A novel submucosal injection material comprising a fully synthetic and self-assembling peptide solution for endoscopic resection of large colorectal laterally spreading tumors

An injection solution is required to create a submucosal cushion to allow safe endoscopic resection [1] [2]. The fully synthetic and self-assembling peptide solution submucosal injection material (PuraLift; 3-D Matrix, Tokyo, Japan) is a non-biologic preparation that self-assembles to create a gel formed of nanofibers when in contact with a neutral pH [3]. It has the same ingredients as the peptide hemostatic agent (PuraStat; 3-D Matrix) [4]. Here we report the first two cases of the use of PuraLift ([Video 1]).

Video 1 Endoscopic submucosal dissection of colorectal laterally spreading tumors using PuraLift as the submucosal injection material.

Case 1: A 74-year-old woman with a 35-mm laterally spreading tumor (LST) located in the lower rectum ([Fig. 1 a]). We diagnosed the lesion as an intramucosal adenocarcinoma (Tis) and performed endoscopic submucosal dissection (ESD) using PuraLift as a submucosal injection agent without any coloring or mixing. The ESD procedure was performed with a colonoscope (PCF-290TI; Olympus, Tokyo, Japan) with an endoscopic cap, a needle-type knife (DualKnife J; Olympus), and a 25G injection needle (Super Grip; Top Co, Kumamoto, Japan). En bloc resection of a 40 × 30-mm specimen was achieved in 35 min without any adverse events ([Fig. 1 b, c, d, e]). Overall, 20 mL of PuraLift was injected. The histological diagnosis was Tis with curative resection. Follow-up colonoscopy was performed 1 month after ESD, showing almost complete healing of artificial ulcers ([Fig. 1 f]).

Fig. 1 Endoscopic images showing a lateral spreading tumor in the lower rectum. a Chromoendoscopy using indigo carmine. b PuraLift was injected into the submucosal layer, and good lifting was achieved. c Mucosal incision. d Large mucosal defect. e The resected specimen. f Follow-up endoscopy 1 month after endoscopic submucosal dissection.

Case 2: A 60-year-old woman with a 60-mm LST located in the transverse colon ([Fig. 2 a]). We diagnosed the lesion as Tis and performed ESD under the same conditions as Case 1. En bloc resection of a 70 × 40-mm specimen was achieved in 130 min, without any delayed adverse events ([Fig. 2 b–f]). Overall, 75 mL of PuraLift was injected. The histological diagnosis was Tis with curative resection.

Fig. 2 Endoscopic images showing a lateral spreading tumor in the transverse colon. a Chromoendoscopy using indigo carmine. b PuraLift was injected into the submucosal layer, and good lifting was achieved. c Mucosal incision. d Submucosal dissection. e Large mucosal defect. f The resected specimen.

This new submucosal injection material was safe and feasible for ESD on large LSTs.

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• References

• 1 Uraoka T, Saito Y, Yamamoto K. et al. Submucosal injection solution for gastrointestinal tract endoscopic mucosal resection and endoscopic submucosal dissection. Drug Des Devel Ther 2009; 2: 131-138
• 2 Jung YS, Park DI. Submucosal injection solutions for endoscopic mucosal resection and endoscopic submucosal dissection of gastrointestinal neoplasms. Gastrointest Interv 2013; 2: 73-77
• 3 Nakata K, Pioche M, Kuribayashi S. et al. The feasibility of a fully synthetic and self-assembled peptide solution as submucosal injection material: a preliminary animal study. Scand J Gastroenterol 2021; 56: 984-989
• 4 Uraoka T, Uedo N, Oyama T. et al. Efficacy and safety of a novel hemostatic peptide solution during endoscopic submucosal dissection: a multicenter randomized controlled trial. Am J Gastroenterol 2023; 118: 276-283