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Bite-on-bite technique for removal of a gastric subepithelial lipoma

Open AccessPublished:February 04, 2019DOI:https://doi.org/10.1016/j.vgie.2018.12.006
      A 55-year-old man with no relevant medical history underwent EGD for the evaluation of dysphagia. A submucosal nodule was found in the gastric antrum, and he was referred to our center for further evaluation and treatment. EGD at our facility found a 1-cm subepithelial lesion in the gastric antrum (Fig. 1). The mucosa overlying the lesion appeared normal, with a "yellowish" hue; the remainder of the stomach and duodenum appeared normal.
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      Figure 11-cm subepithelial lesion in the gastric antrum.
      On EUS, a 7.1- × 1.5-mm isoechoic oval lesion was seen arising from the third layer of the gastric wall in the gastric antrum (Fig. 2). The lesion was thought to be too small for FNA; however, given that the lesion was isoechoic, tissue sampling was warranted to determine the etiology. No perigastric or subhepatic lymph nodes were seen.
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      Figure 2EUS view of 1-cm subepithelial lesion in the gastric antrum, arising from third layer of gastric wall.
      After EUS, the gastroscope was again advanced into the stomach. Using a "bite-on-bite" technique with a standard biopsy forceps, we systematically unroofed the underlying submucosal lesion with repeated forceps bites (Fig. 3). The bites were taken sequentially in the same spot, rather than randomly over the nodule, to properly expose the lesion. The appearance was consistent with a lipoma with glistening fat and a capsule. Using the biopsy forceps to grasp the lesion with avulsion, we peeled the lesion off the gastric wall (Fig. 4). Mild bleeding was controlled with 3 hemoclips (Fig. 5). Final histopathologic analysis confirmed a lipoma (Fig. 6).
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      Figure 3Removal of the overlying epithelial layer with biopsy forceps.
      Figure thumbnail gr4
      Figure 4Use of avulsion to peel the lipoma off the gastric wall.
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      Figure 5Hemostasis achieved with 3 hemoclips.
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      Figure 6Histopathologic view demonstrating a lipoma (H&E, orig. mag. ×100).
      Gastric subepithelial lesions are frequently found incidentally on routine endoscopy.
      • Faulx A.L.
      • Kothari S.
      • Acosta R.D.
      • et al.
      The role of endoscopy in subepithelial lesions of the GI tract.
      They are most commonly benign and asymptomatic, but they often require an assessment and tissue diagnosis to rule out malignant or premalignant diagnoses and to address symptomatic lesions.
      • Polkowski M.
      Endoscopic ultrasound and endoscopic ultrasound-guided fine-needle biopsy for the diagnosis of malignant submucosal tumors.
      Owing to the depth of subepithelial lesions, they can be more challenging to accurately diagnose and safely remove than superficial lesions in the mucosa. As a result, a variety of endoscopic techniques have been described for evaluation and resection of these lesions.
      • Faulx A.L.
      • Kothari S.
      • Acosta R.D.
      • et al.
      The role of endoscopy in subepithelial lesions of the GI tract.
      The bite-on-bite technique of taking sequential stacked biopsy specimens to reach deeper into subepithelial lesions typically has been described as a diagnostic modality.
      • Ji J.S.
      • Lee B.I.
      • Choi K.Y.
      • et al.
      Diagnostic yield of tissue sampling using a bite-on-bite technique for incidental subepithelial lesions.
      However, in this video (Video 1, available online at www.VideoGIE.org), we demonstrate the bite-on-bite technique for safely removing a subepithelial lesion. Although this video specifically shows the removal of a lipoma, this technique could be applied to other small subepithelial lesions, like ectopic pancreas or neuroendocrine tumors, that do not involve the muscularis propria. The most common adverse event associated with this technique is mild bleeding, and major adverse events such as perforation are exceedingly rare.
      There are many endoscopic techniques for the removal of gastric subepithelial lesions, including endoscopic submucosal resection, endoscopic submucosal dissection, and submucosal tunneling, among others.
      • Faulx A.L.
      • Kothari S.
      • Acosta R.D.
      • et al.
      The role of endoscopy in subepithelial lesions of the GI tract.
      Although these techniques have advantages over the bite-on-bite technique, they typically require advanced endoscopic training and specialized equipment.
      • Faulx A.L.
      • Kothari S.
      • Acosta R.D.
      • et al.
      The role of endoscopy in subepithelial lesions of the GI tract.
      The major advantage of the bite-on-bite technique is that it can be performed by general gastroenterologists and requires no special equipment.
      In summary, the bite-on-bite technique is a safe method for the evaluation and potential removal of small gastric subepithelial lesions by the use of standard equipment, without the need for advanced endoscopic training. When this technique is used, subsequent referrals for EUS can potentially be avoided.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      References

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