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Successful endoscopic resection of a giant colonic lipoma causing intussusception
At the Focal Point
NTT EC, Tokyo; Koji Fujita, MD, PhD, Masato Yoneda, MD, PhD, Atsushi Nakajima, MD, PhD, Division of Gastroenterology, Yokohama City University School of Medicine, Yokohama, Japan
doi:10.1016/j.gie.2008.03.009
Commentary Not diagnosed by CE but found by DBE is, in some ways, a distortion of the value of the CE study. The capsule did, in fact, localize the site of bleeding; it just did not allow for a specific diagnosis or lesion removal. This is, however, the limitation of the capsule, regardless of whether a mass or oozing of blood was seen; a CE is not therapeutic and a DBE is. The cause of the bleeding in a sense is irrelevant. The results of a CE told the double-balloon endoscopist where to go. From then on, treatment was obvious, whether the lesion was removed by a DBE or by a more invasive surgical procedure. A DBE could have done the job by itself but the use of CE was complementary and provided a worthwhile road map. The defense rests. Lawrence J. Brandt, MD Associate Editor for Focal Points
Successful endoscopic resection of a giant colonic lipoma causing intussusception
An 82-year-old man with a history of cutaneous lipomas that had been previously resected presented to our hospital with left-lower quadrant pain, blood-streaked diarrhea, and an abdominal CT scan that showed a large sigmoid lipoma causing colo-colonic intussusception (A). At colonoscopy, an 8 cm, smooth, round, pedunculated mass was found 30 cm from the anus (B). Because of the size of the lesion, a partial, piecemeal resection was performed with snare cautery; 4 clips were placed at the base of the lesion because of oozing. Pathology confirmed a submucosal lipoma (C, H&E, orig. mag. 10). His pain resolved and he was discharged.
He returned to our emergency department 3 weeks later with recurrent abdominal pain. A repeat CT scan showed a large remnant lipoma, again with intussusception. Flexible sigmoidoscopy was performed and, as the lesion was now smaller (D), an Endoloop (Polyloop; Olympus America, Center Valley, Pa) was successfully placed around the lesion allowing for its complete resection by use of snare cautery; 5 clips placed across the residual stalk minimized bleeding. The patient had mild abdominal pain after the procedure, and CT scan showed focal wall thickening at the resection site with increased density in the adjacent mesenteric fat, but no evidence of colonic perforation or intussusception.
774 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 4 : 2008
www.giejournal.org
At the Focal Point
He was discharged on a short course of oral antibiotics for presumed postpolypectomy syndrome.
Daniel Wild, MD, Joseph Fiore, MD, Moises Guelrud, MD, Division of Gastroenterology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
DISCLOSURE The authors report that there are no disclosures relevant to this publication.
doi:10.1016/j.gie.2008.02.086
Commentary Intussusception in an adult is rare and almost always caused by a definable lesion. Most colo-colonic intussusception is caused by neoplasia, and approximately half of the lesions are malignant. Benign lesions causing colo-colonic intussusception in adults most commonly are lipomas. CT scan is the diagnostic procedure of choice and, as in this case, allows the causative lesion to be identified. Surgery has been the recommended treatment, with or without a primary reduction of the intussusception, but increasing experience has shown that benign lesions, including large lipomas, may be managed safely just by colonoscopy. It obviously is preferable to remove the offending lesion in one session lest further problems develop, but not having been present at the endoscopy, I cannot render an opinion as to the wisdom of leaving some lipoma behind. Finally, the presence of cutaneous and intraluminal lipomas always raises the question of a syndrome (Gardner, multiple lipomatosis) or disease (Dercum, Madelung), although such a differential would have to be tailored to be age-appropriate and is perhaps best left for another Focal Point. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 68, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 775
NTT EC, Tokyo; Koji Fujita, MD, PhD, Masato Yoneda, MD, PhD, Atsushi Nakajima, MD, PhD, Division of Gastroenterology, Yokohama City University School of Medicine, Yokohama, Japan
doi:10.1016/j.gie.2008.03.009
Commentary Not diagnosed by CE but found by DBE is, in some ways, a distortion of the value of the CE study. The capsule did, in fact, localize the site of bleeding; it just did not allow for a specific diagnosis or lesion removal. This is, however, the limitation of the capsule, regardless of whether a mass or oozing of blood was seen; a CE is not therapeutic and a DBE is. The cause of the bleeding in a sense is irrelevant. The results of a CE told the double-balloon endoscopist where to go. From then on, treatment was obvious, whether the lesion was removed by a DBE or by a more invasive surgical procedure. A DBE could have done the job by itself but the use of CE was complementary and provided a worthwhile road map. The defense rests. Lawrence J. Brandt, MD Associate Editor for Focal Points
Successful endoscopic resection of a giant colonic lipoma causing intussusception
An 82-year-old man with a history of cutaneous lipomas that had been previously resected presented to our hospital with left-lower quadrant pain, blood-streaked diarrhea, and an abdominal CT scan that showed a large sigmoid lipoma causing colo-colonic intussusception (A). At colonoscopy, an 8 cm, smooth, round, pedunculated mass was found 30 cm from the anus (B). Because of the size of the lesion, a partial, piecemeal resection was performed with snare cautery; 4 clips were placed at the base of the lesion because of oozing. Pathology confirmed a submucosal lipoma (C, H&E, orig. mag. 10). His pain resolved and he was discharged.
He returned to our emergency department 3 weeks later with recurrent abdominal pain. A repeat CT scan showed a large remnant lipoma, again with intussusception. Flexible sigmoidoscopy was performed and, as the lesion was now smaller (D), an Endoloop (Polyloop; Olympus America, Center Valley, Pa) was successfully placed around the lesion allowing for its complete resection by use of snare cautery; 5 clips placed across the residual stalk minimized bleeding. The patient had mild abdominal pain after the procedure, and CT scan showed focal wall thickening at the resection site with increased density in the adjacent mesenteric fat, but no evidence of colonic perforation or intussusception.
774 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 4 : 2008
www.giejournal.org
At the Focal Point
He was discharged on a short course of oral antibiotics for presumed postpolypectomy syndrome.
Daniel Wild, MD, Joseph Fiore, MD, Moises Guelrud, MD, Division of Gastroenterology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
DISCLOSURE The authors report that there are no disclosures relevant to this publication.
doi:10.1016/j.gie.2008.02.086
Commentary Intussusception in an adult is rare and almost always caused by a definable lesion. Most colo-colonic intussusception is caused by neoplasia, and approximately half of the lesions are malignant. Benign lesions causing colo-colonic intussusception in adults most commonly are lipomas. CT scan is the diagnostic procedure of choice and, as in this case, allows the causative lesion to be identified. Surgery has been the recommended treatment, with or without a primary reduction of the intussusception, but increasing experience has shown that benign lesions, including large lipomas, may be managed safely just by colonoscopy. It obviously is preferable to remove the offending lesion in one session lest further problems develop, but not having been present at the endoscopy, I cannot render an opinion as to the wisdom of leaving some lipoma behind. Finally, the presence of cutaneous and intraluminal lipomas always raises the question of a syndrome (Gardner, multiple lipomatosis) or disease (Dercum, Madelung), although such a differential would have to be tailored to be age-appropriate and is perhaps best left for another Focal Point. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 68, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 775