Is endoscopic submucosal dissection really contraindicated for a large submucosal lipoma of the colon?

Endoscopic submucosal dissection (ESD) has recently been developed for endoscopic treatment of gastrointestinal tumors, enabling en bloc resection of even large tumors [1] [2]. Although many endoscopists now perform ESD for early-stage gastric cancer, ESD has yet to be established as a safe therapy for colonic diseases, even in Japan. It is still unclear whether ESD is indicated for submucosal tumors (SMTs), and ESD for colonic diseases is still a controversial issue due to the considerable risk of perforation. In the pre-ESD era, SMTs required surgical treatment. Here we describe a unique case of a large submucosal lipoma of the colon which was successfully resected en bloc by ESD.

The patient was a 62-year-old woman with a giant SMT in the descending colon. Colonoscopic examination revealed a yellowish protruding submucosal tumor approximately 5 cm in diameter, suggesting that it might be totally resectable by ESD ([Figures 1 a, b]).

The technical aspects of our ESD procedure for this SMT are as follows. The first step was to create a sufficient submucosal fluid cushion to lift the tumor from the muscle layer. The submucosal injection solution was a mixture of 1 % 1900-kDa hyaluronic acid and 10 % glycerin with 5 % fructose plus 0.9 % saline solution, with a small amount of indigo carmine and epinephrine [3]. The next step was to pre-cut the surrounding mucosa and dissect the connective submucosal tissue under the SMT from the anal side while observing the lower surface of the tumor [4] ([Figures 1 b, c]). It was possible to make the giant SMT hang from the colonic wall by controlling the body position of the patient, and this made it easy to preserve the muscular layer ([Figure 1 d]).

Figure 1 a Colonoscopic view of the large submucosal tumor. The tumor appears evaginated due to gravity, and hangs from the colon wall, suggesting that it would be resectable en bloc by ESD. b Marginal incision and submucosal dissection were performed using an electrocautery needle-knife in combination with a Hook knife (KD-620LR; Olympus, Tokyo, Japan). c After pre-cutting the surrounding mucosa from the anal side, the connective submucosal tissue under the SMT was dissected from the anal side while observing the tumor surface from beneath. d En bloc resection was achieved without complication.

ESD may be sufficient for en bloc resection of submucosal tumors in selected cases.

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References

• 1 Yamamoto H. Endoscopic submucosal dissection of early cancers and large flat adenomas.  Clin Gastroenterol Hepatol. 2005;  3 S74-S76
• 2 Yamamoto H, Kawata H, Sunada K. et al . Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood.  Endoscopy. 2003;  35 690-694
• 3 Fujishiro M, Yahagi N, Nakamura M. et al . Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar.  Gastrointest Endosc. 2006;  63 243-249
• 4 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-512
• 5 Yamamoto H, Yube T, Isoda N. et al . A novel method of endoscopic mucosal resection using sodium hyaluronate.  Gastrointest Endosc. 1999;  50 251-256