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Acetic acid spray for better delineation of recurrent sessile serrated adenoma in the colon

Open AccessPublished:August 30, 2019DOI:https://doi.org/10.1016/j.vgie.2019.08.001

      Abbreviations:

      BLI (blue-light imaging), LED (light-emitting diode), SSL (sessile serrated lesion), WLI (white-light imaging)
      Sessile serrated lesions (SSLs) have a high risk of incomplete endoscopic resection.
      • Pohl H.
      • Srivastava A.
      • Bensen S.P.
      • et al.
      Incomplete polyp resection during colonoscopy: results of the complete adenoma resection (CARE) study.
      The benefit of using acetic acid spray has been reported for SSLs in the colon.
      • Yamamoto S.
      • Shafazand M.
      Acetic acid-indigocarmine mixture for evaluating the margins of sessile serrated adenomas/polyps.
      • Popoutchi P.
      • Mota F.L.
      • Averbach M.
      • et al.
      Acetic acid spray contribution in the endoscopic diagnosis of serrated polyposis syndrome.
      Our previous experience has demonstrated that acetic acid spray, along with indigo carmine, is of substantial benefit for the delineation of SSLs.
      • Yamamoto S.
      • Shafazand M.
      Acetic acid-indigocarmine mixture for evaluating the margins of sessile serrated adenomas/polyps.
      Similarly, the use of acetic acid for a single case of sessile serrated polyposis syndrome was reported and showed clinical usefulness.
      • Popoutchi P.
      • Mota F.L.
      • Averbach M.
      • et al.
      Acetic acid spray contribution in the endoscopic diagnosis of serrated polyposis syndrome.
      SSL is difficult to detect because of its flat morphology and the resemblance of its color to the surrounding normal mucosa. In clinical practice, delineation of recurrent SSLs can sometimes be challenging because of coexisting scar tissue.
      Recently, a new endoscopy system called Eluxeo (Fujifilm Co, Tokyo, Japan) has been developed. The system provides 3 observation modes by generating variable light-emitting diode (LED) light intensity, including blue-light imaging (BLI). BLI consists of short wavelength absorption of hemoglobin (410 nm) combined with white-light spectral colors. BLI can be activated by pressing a button on the endoscope.
      • Rondonotti E.
      • Paggi S.
      • Amato A.
      • et al.
      Blue-light imaging compared with high-definition white light for real-time histology prediction of colorectal polyps less than 1 centimeter: a prospective randomized study.
      The benefits of BLI in assessing colonic polyps has been reported.
      • Bisschops R.
      • Hassan C.
      • Bhandari P.
      • et al.
      BASIC (BLI Adenoma Serrated International Classification) classification for colorectal polyp characterization with blue light imaging.
      To our knowledge, the use of acetic acid for recurrent SSLs has not been presented before now. We hereby describe the first experience of acetic acid and Eluxeo in a case of recurrent SSL (Video 1, available online at www.VideoGIE.org).
      Colonoscopy with a magnifying function and BLI (EC-760ZP-VM; Fujifilm Co) was used. The acetic acid (5%) was diluted in lukewarm water to derive a solution with a concentration of 1.7%. The solution was sprayed directly through the working channel of the endoscope onto the suggestive lesions without the use of a spray catheter. In 10 to 15 seconds, the aceto-whitening reaction began. Thereafter the polyps were assessed with white-light imaging (WLI) and BLI and were characterized before removal of the endoscope.
      An 80-year-old man with a history of 2 polypectomies was referred to us. We performed follow-up colonoscopy 3 years after the last procedure. In the cecum, a polypoid lesion with a diameter of 8 mm was found on a scarred surface where the previous polypectomy was performed. The margin of the lesion was unclear (Figs. 1 and 2). We performed chromoendoscopy using acetic acid (Figs. 3 and 4). With magnification, the surface structure and the delineation became clearer, and the polyp was assessed as a recurrent SSL. It was resected en bloc by EMR (Fig. 5). The use of acetic acid in a concentration <2% was safe, and no adverse events were recorded.
      Figure thumbnail gr1
      Figure 1Polypoid lesion 10 mm in diameter on the scarlike area.
      Figure thumbnail gr2
      Figure 2Observation with blue-light imaging.
      Figure thumbnail gr3
      Figure 3Observation with 1.7% acetic acid in combination with white-light imaging.
      Figure thumbnail gr4
      Figure 4Observation with 1.7% acetic acid in combination with blue-light imaging.
      Acetic acid induces a temporary chemical change to the surface called aceto-whitening reaction. The difference in the reaction helps to differentiate between normal and neoplastic mucosa.
      • Shibagaki K.
      • Amano Y.
      • Ishimura N.
      • et al.
      Magnification endoscopy with acetic acid enhancement and a narrow-band imaging system for pit pattern diagnosis of colorectal neoplasms.
      • Wiessner J.R.
      • Brown H.
      • Haller B.
      • et al.
      Near focus NBI endoscopy plus acetic acid for optical polyp characterization in the colorectum: a proof of principle study.
      Compared with WLI, BLI provides enhanced imaging of superficial structures and vessels because of its intensive light emission.
      • Rondonotti E.
      • Paggi S.
      • Amato A.
      • et al.
      Blue-light imaging compared with high-definition white light for real-time histology prediction of colorectal polyps less than 1 centimeter: a prospective randomized study.
      This may result in better delineation of colonic polyps, including SSLs, similar to narrow-band imaging.
      • Wiessner J.R.
      • Brown H.
      • Haller B.
      • et al.
      Near focus NBI endoscopy plus acetic acid for optical polyp characterization in the colorectum: a proof of principle study.
      The ability of acetic acid to remove adherent mucus may contribute to the clearer views with BLI and acetic acid compared with BLI alone.
      • Shibagaki K.
      • Amano Y.
      • Ishimura N.
      • et al.
      Magnification endoscopy with acetic acid enhancement and a narrow-band imaging system for pit pattern diagnosis of colorectal neoplasms.
      The optical absorption property of the epithelial cells can be altered by acetic acid, and for that reason, BLI may potentially reveal white areas as more whitish than does WLI, which can contribute to better delineation of the lesion by BLI and acetic acid compared with WLI and acetic acid. Because it is not cumbersome to switch to BLI, the use of acetic acid in combination with BLI could be an excellent method to improve the visualization of recurrent SSLs and thereby increase the possibility of performing complete endoscopic resections.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

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