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VIDEO CASE REPORT
Endoscopic submucosal dissection and submucosal tunneling
endoscopic resection for obstructive lipomas of the foregut and
hindgut
Georgios Mavrogenis, MD,
1
Fateh Bazerbachi, MD,
2
Ioannis Tsevgas, MD,
3
Dimitrios Zachariadis, MD
3
GI lipomas are rare, benign, submucosal tumors
that are usually asymptomatic. The most common loca-
tion for these lesions is the colon (64%), whereas
duodenal lipomas account for only 4% of GI lipomas.
1
Large lipomas (>2-4 cm) may cause symptoms
such as bleeding, abdominal pain, obstruction, or
intussusception.
1-16
They typically present as a smooth,
slightly yellow, rounded polyp, with a stalk or a broad-
based attachment. Diagnosis can be confirmed by EUS,
CT scan, or magnetic resonance imaging. There is no
standardized treatment for symptomatic lipomas, and
both surgical
16
and endoscopic approaches have been
described,
1-15
depending on the size and location of
the lesion and on the availability of advanced endoscopic
techniques.
Lipomas with a long and thin stalk are suitable for
snare resection. For larger lesions, snare resection should
be performed with caution because the adipose tissue
is an inefficient conductor of electric current, and pro-
longed cutting may lead to perforation.
3
Amore
conservative approach is the unroofing technique,
3
which consists of opening the superior half of the
lipoma with a snare. Then it is possible to either leave
the contents exposed or remove the adipose tissue
with a snare or biopsy forceps. This technique is safe
and easy; however, it may fail in cases with a large or
long stalk
3
and has a high rate of recurrence.
2
Lately,
there is a trend to remove lipomas by placing a
detachable loop at their base.
2,4,5
This technique leads
to ischemia and shedding of the tumor a few days later.
Application of the “loop and let go technique”eliminates
the risk of perforation or bleeding. For lipomas with a
broad base, where the placement of an endoloop is not
feasible, a variety of endoscopic submucosal dissection
(ESD)-derived techniques can be applied, such as circum-
ferential incision and placement of an endoloop,
6
standard ESD,
7-12
or submucosal tunneling endoscopic
resection (STER).
13-15,17
The main advantage of STER
compared with ESD is that the site of resection is covered
by intact overlying mucosa; thus, in case of muscular
damage or perforation, the site of the resection is sealed.
However, the application of STER has been described for
sessile lesions <3 to 4 cm, located in the esophagus,
gastric body, and antrum. There is only 1 published
report of STER in the duodenum for a small submucosal
tumor.
14
In this video production (Video 1,available
Figure 1. Submucosal mass of the antrum obstructing the passage
toward the bulb in Patient 1.
Figure 2. The lesion was mobile and moved between the bulb and the
antrum in Patient 1.
226 VIDEOGIE Volume 4, No. 5 : 2019 www.VideoGIE.org
online at www.VideoGIE.org), we present step by step
resection of an obstructive duodenal and colonic
lipoma by means of STER and ESD, respectively.
PATIENT 1: STER FOR DUODENAL LIPOMA
A 35-year-old man presented with a 6-month history of
postprandial epigastric pain and nausea. Gastroscopy
revealed a 3-cm soft subepithelial mass that originated
from the duodenal bulb and prolapsed into the antrum
(Figs. 1 and 2). EUS showed a hyperechoic homogenous
mass that originated from the submucosal layer of the
duodenum, consistent with a lipoma. The mass had a
broad base, preventing the application of endoscopic
loop ligation, so the STER technique was applied. A
mixture of hydroxyethyl starch (500 mL) with methylene
blue (1 mL) and epinephrine (1 mg) was injected above
the pylorus. Thereafter, a horizontal incision was made
with a needle-type knife (DualKnifeJ 1.5 mm; Olympus,
Tokyo, Japan) (Fig. 3). Then, a submucosal pocket was
created at the lesser curvature of the antrum and was
extended all along the length of the superior wall of the
duodenal bulb. The anatomic landmark of the pyloric
ring was identified at the beginning of the tunnel. The
endoscope was advanced between the superior pole of
the lesion and the duodenal wall. When necessary,
additional submucosal injection of normal saline solution
was performed with the knife. Dissection of the superior
part of the lesion was followed by dissection of the left
and right lateral borders.
Dissection of the inferior (Fig. 4) and posterior part of
the lesion was achieved with a blunt-tip knife (ITKnife
Figure 3. Creation of an entrance at the lesser curvature of the antrum
close to the pylorus in Patient 1.
Figure 4. Progressive enucleation of the lipoma in Patient 1.
Figure 5. Resected specimen from Patient 1.
Figure 6. Closure of the entrance in Patient 1.
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Mavrogenis et al Video Case Report
nano; Olympus) to diminish the risk of perforation result-
ing from poor visualization or from tangential access. In
addition, a tapered tip cap (ST Hood; Fujifilm, Tokyo,
Japan) was used to push the endoscope into the tight
space between the mass and the underlying duodenal mu-
cosa. The ceramic tip of the knife was gently pushed into
the loose submucosal tissue, and then it was moved later-
ally or pulled toward the endoscope. Finally, the lesion was
completely resected (Fig. 5), and the specimen was
retrieved with a basket. Inspection of the duodenal bulb
showed a bluish discoloration of the superior duodenal
wall that corresponded to the inferior wall of the tunnel.
Examination of the submucosal tunnel did not show any
sign of perforation. At the end of the procedure, small
incisions were made around the edges of the entrance of
the tunnel. These superficial defects allowed clip grip for
traction and apposition. The mucosal defect was partially
closed by using 2 clips. Complete closure was achieved
with additional clips (Fig. 6). The patient was discharged
after 24 hours and had an uneventful recovery. At 10
months of follow-up, the patient remained asymptomatic,
and endoscopy showed a smooth passage of the gastro-
scope to the duodenum.
PATIENT 2: ESD FOR COLONIC LIPOMA
The second patient was a 50-year-old woman with a
2-year history of intermittent abdominal pain. Colonoscopy
disclosed a lipoma of the transverse colon that partially
obstructed the bowel lumen (Fig. 7). Owing to the broad
base of the lesion, we decided to proceed to ESD.
Coagulation dots were placed 5 mm distally to the base
of the lesion to avoid injury of the muscle layer. A
mixture of hydroxyethyl starch, methylene blue, and
epinephrine was used for submucosal injection.
Thereafter, the anterior part of the stalk was incised and
dissected (FlushKnifeBT 1.5 mm; Fujifilm). Dissection
was relatively easy because of the absence of large
vessels. Gradually, a yellow submucosal mass emerged
from the submucosal space. Incision of the posterior part
of the lipoma was performed with the patient in a
retroflexed position. Eventually, the entire lesion was
dissected (Figs. 8 and 9). At the end of the procedure
the artificial ulcer was closed with hemostatic clips. The
patient had an uneventful recovery and remained
asymptomatic at follow-up 2 months later.
In conclusion, this video presents the application of
STER and ESD in the resection of symptomatic broad-
based GI lipomas. This technique could be applied for
selected cases of lipoma when the placement of a detach-
able loop is not technically feasible.
Figure 9. Resected specimen from Patient 2.
Figure 8. En bloc resection in Patient 2.
Figure 7. Lipoma of the transverse colon in Patient 2.
228 VIDEOGIE Volume 4, No. 5 : 2019 www.VideoGIE.org
Video Case Report Mavrogenis et al
DISCLOSURE
All authors disclosed no financial relationships
relevant to this publication.
Abbreviations: ESD, endoscopic submucosal dissection; STER, submuco-
sal tunneling endoscopic resection.
REFERENCES
1. Wu C, Yang JF, Tan Q, et al. En bloc resection of a large symptomatic
duodenal lipoma by endoscopic submucosal dissection. VideoGIE
2017;2:182-4.
2. Lee KJ, Kim GH, Park DY, et al. Endoscopic resection of gastrointestinal
lipomas: a single-center experience. Surg Endosc 2014;28:185-92.
3. Lorenzo D, Gonzalez JM, Benezech A, et al. Endoscopic resection of
giant GI lipoma: a case series. VideoGIE 2016;1:43-6.
4. Lee S-H, Park J-H, Park DH, et al. Endoloop ligation of large peduncu-
lated submucosal tumors (with videos). Gastrointest Endosc 2008;67:
556-60.
5. Ivekovic H, Rustemovic N, Brkic T, et al. Endoscopic ligation (“loop-
and-let-go”) is effective treatment for large colonic lipomas: a prospec-
tive validation study. BMC Gastroenterol 2014;14:122.
6. Agarwal A, Chen YI, Bukhari M, et al. Endoscopic resection of gastric
lipoma with a hybrid technique of unroofing and loop ligation. Video-
GIE 2017;2:172-3.
7. Lee JM, Kim JH, Kim M, et al. Endoscopic submucosal dissection of a large
colonic lipoma: report of two cases. World J Gastroenterol 2015;21:3127-31.
8. Aslan F, Akpinar Z, Cekic C, et al. En bloc resection of a 9 cm giant
gastro-duodenal lipoma by endoscopic submucosal dissection. Dig
Liver Dis 2015;47:88-9.
9. Ichinose M, Hikichi T, Kanno Y, et al. A case of gastric lipoma resected
by ESD with difficulty in preoperative diagnosis. Fukushima J Med Sci
2017;63:160-4.
10. Ingason AB, Theodors A, Agustsson AS, et al. Giant gastric lipoma
successfully remoed by ESD: case report and systematic review. Scand
J Gastroenterol 2018;53:1018-4.
11. Noda H, Ogasawara N, Tamura Y, et al. Successful ESD of a large termi-
nal ileal lipoma. Case Rep Gastroenterol 2016;10:506-11.
12. Lee JM, Kim JH, Kim M, et al. Endoscopic submucosal dissection of a
large colonic lipoma: report of two cases. World J Gastroenterol
2015;21:3127-31.
13. Xie H, Zhang H, Wang X, et al. Submucosal tunneling and endo-
scopic resection of a huge gastric lipoma. Am J Gastroenterol
2017;112:1219.
14. Chiu PWY, Yip HC, Teoh AYB, et al. Per oral endoscopic tumor (POET)
resection for treatment of upper gastrointestinal subepithelial tumors.
Surg Endosc. Epub 2019 Jan 2.
15. Aihara H, Storm AC, Thompson CC. Successful removal of an esopha-
geal submucosal tumor by the submucosal tunneling endoscopic
resection technique. VideoGIE 2016;1:2-3.
16. Cappell MS, Stevens CE, Amin M. Systematic review of giant gastric
lipomas reported since 1980 and report of two new cases in a review
of 117110 esophagogastroduodenoscopies. World J Gastroenterol
2017;23:5619-33.
17. Mavrogenis G, Ntourakis D, Tsevgas I, et al. Submucosal pocket-
assisted enucleation of gastric submucosal lesions. Ann Gastroenterol
2017;30:466.
Department of Gastroenterology, Mediterraneo Hospital, Athens, Greece
(1); Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota,
USA (2); Department of Gastroenterology, Mediterraneo Hospital, Athens,
Greece (3).
Copyright ª2019 American Society for Gastrointestinal Endoscopy.
Published by Elsevier Inc. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.vgie.2019.03.002
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