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Endoloop ligation of large polyps
Letters to the Editor 4. Afridi SA, Fichtenbaum CJ, Taubin H. Review of duodenal diverticula. Am J Gastroenterol 1991;86:935-8. 5. Hajiro K, Yamamoto H, Matsui H, et al. Endoscopic diagnosis and excision of intraluminal duodenal diverticulum. Gastrointest Endosc 1979; 25:151-4. 6. Hiraoka T, Nakamura M, Ohno K, et al. Endoscopic excision of intraluminal duodenal diverticulum. Dig Dis Sci 1985;30:274-81. 7. Ravi J, Joson PM, Ashok PS. Endoscopic incision of intraluminal duodenal diverticulum. Dig Dis Sci 1993;38:762-6. 8. Van Os EC, Petersen BT, Kelly DG, et al. Endoscopic management of an intraluminal duodenal diverticulum. Gastrointest Endosc 1996;44:494-7. doi:10.1016/j.gie.2008.05.026
Endoloop ligation of large polyps To the Editor: Lee et al1 demonstrate the feasibility of endoloop ligation of large pedunculated submucosal tumors in their case series. However, one must be critical of the patient populationdwithout comorbiditiesdselected for their study. Many of the patients had lesions that could have been safely addressed laparoscopically, but instead they participated in a study in which there existed the potential for an adverse outcome (ie, life-threatening secondary hemorrhage from a slow-transecting stalk occurring at home). Were these patients aware of such risk? Perhaps the study could have been designed to address a group of patients with grave surgical risk, such as case 1 in their series. Cases 4 and 5 did not have an endoscopic biopsy diagnosis, and the resected specimen was not retrieved for pathological analysis, making the authors’ diagnosis of lymphangioma and lipoma, respectively, unsupported. Was the diagnosis made on endoscopic appearances? Further, only 3 patients (cases 1-3) underwent EUS to confirm the submucosal plane of the polyps. How were the remaining lesions deemed to be submucosal? Slow transection of polyps may be feasible, but the risk of secondary hemorrhage associated with this approach is unclear, and this techniquedat least for nowdshould probably be limited to patients at high risk for surgery. Shyam Menon, MRCP Department of Gastroenterology Princess Royal Hospital Telford, United Kingdom REFERENCE 1. Lee S-H, Park J-H, Park D-H, et al. Endoloop ligation of large pedunculated submucosal tumors. Gastrointest Endosc 2008;67:556-60. doi:10.1016/j.gie.2008.04.008
Response: We greatly appreciate the letter by Dr Menon pointing out some meaningful arguments regarding the new therawww.giejournal.org
peutic approach to large pedunculated submucosal tumors. Dr Menon addressed several excellent points requiring discussion. He points out the risk of secondary hemorrhage, endoscopic diagnosis of lipoma and lymphangioma without EUS or pathology, and, in some cases, doubtful reasons for omitting EUS. Although limited reports have been published,1,2 there has been no report of life-threatening secondary hemorrhage from a slow-transecting stalk. In the case of endoloop-assisted snare resection, there exists the potential for a delayed bleeding risk due to the premature detachment of the endoloop from the ligating point.3 On the other hand, in endoloop ligation, there is no risk of early detachment of the snare because it is held between the lesion and bowel wall. In addition, ligation of the pedicle causes ischemic necrosis, so during the slow progression to final transaction through ischemic necrosis, mechanical ligation of the pedicle, as well as repeated inflammation and fibrosis, could prevent delayed bleeding. As might be expected in our case series, there was no procedure-related bleeding. Most cases of GI lipomas are relatively easy to diagnose with typical endoscopic signs, such as the cushion or pillow sign, the naked fat sign, and tenting sign. As Chak4 described in his review article, ‘‘It is not clear that performance of EUS is necessary for lipomatous lesions that are characteristically obvious.’’ For the same reasons, cystic lymphangioma can be confirmed with typical endoscopic findings, such as the cushion sign, transparent mucosa, and fluid gush-out after repeated biopsies. In our cases, we diagnosed these lesions endoscopically without great difficulty. EUS is definitely helpful in confirming the origin of submucosal lesions, and is an essential tool for therapeutic procedure. However, cases of lipoma and lymphagioma are typically located in the submucosal layer; also, the lesions remaining after a ligation transaction could disappear through the same mechanism as the unroofing technique.5 That is the reason we did not perform EUS in 7 patients. Once again, we would like to thank Dr Menon for his interest in our article.6 Suck-Ho Lee, MD Il-Kwun Chung, MD Sang-Heum Park, MD Sun-Joo Kim, MD Division of Gastroenterology Department of Internal Medicine Soon Chun Hyang University Cheonan Hospital Cheonan, Korea REFERENCES 1. Raju GS, Gomez G. Endoloop ligation of a large colonic lipoma: a novel technique. Gastrointest Endosc 2005;62:988-90.
Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1245
Endoloop ligation of large polyps To the Editor: Lee et al1 demonstrate the feasibility of endoloop ligation of large pedunculated submucosal tumors in their case series. However, one must be critical of the patient populationdwithout comorbiditiesdselected for their study. Many of the patients had lesions that could have been safely addressed laparoscopically, but instead they participated in a study in which there existed the potential for an adverse outcome (ie, life-threatening secondary hemorrhage from a slow-transecting stalk occurring at home). Were these patients aware of such risk? Perhaps the study could have been designed to address a group of patients with grave surgical risk, such as case 1 in their series. Cases 4 and 5 did not have an endoscopic biopsy diagnosis, and the resected specimen was not retrieved for pathological analysis, making the authors’ diagnosis of lymphangioma and lipoma, respectively, unsupported. Was the diagnosis made on endoscopic appearances? Further, only 3 patients (cases 1-3) underwent EUS to confirm the submucosal plane of the polyps. How were the remaining lesions deemed to be submucosal? Slow transection of polyps may be feasible, but the risk of secondary hemorrhage associated with this approach is unclear, and this techniquedat least for nowdshould probably be limited to patients at high risk for surgery. Shyam Menon, MRCP Department of Gastroenterology Princess Royal Hospital Telford, United Kingdom REFERENCE 1. Lee S-H, Park J-H, Park D-H, et al. Endoloop ligation of large pedunculated submucosal tumors. Gastrointest Endosc 2008;67:556-60. doi:10.1016/j.gie.2008.04.008
Response: We greatly appreciate the letter by Dr Menon pointing out some meaningful arguments regarding the new therawww.giejournal.org
peutic approach to large pedunculated submucosal tumors. Dr Menon addressed several excellent points requiring discussion. He points out the risk of secondary hemorrhage, endoscopic diagnosis of lipoma and lymphangioma without EUS or pathology, and, in some cases, doubtful reasons for omitting EUS. Although limited reports have been published,1,2 there has been no report of life-threatening secondary hemorrhage from a slow-transecting stalk. In the case of endoloop-assisted snare resection, there exists the potential for a delayed bleeding risk due to the premature detachment of the endoloop from the ligating point.3 On the other hand, in endoloop ligation, there is no risk of early detachment of the snare because it is held between the lesion and bowel wall. In addition, ligation of the pedicle causes ischemic necrosis, so during the slow progression to final transaction through ischemic necrosis, mechanical ligation of the pedicle, as well as repeated inflammation and fibrosis, could prevent delayed bleeding. As might be expected in our case series, there was no procedure-related bleeding. Most cases of GI lipomas are relatively easy to diagnose with typical endoscopic signs, such as the cushion or pillow sign, the naked fat sign, and tenting sign. As Chak4 described in his review article, ‘‘It is not clear that performance of EUS is necessary for lipomatous lesions that are characteristically obvious.’’ For the same reasons, cystic lymphangioma can be confirmed with typical endoscopic findings, such as the cushion sign, transparent mucosa, and fluid gush-out after repeated biopsies. In our cases, we diagnosed these lesions endoscopically without great difficulty. EUS is definitely helpful in confirming the origin of submucosal lesions, and is an essential tool for therapeutic procedure. However, cases of lipoma and lymphagioma are typically located in the submucosal layer; also, the lesions remaining after a ligation transaction could disappear through the same mechanism as the unroofing technique.5 That is the reason we did not perform EUS in 7 patients. Once again, we would like to thank Dr Menon for his interest in our article.6 Suck-Ho Lee, MD Il-Kwun Chung, MD Sang-Heum Park, MD Sun-Joo Kim, MD Division of Gastroenterology Department of Internal Medicine Soon Chun Hyang University Cheonan Hospital Cheonan, Korea REFERENCES 1. Raju GS, Gomez G. Endoloop ligation of a large colonic lipoma: a novel technique. Gastrointest Endosc 2005;62:988-90.
Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1245