Endoscopic liposuction, dilemmas in removing large gastric lipomas. Gastric lipomas are rare adipose tumors that constitute less than 1% of gastric tumors and arise from the submucosal layer of the stomach. They are generally benign and are only removed when symptomatic, which typically manifests as gastric outlet obstruction or bleeding due to ulceration. Various endoscopic techniques, including ESD for removal, have been described. 75% of gastric lipomas are located in the antrum, hence their predisposition to present with gastric outlet obstruction. Over 90% originate from the submucosal layer of the stomach with the remaining arising from the subsurosal layer. Although in all cases, endoscopic ultrasound should be used to determine the layer of origin, particularly before attempted resection. Notably, these lesions are surrounded by a thick, fibrous capsule. Our case involves a 69-year-old woman who was admitted to the hospital with abdominal pain and weight loss. A CT of the abdomen and pelvis demonstrated a 5.7 by 4.5 centimeter focus of fat density in the distal gastric body consistent with the lipoma. An EGD was performed for further evaluation, which showed the same findings as seen on CT of a large lipoma originating on a stalk in the distal body, which was intermittently obstructing the pylorus. Her medical history was notable for marked obesity, PBC, COPD, and lymphedema, making her a poor surgical candidate. Therefore, after multidisciplinary discussion, a decision was made to proceed with endoscopic resection. This is the endoscopic view of the large gastric lipoma ball valving into the pylorus. You can see it originates on a thick stalk in the distal gastric body and essentially completely obstructs gastric output. The size of the lesion can be appreciated here with a forward-viewing scope. Once the lesion was evaluated endoscopically, an EUS was performed to confirm the diagnosis. This demonstrated a large, hyperechoic lesion arising from the submucosa measuring over 5 centimeters. Therefore, the decision was made to pursue ESD. To begin, the borders of the lesion were marked with APC. Submucosal injection was then performed using a combination of head of starch with methylene blue and diluted epinephrine. Once a lift was performed, the initial mucosal incision was made using a needle knife along the marked edges. Then submucosal dissection was performed to completely resect the lesion from the gastric wall. Here you can see the end of the dissection when the mass separated from the gastric wall. Once the lesion was resected, the closure was performed. Initially, a hemostatic gel was applied to cover the entire base. Then, a loop and clip cinch technique was used to close the site through a double channel scope. With this technique, a clip is used to attach a loop to the edges of the resection site and then the loop is cinched closed. Here you can see the resected mass in the gastric fundus, at which point the focus returned on how to remove this lesion. Its size precluded on-block removal. There was a discussion around leaving the lesion to be broken down by digestive enzymes. However, its size raised a concern for potential intestinal obstruction with this approach. Therefore, piecemeal resection was planned. Initially, a snare resection was attempted, but our largest snare, which was 33 millimeters, was unable to fit around the lesion. Additionally, because it was resected from the wall of the stomach and because of its fat-containing nature, cautery was not effective. The goal became to expose the fat inside the lesion. Two graspers were used to pierce the capsule through a double-channel scope. This allowed fat to extrude from the mass. Then, needle-knife cutting was applied to the area where the capsule was pierced by the graspers. This allowed for further dissection of the capsule to expose the underlying fat. Once the capsule was opened and fat was exposed, a snare was used to mechanically break apart the lesion and allow for piecemeal resection. Individual pieces were removed with a net, and complete retrieval was achieved. This case brought up several interesting points regarding endoscopic removal of large gastric lipomas. It demonstrates that resection can be performed safely, but more importantly, it shows that retrieval can be challenging because of size and inability to break the lesion into smaller fragments. Fragmentation is particularly difficult with lipomas given the tough, fibrous capsule and poor electrical conductivity of fat through a lesion when it is no longer connected to the GI tract wall. Although case reports exist describing resection of large gastric lipomas greater than 3 cm, the approach to and method of retrieval are not often discussed. While it has been hypothesized that retrieval may not be necessary because gastric acid will break down the capsule and allow for passage into the duodenum, intestinal obstruction due to retained specimen has been described in the literature. In conclusion, symptomatic large gastric lipomas should be removed and ESD offers a promising non-surgical option. The approach to retrieval should be a part of pre-procedure planning to avoid a retained specimen and the potential for intestinal obstruction, particularly with larger lesions. The optimal way to achieve retrieval of these specimens has not yet been established, but techniques continue to evolve with a variety of new endoscopic devices.

gastric lipomas

endoscopic submucosal dissection

ultrasound guidance

fragmentation

retrieval planning