Hypertonic Solution As an Optimal Submucosal Injection Solution for Endoscopic Resection of Gastrointestinal Mucosal Lesions: Systematic Review and Network Meta-Analysis

Objectives Based on different physicochemical properties, common submucosal injection solutions could be classified into three categories: normal saline solution (NS), hypertonic solution (HS), and viscous solution (VS). We compared the efficacy and safety of various categories of solutions in this network meta‐analysis of randomized controlled trials (RCTs) to identify the optimal submucosal injection fluid. Methods PubMed, Embase, Web of Science, and the Cochrane Library were searched for RCTs that compared the efficacy and safety of NS, HS, and VS during endoscopic resection for gastrointestinal (GI) mucosal lesions. Pairwise and network analyses were conducted to determine the ranking of different fluids. Results Thirteen RCTs were included in the final analysis with 1637 patients (1639 lesions). HS outperformed NS in rates of en bloc (pooled relative risk [RR] 1.50; 95% confidence interval [CI] 1.10–1.90), overall bleeding (pooled odds ratio [OR] 0.33; 95% CI 0.10–0.88; lesions >10 mm OR 4.65 × 10 −2 ; 95% CI 1.10 × 10 −3 –0.46), and intraoperative bleeding (lesions >10 mm OR 7.10 × 10 −6 ; 95% CI 4.30 × 10 −18 –0.26). HS showed the highest probability of ranking first in each outcome except for the volume of injection. Although VS was superior to NS in rates of en bloc, overall, and intraoperative bleeding in the lesions >10 mm subgroup, and required less fluid in pooled analysis, it ranked last in cost of submucosal injection solution. Conclusions Both HS and VS were superior to NS in comparisons of efficacy and safety. Considering the better performance and potentially low cost, HS might be an optimal choice during gastrointestinal endoscopic resection, especially for colorectal endoscopic mucosal resection.