A Comparison of Eleview Versus Hetastarch as Injectate for EMR
A Comparison of Eleview Versus Hetastarch as Injectate for EMR
EMR is a technique used for the removal of flat or sessile neoplasms confined to the
 superficial layers of the GI tract using a snare. Injection-assisted EMR is commonly used
 during resections of larger flat lesions as it provides submucosal lift of polyps, adenomas,
 other gastrointestinal mucosal lesions or early-stage cancers prior to EMR. This has been
 found to minimize mechanical or electrocautery damage to the deep layers of the
 gastrointestinal tract wall as the injectate provides a "safety cushion" as such between the
 area to be removed and healthy mucosal tissue.

 Several solutions are used today for injecting lesions including saline, hyaluronic acid, and
 hydroxyethyl starch (Hetastarch). Saline solution has been found to dissipate within minutes,
 which may result in a lower quality lesion lift. Hyaluronic acid provides a longer lift, but
 is expensive and is not readily available in the U.S.

 A new injectate known as Eleview has been developed for use in gastrointestinal endoscopic
 procedures and recently approved by the FDA. This injectate boasts a cushion of excellent
 height and duration through the use of an oil-in-water emulsion. However, the initial cost of
 this material is quite high ($80 per 10 ml).

 Hetastarch, which is the current injectate used by Dr Rex, is a safe and considerably
 inexpensive solution that provides prolonged submucosal elevation and lowers procedure times.
 Our study will aim to compare Eleview to Hetastarch in the hopes of finding the ideal
 submucosal injectate.

 This trial will focus on polyps of size ≥11 mm removed by snare EMR technique. Patients with
 lesions deemed not suitable for EMR due to features suggestive of sub-mucosal invasion will
 not be included.
Injectate randomization:

 Study patients will be randomly assigned to the Eleview or the Hetastarch treatment group in
 a 1:1 ratio. Randomization will occur at the site using envelopes provided by the
 Investigator. The envelope's contents will specify the treatment assignment for each patient
 and opened by the research team (PI will be blinded). The investigators will monitor the
 safety and effectiveness data. The appropriate solutions will be injected into the submucosal
 space beneath the lesion(s) to be excised before the lesion(s) is/are removed. Subjects in
 both groups will receive the appropriate volume of injectate deemed necessary by the PI for
 the individual patient.

 Sample size and Statistical Analysis At least 200 patients will be enrolled. 100 of these
 patients will be randomized to Eleview injectate and 100 will be given the standard of care,
 Hetastarch injectate only. Efficacy and safety of Eleview injectate has only been reviewed in
 one previous study. Therefore, the planned sample size was not calculated using a statistical
 power analysis, but was regarded as sufficient to repeat the objectives of the COSMO study
 (2017) and satisfy the exploratory purposes of the present study.

 Study personnel will carry out a simple randomization using a commonly used online generator.
 Randomization assignments will then be sealed until day of procedure until patient
 eligibility has been confirmed. The Principal Investigator will remain blinded and will
 perform all data analysis after completion of the study.

 Data will be summarized and compared using classic descriptive statistics, i.e. mean,
 standard deviation, coefficient of variation (%), minimum, median and maximum values for
 quantitative variables, and frequencies for qualitative variables.

 The Sydney Resection Quotient will be compared between treatment groups using a Wilcoxon
 Rank-Sum test. The proportion of subjects with en bloc resection of all endoscopically
 visible lesions will also be compared between treatment groups using a Fisher's exact test. A
 nominal alpha level of 0.05 will be used for both the comparisons.

 No formal comparison will be performed for the secondary endpoints.
Inclusion Criteria:

 1. Sex and age: men and women > 18 years old

 2. Subjects referred for EMR of polyps of size ≥11 mm

 3. ASA score 1, 2 or 3.

 4. Contraception: Women of childbearing potential must have a negative pregnancy test
 (one is provided as the standard of care) or sign a waiver. Post-menopausal women must
 have been in that status for at least 1 year (per standard of care).

 5. Subject is willing and able to participate in the study procedures and to understand
 and sign the informed consent

 Exclusion Criteria:

 1. Age: Subjects is under 18 years old

 2. Consent: Vulnerable subjects including those who are unable to consent

 3. Pregnancy: Pregnant or breastfeeding women

 4. ASA score <3

 5. Physical findings: Abnormal physical findings that may interfere with the study
 objectives

 6. Study participation: Subjects currently participating in another clinical study or
 previously enrolled in another clinical study in the last 30 days

 7. Excluded lesions:

 -  Lesions less than 11 mm in largest dimension

 -  Lesions involving the muscularis propria (T2 lesions)

 -  Ulcerated depressed lesions (Paris type III) or pathology proven invasive
 carcinoma

 -  Proven malignant disease locally advanced or with metastasis

 -  Active inflammatory bowel disease lesion, e.g ulcerative colitis, Crohn's disease

 -  Endoscopic appearance of invasive malignancy

 8. Previous partial resection or attempted resection of the lesion

 9. Allergy: Proven or potential allergic reaction to study products or history of
 anaphylaxis to drugs

 10. Severe liver disease.

 11. Known or suspected gastrointestinal obstruction or perforation, active diverticulitis,
 toxic megacolon,

 12. Inflammatory bowel disease e.g ulcerative colitis or Crohn's disease

 13. Hemostasis disorders (eg Von Willebrand disease, factor V Leiden thrombophilia or
 haemophilia), known clotting disorder (INR>1.5).

 14. Subject with any other current serious medical conditions that would increase the
 risks associated with taking part in the study.

 15. Patients must be advised to stop anticoagulation medications prior to the procedure
 per local practice guidelines and should re-start as clinically indicated after the
 procedure.