captured on endoscopic ultrasound. Gastrointest Endosc 2022; 96:568-569. [PMID: 35995466 DOI: 10.1016/j.gie.2022.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 03/06/2022] [Indexed: 12/11/2022]
Affiliation(s)
- Sanjay Rau
- Division of Internal Medicine, Jefferson Health Northeast, Philadelphia, Pennsylvania, USA
| | - Donelle Cummings
- Division of Gastroenterology, New York Medical College, NYC Health+Hospitals/Metropolitan, New York, New York, USA
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Kwok K, Tran T, Lew D. Polypectomy for Large Polyps with Endoscopic Mucosal Resection. Gastrointest Endosc Clin N Am 2022; 32:259-276. [PMID: 35361335 DOI: 10.1016/j.giec.2021.12.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Beginning in 1955, when the saline injection was first described to prevent transmural injury during polyp fulguration, endoscopic mucosal resection (EMR) has grown exponentially, both in scope and in practice. Because EMR is an organ-preserving technique even for large polyps, this allows for comparable outcomes to surgery, but substantially improved cost savings and significantly reduced morbidity and mortality. To achieve this, however, one must master the 4 fundamental components that are critical to the success of EMR- time, team, tools, and technique. This article aims to provide a compendium of state of the art updates within the field of endoluminal resection.
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Affiliation(s)
- Karl Kwok
- Interventional Endoscopy, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, 1526 North Edgemont Street, 7th Floor, Los Angeles, CA 90027, USA.
| | - Tri Tran
- Department of Medicine, Kaiser Permanente, Los Angeles Medical Center, 4867 W Sunset Boulevard, Los Angeles, CA 90027, USA
| | - Daniel Lew
- Division of Gastroenterology, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048, USA
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Yang D, Saulino D, Draganov PV. Histologic changes with a novel submucosal lifting gel for endoscopic resection: more than just a lift. Gastrointest Endosc 2022; 95:198. [PMID: 34895615 DOI: 10.1016/j.gie.2021.07.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Dennis Yang
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
| | - David Saulino
- Department of Pathology, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Karamchandani DM, Hammad H, Chetty R, Arnold CA. New Kids on the Block. Arch Pathol Lab Med 2021; 145:1569-1584. [PMID: 33571357 DOI: 10.5858/arpa.2020-0535-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT.— With the increasing development and use of iatrogenic agents, pathologists are encountering more novel foreign materials in retrieved gastrointestinal specimens. These colorful and unusual-appearing foreign materials can pose a diagnostic dilemma to those unaware of their morphology, especially if the relevant clinical history is lacking. OBJECTIVE.— To discuss the histopathologic features, clinical scenarios and significance, and differential diagnosis of relatively recently described, yet quickly expanding, family of iatrogenic agents that can present as foreign materials in gastrointestinal specimens-pharmaceutical fillers (crospovidone and microcrystalline cellulose), submucosal lifting agents (Eleview and ORISE), lanthanum carbonate, hydrophilic polymers, OsmoPrep, yttrium 90 microspheres (SIR-Sphere and TheraSphere), and resins (sodium polystyrene sulfonate, sevelamer, and bile acid sequestrants). DATA SOURCES.— We collate the findings of published literature, including recently published research papers, and authors' personal experiences from clinical sign-out and consult cases. CONCLUSIONS.— Correct identification of these iatrogenic agents is important because the presence of some novel agents can explain the histopathologic findings seen in the background specimen, and specific novel agents can serve as diagnostic clues to prompt the pathologist to consider other important and related diagnoses. Awareness of even biologically inert agents is important for accurate diagnosis and to avoid unnecessary and expensive diagnostic studies.
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Affiliation(s)
- Dipti M Karamchandani
- From the Department of Pathology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania (Karamchandani)
| | - Hazed Hammad
- The Department of Internal Medicine, Division of Gastroenterology and Hepatology (Hammad), University of Colorado, Anschutz Medical Center, Denver
| | - Runjan Chetty
- The Histopathology Department, Brighton & Sussex University Hospitals, Brighton, United Kingdom (Chetty)
| | - Christina A Arnold
- The Department of Pathology (Arnold), University of Colorado, Anschutz Medical Center, Denver
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Histologic mimics and diagnostic pitfalls of gastrointestinal endoscopic lifting media, ORISE™ gel and Eleview®. Hum Pathol 2021; 119:28-40. [PMID: 34606848 DOI: 10.1016/j.humpath.2021.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 09/20/2021] [Indexed: 12/24/2022]
Abstract
Synthetic lifting media, ORISE™ gel and Eleview®, are increasingly used in gastrointestinal endoscopy, but neither comparative features nor pitfalls are well-established. Media histopathology, morphologic mimics, and complications are described, along with helpful stains and endoscopist media preference. A 3-year retrospective search was performed. A total of 123 cases (108 endoscopies and 15 subsequent surgeries) were identified. ORISE gel was used in 86 (79.6%), Eleview in 20 (13.9%), and others in 7 (6.5%). ORISE gel was histologically identified in 58.1% (n = 50) of endoscopic specimens and all 15 resections. Eleview media were not detected histologically. ORISE gel mimicked mucin in hematoxylin and eosin-stained biopsies, concerning for adenocarcinoma misdiagnosis and/or upstaging, but did not stain for mucin. Acid-fast bacterial staining highlights ORISE gel for specific and definitive identification. In resections, ORISE evolves into an amorphous eosinophilic material, often with exuberant giant cell reaction and transmural bowel penetration. Polyp formation leads to polypectomy in one patient, and operative lesions concerning for adenocarcinoma resulted in frozen sections in two patients. ORISE gel mimics mucin, malignant masses, amyloid, pulse granulomata, elastofibromas, and infectious granulomata. No significant endoscopist media preference was identified. Recognition of ORISE gel in tissues eliminates multiple pitfalls. Eleview was not detectable, yielded none of the pitfalls seen with ORISE gel, and, on our survey, has equivalent endoscopist acceptance. In this largest published series to date, Eleview is clearly preferable to ORISE gel.
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Submucosal lifting agent ORISE gel causes extensive foreign body granuloma post endoscopic resection. Int J Colorectal Dis 2021; 36:419-422. [PMID: 32959116 DOI: 10.1007/s00384-020-03764-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Submucosal injection of lifting solution is often performed to facilitate endoscopic mucosal resection or endoscopic submucosal dissection. ORISETM gel is a synthetic solution recently approved by the US Food and Drug Administration (FDA) in 2018 for use as submucosal lifting solution for endoscopic resection procedures and has gained popularity for its convenient pre-filled syringe. However, here the present two cases show that ORISETM gel induces marked foreign body giant cell granulomatous reaction in the submucosa and muscularis propria following endoscopic resection. METHODS AND RESULTS A 73-year-old female underwent laparoscopic right colectomy after her initial endoscopic polypectomy of a hyperplastic polyp, and a 78-year-old male had partial gastrectomy following endoscopic mucosal resection of an invasive adenocarcinoma. Both patients had submucosal injection of ORISETM gel during endoscopic procedures, and the surgical resection specimens showed ORISETM gel deposition and extensive foreign body giant cell granulomatous reaction in the submucosa and muscularis propria. CONCLUSION These cases raise the awareness that ORISETM gel stimulates extensive foreign body reaction at the injection site, and the further consequence is still unclear.
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