Dilute epinephrine and commercially available viscous submucosal lifting agent for duodenal cold EMR. Cold EMR is gaining popularity, particularly for duodenal resection of duodenal adenoma. One challenge of cold EMR in the duodenum is bleeding or oozing, which can impair field visibility and the ability to perform resection. Combining dilute epinephrine and lifting agents such as saline, methylene blue, or hexastarch has been described in the past for improving visualization. However, epinephrine use with viscous agents has not been previously described. Some of the benefits of dilute epinephrine and a viscous lifting agent mixture include decreased oozing or bleeding during the procedure, which can in turn improve visualization and potentially resection, as well as providing a prolonged lift duration. A 72-year-old man was referred for management of a duodenal adenoma. A mixture of epinephrine and a commercially available lifting agent was prepared in order to perform cold snare resection of the lesion while achieving hemostasis. Here you can see an endoscopic view of the duodenal adenoma prior to lifting and resection. The mixture of the lifting agent and the epinephrine was prepared as follows. Here you can see the required initial supplies, which include 10 cc's of normal saline, one milligram epinephrine per 10 cc syringe, and a commercially available lifting agent. A 25 gauge needle is attached to the epinephrine syringe. One cc from the normal saline syringe is emptied, allowing room for the epinephrine. Then one cc of epinephrine is added to the saline syringe to make a dilute concentration of 1 to 10,000. One cc from the lifting agent syringe is emptied to allow room for the dilute epinephrine solution. Here you can see the epinephrine is being added to the commercially available lifting agent. Once the solution is combined into the 10 cc syringe, we recommend using a three-way stopcock as shown here to allow the solution to be evenly mixed. Here you can see a portion of the duodenal adenoma being lifted using the agent and an additional area of lifting is applied. A final inspection of the lesion is performed prior to resection. The lesion is then subsequently resected using piecemeal cold EMR. You can note here despite the duodenum being very vascular there's minimal bleeding likely due to the epinephrine in the lifting agent. Here you can see the area of defect is inspected using water immersion and there's no areas of residual adenoma or bleeding. In conclusion epinephrine can be safely added to commercially available lifting agents to prepare a solution which can provide lesional lifting and prevention of bleeding. Supplies needed to do this are usually readily available in most endoscopy units and preparation is simple. This technique can also be applied to other areas where you need a clean visual field and adequate lift such as ESD or colonic EMR.

duodenal cold EMR

dilute epinephrine

viscous lifting agent

bleeding

visualization