Handcrafted two-channel colonoscope for removing large lipomas

Endoscopy 2006; 38: 644 - 647

We read with interest the article by Koo & Kaffes [1] on a novel endoscopic technique for removing large colonic lipomas in which an endoloop was used to reduce the potential risk of bleeding. The device allowed successful endoscopic removal of four lipomas in three symptomatic patients, resulting in resolution of their symptoms without major complications. They used a two-channel endoscope, and placed an endoloop around the tumor base with the assistance of a grasping forceps. The technique had already been reported for the endoscopic removal of large pedunculated polyps [2] and large lipomas [3]. The main drawback of this technique, however, is that two-channel endoscopes are not available in every hospital [4].

Colonic lipomas, rare benign adipose tumors, can be diagnosed during colonoscopy on the basis of their fatty, yellow appearance and by eliciting the “cushion” or “pillow” sign and the “naked fat” sign [3] [5]. Although most lipomas remain asymptomatic and need no treatment, large lipomas can cause symptoms, including pain, diarrhea, obstruction, bleeding, and intussusception [3] [5] [6]. Removal of such lesions is indicated, and endoscopic removal is preferable to surgery [6].

Endoscopic removal of large lipomas can be technically difficult [5] and is associated with an increased risk of bleeding or perforation [1] [3] [5] [6]. Large colonic lesions occlude the intestinal lumen, which makes it difficult to snare the lesions [2] [4]. Endosonographic guidance [5] [6] and/or submucosal injection of saline or epinephrine [6] have been reported to lead to safer endoscopic removal of large lipomas. Although these techniques are useful, the application of an endoloop has the greatest advantage by securing the base of elevations before transection [3] [5].

To facilitate the removal of large pedunculated polyps, Akahoshi et al. [2] developed a technique of grasping forceps-assisted endoscopic resection using a two-channel endoscope and an endoloop, aiming to reduce the incidence of complications and minimize the technical difficulties. A two-channel endoscope, however, is not available in all hospitals. We therefore devised a simple and inexpensive way of constructing a two-channel endoscope by taping a plastic tube along the shaft of a standard colonoscope ([Figure 1]), and used this modified endoscope for grasping forceps-assisted endoscopic resection of 12 giant pedunculated polyps in ten patients, resulting in excellent outcomes [4].

Figure 1 By taping a plastic tube along the shaft of a standard colonoscope, the colonoscope effectively has two working channels.

Using our technique [4], large lipomas can be removed safely without technical difficulties and this method also ensures a reliable one-piece resection. Scheduled piecemeal resection has been recommended for large colonic tumors with low malignant potential [7], as for colonic lipomas. Although retrieval of several pieces of tissue after piecemeal resection is tedious, time-consuming, and at times frustrating, we believe that piecemeal resection of large lipomas is also useful, especially lipomas in the distal colon, because of their benign nature [3] [5].

We therefore recommend the use of a handcrafted, two-channel colonoscope for the removal of large lipomas to prevent complications and reduce technical difficulties. Although technical problems still need to be ironed out before this gains widespread acceptance, this approach represents the only option for selected patients who require surgical resection of large lipomas. The colonoscope can be put together easily, and could be available in all hospitals. We also believe that piecemeal resection of large lipomas, especially lipomas in the distal colon, is an effective alternative.

Competing interests: None

References

• 1 Koo J, Kaffes A. Endoscopic resection of large colonic lipomas assisted by a prototype single-use endoloop device.  Endoscopy. 2006;  38 644-647
• 2 Akahoshi K, Kojima H, Fujimaru T. et al . Grasping-forceps-assisted endoscopic resection of large pedunculated GI polypoid lesions.  Gastrointest Endosc. 1999;  50 95-98
• 3 Raju G S, Gomez G. Endoloop ligation of a large colonic lipoma: a novel technique.  Gastrointest Endosc. 2005;  62 988-990
• 4 Matsushita M, Takakuwa H, Matsubayashi Y. et al . Handcrafted two-channel colonoscope for grasping-forceps-assisted resection of giant pedunculated polyps.  Gastrointest Endosc. 2005;  62 132-136
• 5 Murray M A, Kwan V, Williams S T. et al . Detachable nylon loop assisted removal of large clinically significant colonic lipomas.  Gastrointest Endosc. 2005;  61 756-759
• 6 Kim C Y, Bandres D, Tio T L. et al . Endoscopic removal of large colonic lipomas.  Gastrointest Endosc. 2002;  55 929-931
• 7 Tanaka S, Haruma K, Oka S. et al . Clinicopathological features and endoscopic treatment of superficially spreading colorectal neoplasms larger than 20 mm.  Gastrointest Endosc. 2001;  54 62-66