This article is more than 5 years old. Information may no longer be current.
Eleview superior to hetastarch in colorectal endoscopic mucosal resections
Eleview, a viscous solution that provides cushion during endoscopic mucosal resection, was superior to hetastarch, according to study results published in Gastrointestinal Endoscopy.
Douglas K. Rex, MD, director of endoscopy at Indiana University Hospital, and colleagues wrote that they have generally used hetastarch over Eleview (SIC-8000, Aries Pharmaceuticals) for cost reasons.
“Hetastarch has been widely used as a submucosal injection agent. Eleview was the first FDA approved agent but is expensive,” Rex told Healio Gastroenterology and Liver Disease. “We sought to investigate whether one of the agents is superior.”
The study included 158 patients who were referred to a tertiary center with flat or sessile lesions at least 15 mm in size. They underwent endoscopic mucosal resection with either Eleview or hetastarch, and the primary outcomes were the Sydney Resection Quotient (SRQ) — defined as the size of the polyp in millimeters divided by the number of pieces resected — and the rate of en bloc resection.
For total adenomas, researchers used Eleview on 84 and hetastarch on 75. In 57 serrated lesions, they used Eleview on 30 and hetastarch on 27.
Rex and colleagues found that the Eleview group had better SRQ scores compared with the hetastarch group (9.3 vs. 8.1; P = .001). However, there was no difference in the proportion of lesions with en bloc resections.
Researchers also found Eleview required less volume of solution during resection compared with hetastarch (14.8 mL vs. 20.6 mL; P = .038).
“Currently the cost differences between SIC-8000 and hetastarch are reduced because both indigo carmine and methylene blue have become more expensive,” Rex and colleagues wrote. “Because one of these agents is typically added to hetastarch before injection, the cost of those agents is added to the cost of hetastarch. In contrast, SIC-8000 comes from the manufacturer with methylene blue added.” – by Alex Young
Disclosures: Rex reports serving as a consultant for Aries Pharmaceuticals.
Perspective
Back to Top
One of the important developments for endoscopic resection in the last several years has been the broadening use of viscous solutions for submucosal injection.
Recently, two proprietary, pre-mixed submucosal injection solutions have become available in the U.S., Eleview (SIC-8000, Cosmo Pharmaceuticals), and ORISE (Boston Scientific). Viscous solutions create a submucosal cushion that lasts for a longer duration, and there is a fair amount of evidence that use of these solutions is associated with higher en-bloc resection rates than using saline as the lifting agent.
The proprietary viscous solutions offer the major advantage of convenience, as they are pre-mixed and usable right out of the package. Additionally, methylene blue has increased in price recently, making the proprietary viscous solutions increasingly cost competitive compared with ‘home-made’ solutions mixing normal saline (or hetastarch) and methylene blue.
However, there are relatively few published data regarding the proprietary solutions, so this recent article by Rex and colleagues regarding SIC-8000 (Eleview) is an important contribution. In this double-blinded, randomized trial the investigators compared polyp resection outcomes when using SIC-8000 vs. a hetastarch solution (with methylene blue). Flat or sessile adenomas 15 mm or larger were included. The primary endpoint was the Sydney Resection Quotient, and the secondary endpoint was en-bloc resection of lesions.
The investigators found that SRQ was higher in the SIC-8000 group (9.3 vs. 8.1) while there was no difference in en-bloc resection.
This study is further confirmation that SIC-8000 is a viable choice for a viscous solution, but I am not convinced that the slightly higher SRQ compared with hetastarch is clinically meaningful. For the time being, endoscopists performing endoscopic resection can reasonably choose between several options for viscous solutions based on factors including convenience, availability and cost. Additionally, it’s worth noting that while normal saline remains the most commonly used submucosal injection solution in clinical practice, the weight of evidence is really pointing toward choosing viscous solutions, particularly for larger polyps that are on the edge of en-bloc resectability, and for polyps requiring piecemeal EMR (or ESD) approaches.