A hematoma caused by an excessively superficial injection: go under the red bleb!

Effective submucosal injection is key for efficient and safe endoscopic resection, such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Deep injection into the muscularis propria is dangerous and may result in a false non-lifting sign. A too superficial injection in the muscularis mucosae is a classic issue, associated with rapid poor lifting and a hematoma of the muscularis mucosa caused by injury to the extensive vascularization. Such a situation complicates many endoscopic resections [1]. During EMR, the scenario may compromise technical success because the lesion is not lifted. During ESD, the difficulty increases because of major bleeding and loss of the dissection plan.

We report a simple trick that greatly assists such a situation. A 2-cm-diameter, granular, laterally spreading tumor of the right colon ([Fig. 1]) was scheduled for standard EMR. The first injection was too superficial and triggered a major hematoma of the muscularis mucosae that complicated safe and efficient EMR ([Fig. 2]). We switched to ESD with traction of the dissection plane under the hematoma. We performed a second injection 1 cm distant from the hematoma. We then created a mucosal incision no closer than 1 cm from the hematoma. After dissection of the first submucosal fibers, we installed our previously reported double-clip traction device using two clips and a rubber band [2] [3]. The resultant good positioning of the submucosal plane allowed access to the deep submucosal plane under the red bleb caused by the first excessively superficial injection ([Fig. 3]). Extension of the margin and a descent under the red bleb allowed us to avoid major bleeding and perform rapid successful ESD of a 2-cm-diameter adenoma exhibiting low-grade dysplasia ([Video 1]).

Fig. 1 Granular-type laterally spreading tumor in the right colon.

Fig. 2 Hematoma resulting from an excessively superficial injection.

Fig. 3 Endoscopic submucosal dissection under the hematoma.

Video 1 A hematoma caused by an excessively superficial injection: go under the red bleb!

In conclusion, if a submucosal hematoma develops because an injection is too superficial, performing deep ESD under traction after extending the margin under the red bleb facilitates endoscopic resection in this well-known, challenging situation.

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• References

• 1 Nanda KS, Sonson RJ, Bourke MJ. Intramucosal injection: part of the spectrum of outcomes from submucosal injection during endoscopic resection. Gastrointest Endosc 2014; 80: 733-735
• 2 Jacques J, Charissoux A, Legros R. et al. Double-clip counter-traction using a rubber band is a useful and adaptive tool for colonic endoscopic submucosal dissection. Endoscopy 2018; 50: 179-181
• 3 Jacques J, Charissoux A, Bordillon P. et al. High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 2019; 7: E1166-E1174