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          Abstract

          We appreciate Dr Bronswijk's interest and comments 1 on our published giant colon lipoma resection case. 2 Similar concerns were raised and published before. 3 We disagree with Dr Bronswijk's suggestion that the unroofing technique should be considered the primary endoscopic technique for all giant colon lipomas. Although unroofing management of GI submucosal neoplasms has been reported, in many cases, complete resection or resolution cannot be achieved. Of the reported cases of colon lipomas treated by the unroofing technique, most patients needed a second-look endoscopy to enable the resection base to be visualized. Even those patients' obstructive symptoms resolved from debulking therapy, and the only scar tissue was seen at the partial resection site; we do not know whether there was any residual lipomatous tissue below the scar. Because there are no long-term follow-up data, we do not know whether those giant lipomas will recur. Tomiki et al 4 reported one 2-cm colon lipoma and another 5-cm colon lipoma managed by unroofing. Additional endoscopic resection was required because the initial unroofing was incomplete. Those authors recommended that patients with abdominal pain and hemorrhage should be treated in consideration of complete resection, but not by unroofing, which could leave a residual tumor. The management of symptomatic large and giant colon lipomas should be individualized based on local expertise, the patient's age, and comorbid conditions. If the endoscopists lack certain therapeutic skills and experience, or if the patient is quite senior with significant comorbid conditions, endoscopic unroofing for symptomatic relief is quite reasonable and should be considered the primary option along with a looping and let-go technique. If the endoscopists are skilled at EMR or submucosal dissection and the patient is quite young, endoscopic complete resection should be considered. Disclosure The author disclosed no financial relationships relevant to this publication.

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          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.
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            Endoclip-assisted giant colon lipoma resection

            Not infrequently, endoscopists encounter colon lipomas during colonoscopy. These lipomas are usually small ( 4 cm) are usually symptomatic. 1 For symptomatic lipomas, endoscopic or surgical resection is needed.2, 3, 4, 5, 6, 7, 8, 9 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.3, 4 Endoscopic resection of these large and giant lipomas carries a perforation risk as high as 8%.1, 4 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 1 Endoscopic 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 2 Endoscopic 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 3 Two endoclips are placed to partially ligate the stalk before needle-knife dissection. Figure 4 Sequential clipping and dissection of the stalk. Figure 5 Endoclips 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 6 The resected lipoma obstructing the anal canal. Figure 7 Resected 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.
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              Endoscopic resection of giant colon lipomas: get rid of the roof!

              To the Editor: With great interest I have read the video case report by Tang and Naga, 1 “Endoclip-assisted giant colon lipoma resection,” published in the April issue of VideoGIE. The authors describe an alternative technique for resection of giant colon lipomas when classic snare resection or a loop-and-let-go approach is not feasible because of the sheer dimensions of the lesion. In their case, successful resection was performed by means of a needle-knife and clipping of the base. Mild per-procedural bleeding occurred, for which clipping was performed. We completely agree with the authors that snare resection or a “loop-and-let-go” approach was not a valid therapeutic option in this specific case. However, it is crucial for the reader to know that, compared with a dissection-based technique, there is a safer, more cost-effective, and less technically demanding alternative for endoscopic management of giant colon lipomas. GI lipomas are benign lesions, which can be identified quite easily by several typical endoscopic features, such as the typical yellow hue, the naked fat sign, the typical subepithelial or submucosal location, and the pillow sign. Although generally asymptomatic, larger lesions can lead to obstructive symptoms, intussusception, ulceration, pain, diarrhea, and bleeding, which may necessitate endoscopic treatment. Several techniques have been reported in the context of large colon lipomas, where loop-assisted techniques or snare resections are deemed unfeasible. Endoscopic submucosal dissection (ESD),2, 3 endoclip-assisted dissection techniques, 4 and, most importantly, simple unroofing have been described.5, 6, 7, 8 Documented for the first time in 1997, the unroofing technique relies on intraluminal expulsion of the residual submucosal content, following snare resection of the distal part of the subepithelial mass. 9 Subsequent spontaneous evacuation of the underlying residual lipomatous tissue will lead to complete resolution of these lesions. Because only a snare resection is needed, little endoscopic experience is required, procedure time and costs are kept to a minimum, and possible dissection-related adverse events can be averted. Although no R0 resection will be obtained, relevance is limited in the context of these benign lesions. Moreover, tissue from partial resection can still be sent for pathologic evaluation in an effort to confirm the visual diagnosis. Regarding efficacy, there are reports of cases in which reintervention was required, presumably after insufficient unroofing, because re-epithelialization of a limited unroofing site may hamper expulsion of the submucosal content.10, 11 Comparative studies evaluating the different techniques for resection of giant colon lipomas are scarce. Only 1 retrospective analysis has compared unroofing, EMR, and ESD in resection of 28 giant colon lipomas, which showed complete resolution with all 3 techniques. 12 Owing to the superior safety profile, cost effectiveness, and ease of resection, the unroofing technique should be considered the primary endoscopic technique for resection of giant colonic lipomas before resorting to dissection-based techniques. However, sufficient unroofing should be pursued in an effort to prevent incomplete clearance of the lesion. Disclosure The author disclosed no financial relationships relevant to this publication.
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                Author and article information

                Journal
                VideoGIE
                VideoGIE
                VideoGIE
                Elsevier
                2468-4481
                27 June 2019
                July 2019
                27 June 2019
                : 4
                : 7
                : 342
                Affiliations
                [1]Division of Gastroenterology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
                Article
                S2468-4481(19)30109-2
                10.1016/j.vgie.2019.04.012
                6617238
                469e8617-a834-4c40-bbcd-3e71c324806c
                © 2019 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/).

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