Endoscopic Resection of a Giant Colonic Lipoma causing Severe Anemia

Abstract

A 62-year-old man with comorbidities of stroke and diabetes under treatment with oral anticoagulants presented with severe anemia (hemoglobin 6 g/dl). Upper esogastroduodenoscopy showed normal aspect. At colonoscopy, a pedunculated, ulcerated, necrotized giant tumor of about 5 cm with a thick stalk of 1.5 cm was found at the ileo-cecal valve (Fig. 1). Biopsies were taken, but the results were inconclusive. The patient opted for endoscopic removal, after being informed about the risk of perforation and bleeding. Dabigatran therapy was interrupted two days prior to the procedure. Endoloop insertion was attempted, but the tumor was too large to fit into it. Hemoclips were inserted at the base of the stalk and the tumor was excised by electrosurgical snare (200W). The base of the resected specimen, no longer attached to the large polyp, entered back into the small bowel. Hemoclips were placed in the small bowel to close the ulcer margins (Fig. 2). No complications were recorded and the patient was discharged 48 h later from the hospital. The anticoagulant therapy was resumed. The pathology examination surprisingly revealed an atypical lipoma, without malignancy (Fig. 3, H&E x5).Colonic lipomas rarely cause symptoms and are usually detected incidentally. However, if the tumor is large, it may produce symptoms, such as abdominal pain, rectal bleeding, obstruction, intussusception. Large colonic lipomas can be mistaken for malignancy, which may result in extensive surgical operations [1,2].

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

“…Bar-Meir et al, 1981 18 1/1 (100%) 1/1 (100%) 0% -Geraci et al, 2010 2 1/1 (100%) 1/1 (100%) 0% -Kim et al, 2002 19 2/4 (50%) 4/4 (100%) 1/4 (25%) Pain Lee et al, 2014 14 15/15 (100%) N/A 0% -Lim et al, 2012 20 1/1 (100%) N/A 0% -Lorenzo et al, 2016 12 1/1 (100%) 1/1 (100%) 0% -Pfeil et al, 1990 21 7/7 (100%) 6/6 (100%) 3/7 (42,9%) Perforation Popa et al, 2015 5 1/1 (100%) N/A 0% -Dissection-based techniques:…”

“…However, in situations where the dimensions of the lesion make these methods unfeasible, endoscopic submucosal dissection (ESD), 3,4 other dissection-based techniques and, most importantly, simple unroofing may offer effective alternative treatment options. [5][6][7][8][9][10] Mentioned 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 11 (Figure 1). Subsequent spontaneous evacuation of the underlying residual lipomatous tissue is said to lead to complete resolution of these lesions.…”

“…In the context of large colon lipomas, several endoscopic techniques have been reported, such as loop‐assisted techniques and snare resection. However, in situations where the dimensions of the lesion make these methods unfeasible, endoscopic submucosal dissection (ESD), 3,4 other dissection‐based techniques and, most importantly, simple unroofing may offer effective alternative treatment options 5–10 …”

“…However, in situations where the dimensions of the lesion make these methods unfeasible, endoscopic submucosal dissection (ESD), 3,4 other dissection-based techniques and, most importantly, simple unroofing may offer effective alternative treatment options. 5–10…”

Endoscopic resection of giant colon lipomas: get rid of the roof!

“…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…”