Endoscopic resection of a large colonic lipoma by unroofing technique

Obscure gastrointestinal bleeding from a large jejunal lipoma treated using an endoscopic unroofing technique with double balloon enteroscopy: a case study

Small intestinal lipomas are rare, but may cause obscure gastrointestinal bleeding. The endoscopic unroofing technique excises only the upper third of the lipoma and allows both histological confirmation and complete treatment with minimal risk of perforation. We present a rare case of obscure gastrointestinal bleeding caused by a jejunal lipoma. A 75-year-old man on antiplatelet therapy presented to our department with melena and anemia. Computed tomography revealed he had a 45-mm jejunal submucosal tumor with fat attenuation. Endoscopic resection using an endoscopic unroofing technique with double balloon enteroscopy was successfully performed. The tumor was confirmed to be a lipoma.

Spontaneous expulsion of a duodenal lipoma after endoscopic biopsy: A case report

BACKGROUND

Gastrointestinal (GI) lipomas are benign submucosal tumors of mature adipocytes that arise mainly in the colon and stomach, sometimes in the ileum and jejunum, and rarely in the duodenum. Patients with symptomatic lipomas require endoscopic or surgical treatment. Spontaneous expulsion of lipomas after biopsy is a rare condition that has limited case reports.

CASE SUMMARY

A 56-year-old man presented to our hospital with intermittent postprandial epigastric fullness. Esophagogastroduodenoscopy (EGD) revealed a 10-mm soft yellowish submucosal lesion with the “pillow sign,” located in the second portion of duodenum. Endoscopic ultrasonography (EUS) using a 12-MHz catheter probe showed a hyperechoic, homogenous, and round solid lesion (OLYMPUS EUS EU-ME2, UM-DP12-25R, 12-MHz radial miniprobe, Olympus Corporation, Tokyo, Japan). Deep biopsy was performed using the bite-on-bite technique with forceps. Histological examination was compatible with submucosal lipoma. The lesion spontaneously expelled 12 d after the biopsy. Follow-up EUS performed after 2 mo confirmed this condition.

CONCLUSION

Deep biopsy could lead to spontaneous GI lipoma expulsion. This might be the first step in lipoma diagnosis and treatment.

Endoscopic treatment of large symptomatic colon lipomas: A systematic review of efficacy and safety

BACKGROUND

Various techniques have been described for endoscopic resection of large symptomatic colon lipomas. Lipoma unroofing might provide a safer, more time efficient and easier technique compared to dissection-based techniques, endoscopic mucosal resection (EMR) or loop-assisted resection. The aim of this systematic review was to compare efficacy and safety (endoscopic resolution rates, clinical remission rates and adverse events) of lipoma unroofing with respect to dissection-based techniques, EMR or loop-assisted resection.

METHODS

As most outcomes were binary in nature and several outcomes did not occur in some studies, routine calculation of standard errors in outcome probability was not possible. Therefore, original patient data were extracted, after which efficacy and safety were compared.

RESULTS

Twenty four studies met the selection criteria, which encompassed 77 lesions (46.8% female, mean age 63 years (interquartile range (IQR) 53-72 years), mean size 45.4 mm (IQR 30.0-60.0 mm). Ten patients underwent unroofing (13.0%), whereas 7 (9.1%), 31 (40.3%) and 29 patients (37.7%) underwent dissection-based techniques, EMR and loop-assisted-snare resection, respectively. Endoscopic resolution rates were 60%, 100% (p = 0.103), 93.6% (p = 0.024) and 93.1% (p = 0.028). Clinical remission rates were identical in all four groups (100%). Amongst patients who underwent EMR and loop-assisted techniques, adverse events were identified in 12.9% (p = 0.556) and 13.8% (p = 0.556), respectively, compared to none in the unroofing and dissection-based resection group.

CONCLUSIONS

In patients with large colon lipomas, endoscopic treatment by unroofing, dissection-based resection, EMR and loop-assisted resection provided similar clinical remission rates. Amongst patients undergoing EMR and loop-assisted resection, increased endoscopic resolution rates were seen at the expense of more adverse events, although the latter did not reach statistical significance. Until more reliable comparative data are available, the most optimal resection technique should rely on local expertise and patient profile.

Endoscopic Treatment of Intussusception From Massive Colonic Lipomas via Endoscopic Mucosal Resection: A Case Series

Although the safety and effectiveness of endoscopic resection of colonic lipomas has already been described, the ideal excisional technique continues to be debated. Notably, a majority of the proposed techniques focus on small, incidentally found lipomas. We report 3 patients with massive (≥8 cm) colonic lipomas presenting as intussusception that were successfully treated by piecemeal endoscopic mucosal resection. We propose endoscopic mucosal resection as the endoscopic treatment of choice and feasible alternative to surgery for the management of intussuscepting lipomas.

Curative endoscopic treatment of intussusception due to a giant colonic lipoma using a wedged balloon and ligation with detachable snares

A 67-year-old woman presented with symptoms of bowel obstruction. Radiographic and ultrasonographic findings suggested colo-colonic intussusception caused by a colonic lipoma. Colonoscopy with an endoscope tip balloon was performed for reduction. The intussusception was partially reduced by injecting dilute contrast media with a wedged inflated balloon at the endoscope tip. For definitive treatment of the polyp, ischemia was induced using a detachable snare. The abdominal pain well improved after endoscopic treatment. However, ultrasonography suggested a residual lesion. Another detachable snare was applied to the stalk on day 6. A large amount of dark-red necrotic tissue was passed per anus the following day. One month later, complete scarring of the site was confirmed colonoscopically. This is the first report of curative endoscopic treatment of an intussusception due to a giant colonic lipoma with detachable snares after the reduction with a wedged balloon of colonoscope tip.

Endoscopic resection of a giant colonic lipoma with endoloop-assisted unroofing technique: A case report

RATIONALE

Colonic lipomas are uncommon benign submucosal adipose tumorsthat are usually asymptomatic. Large lipomas can cause symptoms require treatment in principle. We report 1 case of giant colonic lipoma removed with endoloop-assisted unroofing technique instead of conventional surgical bowel resection.

PATIENT CONCERNS

A 62-year-old female patient presented with intermittent abdominal discomfort for 1 month.

DIAGNOSIS

The patient was diagnosed as having a giant colonic lipoma.

INTERVENTION

Endoscopic resection with endoloop-assisted unroofing technique was performed. On the 22nd day after resection, intestinal obstruction occurred by shedding mass was found; the symptoms of this patient disappeared soon after removal of the mass by endoscopy.

OUTCOMES

A follow-up colonoscopy 6 months later showed a scarred mucosa at the ligation site and no residual lipoma was observed.

LESSONS

Endoscopic resection with endoloop-assisted unroofing technique remains a viable option for giant lipomas; however, postoperative intestinal obstruction caused by shedding mass should be noted.

Two Patients with Large Colonic Lipomas for which Endoscopic Unroofing was Ineffective

Endoscopic unroofing is effective for treating large colonic lipomas. However, additional endoscopic resection is occasionally required when the outcomes of initial unroofing are incomplete. The colonoscopy of an 82-year-old woman with abdominal pain revealed a yellowish lipoma of about 20 mm in the transverse colon. The mass was treated by unroofing, but a follow-up colonoscopy 5 days later revealed residual lipoma. One month later, the regenerated surface had become covered with mucosa, and the status of the lipoma had returned to that before unroofing. The colonoscopy of a 74-year-old man with abdominal pain and melena revealed a 50-mm-wide protruding lipoma in the transverse colon. The mucosa of the upper third of the lipoma was excised using an electric knife and snare, which allowed the immediate partial drainage of adipose tissue. Unroofing proceeded, but 7 days later, the unroofed surface had become coated with a white substance, and the residual lipoma required additional endoscopic resection. Colonic lipomas are often asymptomatic. However, patients with abdominal pain and hemorrhage should be treated in consideration of complete resection, but not by unroofing, which could leave a residual tumor. Drainage should be confirmed after unroofing and any residual lipoma should be treated by additional resection.

Is endoscopic resection a correct treatment for atypical gastrointestinal lipomas?

We would like offering our experience about a very rare and underestimated type of gastrointestinal lipoma, which is the lipoma with precancerous or frankly malignant features of the mucosal epithelium, the so-called atypical lipoma. So far, only few cases have been described in the world literature. Recently, we grappled with what we think the first case of atypical colonic lipoma presenting with adenocarcinomatous transformation of the overlying epithelium, as discussed in more detail below. We propose a new definition and classification for this kind of lesions and discuss about their diagnosis, treatment and prognosis.

Unroofing Technique as an Option for the Endoscopic Treatment of Giant Gastrointestinal Lipomas

Gastrointestinal lipomas are usually asymptomatic, detected incidentally. However, they can cause severe symptoms such as obstruction, invagination, and bleeding. The transsection of an infarcted or large lipoma by needle sphincterotome (needle knife) and/or snare polypectomy of the upper part of the tumour is an option for the endoscopy treatment of giant infarcted lipomas. Cutting a top of lipoma (unroofing technique) allowed flow out of adipose tissue from the lipoma.

Endoscopic resection of giant colonic lipoma: case series with partial resection

Colonic lipoma, a very rare form of benign tumor, is typically detected incidentally in asymptomatic patients. The size of lipoma is reported variously from 2 mm to 30 cm, with higher likelihood of symptoms as the size is bigger. Cases with symptom or bigger lesion are surgically resected in principle; endoscopic resection, which has developed recently with groundbreaking advance of endoscopic excision technology, is being used more often but with rare report of success due to high chance of complications such as bowel perforation or bleeding. The authors report here, together with a literature review, our experiences of three cases of giant colonic lipomas showing complete remission after aggressive unroofing technique, at certain intervals, using snare catheter at the origin of the lipoma so that the remaining lipoma could be drained out of the exposed surface spontaneously, in order to reduce complications.