Post written by Sukit Pattarajierapan, MD, from the Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.

Our video presents a case of endoscopic submucosal dissection (ESD) of a symptomatic giant colonic lipoma that was challenging during both resection and specimen retrieval.

A 59-year-old man without comorbidities presented to our hospital with intermittent abdominal pain. Colonoscopy revealed a soft, yellowish submucosal tumor measuring 8 cm in diameter in the ascending colon with a positive “pillow sign.” Abdominal CT revealed colo-colonic intussusception of the cecum and ascending colon into the transverse colon, with a large fatty mass as the pathological leading point. CT and colonoscopic findings indicated that the most likely diagnosis was a giant lipoma.

An endoscopic resection was performed after discussion with the patient. The potential resection techniques were loop-assisted resection or ESD, depending on the intraoperative findings. During the procedure, the tumor could not be caught using an Endoloop (Olympus, Tokyo, Japan) because it was too large; therefore, ESD was performed.

The patient’s position was altered from the left lateral decubitus to the supine position to allow gravity to aid traction. The submucosal injection was performed with glycerol mixed with indigo carmine and adrenaline. We used a DualKnife (Olympus) to make the incision and dissect along the base of the tumor. In the core of the pseudopedicle of the lipoma, the invaginated muscularis propria with large feeding vessels was identified and cauterized with coagulating forceps. An insulated-tip knife nano (Olympus) was used during the latter part of the dissection after the muscular core was cut. The tumor was successfully removed, and the mucosal defect was closed using endoscopic clips.

Specimen retrieval was difficult owing to the vacuum effect of this large specimen. To overcome this difficulty, we swung the tip of the colonoscope with the right and left knob simultaneously with CO₂ insufflation.

Finally, the vacuum seal was broken, and the specimen was successfully retrieved. The lipoma measured 8 × 5 × 3.5 cm on ex vivo examination. The procedural time was 100 minutes. The patient was discharged 2 days postoperatively without adverse events, and pathologic examination confirmed the lipoma diagnosis.

This video is featured because ESD of a giant colonic lipoma could be difficult during both resection and specimen retrieval if the tumor is huge. Our technical tips to overcome the difficulty are:

1. Use proper patient positioning to make the giant colonic lipoma hang from the colonic wall by gravity.
2. Cauterize with coagulating forceps before further dissection the feeding vessels typically contained in the core of the muscular pseudopedicle, which is formed when the muscularis propria layer of the colon becomes invaginated into the stalk of giant pedunculated lipomas.
3. Swing the tip of the colonoscope with the right and left knob simultaneously with CO₂ insufflation to break the vacuum seal that may lead to difficult specimen retrieval of giant colonic lipomas.

ESD is a safe and effective endoscopic treatment for symptomatic giant colonic lipomas. The difficulty during the procedure and specimen retrieval can be overcome with these technical tips.

Colonoscopy revealed a soft, yellowish submucosal tumor of the ascending colon measuring 8 cm in diameter with a positive “pillow sign.”

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