title: Solutions for submucosal injection in endoscopic resection: a systematic review and meta-analysis.
abstract: OBJECTIVE
  Submucosal injection is standard practice in endoscopic mucosal resection of gastrointestinal lesions. Several solutions are used. Our aim was to systematically review their efficacy and safety.
  
  
  METHODS
  We performed a systematic review and meta-analysis using a random effects model of randomized controlled trials (RCTs) from MEDLINE. Studies in animal models were qualitatively assessed for efficacy and safety.
  
  
  RESULTS
  In total, 54 studies were qualitatively assessed. Eleven RCTs were analyzed, two of which were on endoscopic submucosal dissection (ESD). The quantitative synthesis included nine RCTs on endoscopic mucosal resection (EMR), comprising 792 subjects and 793 lesions. Mean lesion size was 20.9 mm (range 8.5 - 46 mm). A total of 209 lesions were randomized to sodium hyaluronate (SH) vs normal saline (NS), 72 to 50 % dextrose (D50) vs NS, 82 to D50 vs SH, 43 to succinylated gelatin, 25 to hydroxyethyl starch and 36 to fibrinogen. In total, 385 were randomized to NS as controls. NS and SH are the best studied solutions and seem to be equally effective in achieving complete resection (OR 1.09; 95 %CI 0.82, 1.45). No solution was proven to be superior in complete resection rate, post-polypectomy bleeding or coagulation syndrome/perforation incidence. Many solutions have been tested in animal studies and most seem more effective for mucosal elevation than NS.
  
  
  CONCLUSIONS
  There are several solutions in clinical use and many more under research, but most are poorly studied. SH seems to be clinically equivalent to NS. There are no significant differences in post-polypectomy complications. Larger RCTs are needed to determine any small differences that may exist between solutions.
authors.affiliation: Department of Gastroenterology, Hospital Beatriz Ângelo, Lisboa, Portugal.
authors.forename: Alexandre Oliveira
authors.initials: AO
authors.lastname: Ferreira
authors.affiliation: Department of Gastroenterology, Instituto Português do Oncologia de Lisboa, Lisboa, Portugal.
authors.forename: Joana
authors.initials: J
authors.lastname: Moleiro
authors.affiliation: Department of Gastroenterology, Hospital Beatriz Ângelo, Lisboa, Portugal.
authors.forename: Joana
authors.initials: J
authors.lastname: Torres
authors.affiliation: Department of Gastroenterology, Instituto Português do Oncologia do Porto, Porto, Portugal; CIDES/CINTESIS, Faculty of Medicine - University of Porto, Porto, Portugal.
authors.forename: Mario
authors.initials: M
authors.lastname: Dinis-Ribeiro