Advertisement

Endoclip-assisted giant colon lipoma resection

Open AccessPublished:February 12, 2019DOI:https://doi.org/10.1016/j.vgie.2018.12.012
      Not infrequently, endoscopists encounter colon lipomas during colonoscopy. These lipomas are usually small (<2 cm) and appear as yellowish, soft, submucosal nodules.
      • Crocetti D.
      • Sapienza P.
      • Sterpetti A.V.
      • et al.
      Surgery for symptomatic colon lipoma: a systematic review of the literature.
      Colon lipomas are 90% submucosal only, and in up to 10% of cases, muscularis propria or subserosal layers are involved.
      • Crocetti D.
      • Sapienza P.
      • Sterpetti A.V.
      • et al.
      Surgery for symptomatic colon lipoma: a systematic review of the literature.
      As lipomas grow in size, with intestinal peristalsis, they can become pedunculated or form a pedicle or stalk. The vast majority of lipomas are an incidental finding, and they do not cause any symptoms. Endoscopic removal is not indicated or necessary. Medium-to-large (2-4 cm) colon lipomas can potentially cause obstructive symptoms such as pain, bloating, constipation, postobstructive diarrhea, intussusception, or bleeding.
      • Crocetti D.
      • Sapienza P.
      • Sterpetti A.V.
      • et al.
      Surgery for symptomatic colon lipoma: a systematic review of the literature.
      According to a recent review, giant lipomas (>4 cm) are usually symptomatic.
      • Crocetti D.
      • Sapienza P.
      • Sterpetti A.V.
      • et al.
      Surgery for symptomatic colon lipoma: a systematic review of the literature.
      For symptomatic lipomas, endoscopic or surgical resection is needed.
      • Peters Jr., M.B.
      • Obermeyer R.J.
      • Ojeda H.F.
      • et al.
      Laparoscopic management of colonic lipomas: a case report and review of the literature.
      • Khawaja F.I.
      Pedunculated lipoma of the colon: risks of endoscopic removal.
      • Pfeil S.A.
      • Weaver M.G.
      • Abdul-Karim F.W.
      • et al.
      Colonic lipomas: outcome of endoscopic removal.
      • Kim C.Y.
      • Bandres D.
      • Tio T.L.
      • et al.
      Endoscopic removal of large colonic lipomas.
      • Raju G.S.
      • Gomez G.
      Endoloop ligation of a large colonic lipoma: a novel technique.
      • Ivekovic H.
      • Rustemovic N.
      • Brkic T.
      • et al.
      Endoscopic ligation (“loop-and-let-go”) is effective treatment for large colonic lipomas: a prospective validation study.
      • Sugimoto K.
      • Sato K.
      • Maekawa H.
      • et al.
      Unroofing technique for endoscopic resection of a large colonic lipoma.
      • Lee K.J.
      • Kim G.H.
      • Park D.Y.
      • et al.
      Endoscopic resection of gastrointestinal lipomas: a single-center experience.
      For large and giant pedunculated lipomas, the normal muscular propria layer of the colon surrounding the pedicle can be evaginated into the stalk, forming a pseudopedicle.
      • Khawaja F.I.
      Pedunculated lipoma of the colon: risks of endoscopic removal.
      • Pfeil S.A.
      • Weaver M.G.
      • Abdul-Karim F.W.
      • et al.
      Colonic lipomas: outcome of endoscopic removal.
      Endoscopic resection of these large and giant lipomas carries a perforation risk as high as 8%.
      • Crocetti D.
      • Sapienza P.
      • Sterpetti A.V.
      • et al.
      Surgery for symptomatic colon lipoma: a systematic review of the literature.
      • Pfeil S.A.
      • Weaver M.G.
      • Abdul-Karim F.W.
      • et al.
      Colonic lipomas: outcome of endoscopic removal.
      We report a case of symptomatic giant sigmoid colon lipoma (7-cm × 6-cm) that was successfully removed with endoclip-assisted dissection.
      A 62-year-old healthy woman experienced progressive lower abdominal cramps, constipation, and fecal urgency. A colonoscopy conducted elsewhere revealed a large colon submucosal mass in the distal sigmoid colon. She was referred to us for EUS and potential endoscopic resection. On EUS with use of a linear probe, a >6 cm well-defined, submucosal, soft mass was seen, and it caused nearly total luminal obstruction (Fig. 1). The echo textures were homogenous and hyperechoic, typical of a lipoma.
      Figure thumbnail gr1
      Figure 1Endoscopic image of the 7-cm × 6-cm lipoma causing near total obstruction.
      The patient consented to endoscopic removal before the procedure. A double-channel therapeutic gastroscope (GIF-2TH180, Olympus, Tokyo, Japan) was used for resection. Considering the size of the lipoma, the thick stalk (Fig. 2), and the possibility of a pseudopedicle in the stalk, we decided to proceed with endoclip-assisted, stepwise, pedicle dissection to remove the lipoma. The traditional “loop then snare resection” approach was not considered because of the giant size of the lipoma.
      Figure thumbnail gr2
      Figure 2Endoscopic image of the thick lipoma stalk (arrows).
      We chose clips with a 16-mm opening arm span (Instinct clips; Cook Medical, Winston-Salem, NC, USA) for maximal stalk ligation (Fig. 3). We used an endoscopic needle-knife (Huibregtse needle-knife, HPC-2; Cook Medical), and the stalk distal to the placed endoclips was partially dissected (Fig. 4). With endoscopic needle injection of diluted epinephrine (1:10,000) proximal to the placed endoclips and additional sequential clip placement, the stalk was completely dissected. A total of 4 endoclips were placed at the resection base to close the base and to stop some mild oozing at the base (Fig. 5). In addition, argon plasma coagulation (ERBE USA, Marietta, Ga, USA) was applied at the base at certain spots suspected of mild oozing.
      Figure thumbnail gr3
      Figure 3Two endoclips are placed to partially ligate the stalk before needle-knife dissection.
      Figure thumbnail gr4
      Figure 4Sequential clipping and dissection of the stalk.
      Figure thumbnail gr5
      Figure 5Endoclips placed on the resection base of the lipoma.
      The freed lipoma descended to the anal outlet (Fig. 6) and spontaneously expulsed externally with the passing of gas (Fig. 7). On ex vivo evaluation, the lipoma measured 7.1 cm × 5.6 cm × 4.2 cm. The patient was discharged home after the procedure. She did not report bleeding, fever, or pain during the follow-up period except for mild left-lower quadrant discomfort that lasted about 10 hours. All of her obstructive GI symptoms resolved the day after endoscopic resection.
      Figure thumbnail gr6
      Figure 6The resected lipoma obstructing the anal canal.
      Figure thumbnail gr7
      Figure 7Resected lipoma: 7.1 cm × 5.6 cm × 4.2 cm on ex vivo evaluation.
      We propose that endoclip-assisted, stepwise stalk dissection is a viable and safe option in patients with symptomatic medium-to-large (2-4 cm) and giant (>4 cm) colon lipomas. Endoclip ligation aims to prevent intraoperative and postprocedural bleeding and minimizes the risk of perforation due to dissection, especially with the possibility of underlying pseudopedicle. We used an endoscopic needle-knife for dissection because we did not have endoscopic submucosal dissection (ESD) devices readily available. It is probably easier to use an ESD device for dissection, such as a hook knife or an insulated tip knife (Video 1, available online at www.VideoGIE.org).

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

      Supplementary data

      References

        • Crocetti D.
        • Sapienza P.
        • Sterpetti A.V.
        • et al.
        Surgery for symptomatic colon lipoma: a systematic review of the literature.
        Anticancer Res. 2014; 34: 6271-6276
        • Peters Jr., M.B.
        • Obermeyer R.J.
        • Ojeda H.F.
        • et al.
        Laparoscopic management of colonic lipomas: a case report and review of the literature.
        JSLS. 2005; 9: 342-344
        • Khawaja F.I.
        Pedunculated lipoma of the colon: risks of endoscopic removal.
        South Med J. 1987; 80: 1176-1179
        • Pfeil S.A.
        • Weaver M.G.
        • Abdul-Karim F.W.
        • et al.
        Colonic lipomas: outcome of endoscopic removal.
        Gastrointest Endosc. 1990; 36: 435-438
        • Kim C.Y.
        • Bandres D.
        • Tio T.L.
        • et al.
        Endoscopic removal of large colonic lipomas.
        Gastrointest Endosc. 2002; 55: 929-931
        • Raju G.S.
        • Gomez G.
        Endoloop ligation of a large colonic lipoma: a novel technique.
        Gastrointest Endosc. 2005; 62: 988-990
        • Ivekovic H.
        • Rustemovic N.
        • Brkic T.
        • et al.
        Endoscopic ligation (“loop-and-let-go”) is effective treatment for large colonic lipomas: a prospective validation study.
        BMC Gastroenterol. 2014; 14: 122
        • Sugimoto K.
        • Sato K.
        • Maekawa H.
        • et al.
        Unroofing technique for endoscopic resection of a large colonic lipoma.
        Case Rep Gastroenterol. 2012; 6: 557-562
        • Lee K.J.
        • Kim G.H.
        • Park D.Y.
        • et al.
        Endoscopic resection of gastrointestinal lipomas: a single-center experience.
        Surg Endosc. 2014; 28: 185-192