Successful removal of a giant esophageal lipoma by endoscopic submucosal dissection. Primary author, Dr. Ahmed Mohamed El-Maligoui. Co-authors include Amaya Deshmukh, Dr. Nassim Parsa, Dr. Javier Tejedor Tejada, and senior author, Dr. Jose Nieto. These are our disclosures. Esophageal lipomas are benign tumors of the esophagus, accounting for 0.4% of all benign neoplasms of the gastrointestinal tract. The majority of these lesions are small and asymptomatic. However, larger lesions can cause symptoms such as dysphagia and regurgitation. Traditionally, these lesions were removed via surgical extramucosal enucleation through thoracoscopic or laparoscopic approach. In this video, we present the application of ESD for removing a giant symptomatic broad-based esophageal lipoma. A 47-year-old male with no significant past medical history presented with progressive dysphagia of both solids and liquids of one year with significant weight loss. EGD demonstrated a large mid-esophageal bulging submucosal lesion extending to the lower esophagus. Following this, a contrast-enhanced chest CT was obtained showing a 7-centimeter mid-esophageal hypodense lesion extending to the lower esophagus, which is characteristic of a lipoma. Here, the contrast-enhanced CT of the chest showcases the large esophageal lipoma, which was almost 7 centimeters in length. A multidisciplinary team of thoracic surgeons and endoscopists chose endoscopic submucosal dissection of the lesion as the optimal next step. ESD allowed for almost total access to the lipoma. The base could not be reached. Due to its large size, piecemeal resection using a braided snare was required. Endoscopic suturing was also necessary due to the large mucosal defect. As the endoscope was passed into the mid-esophageal region, the submucosal tissue surrounding the lesion was elevated using an injection of lifting gel. Then, a hybrid IT knife was used to make a longitudinal mucosal incision at the site of the lesion and elevated submucosal tissue. Continued submucosal dissection occurred until near total access to the lipoma was achieved. However, due to the large size of the lipoma, the base was unable to be accessed. Here, the full extent of the lipoma can be visualized upon gross examination. Due to the large size of the lipoma, a combined approach using endoscopic submucosal dissection and piecemeal resection was necessary. Piecemeal resection occurred using a braided snare. Here is the mucosal defect after resection was complete. A large mucosal defect was left after the piecemeal resection of the lipoma. Initially, a hemoclip was applied to close the defect. However, it was not sufficient to fully close the mucosal gap. Then, an endoscopic suturing device was introduced to close the mucosal defect completely. Multiple bites with the suturing device were taken at the four to five o'clock position using absorbable suture material. After endoscopic suturing was complete, a small hole was still left in the mucosa. A hemoclip was applied to fully obliterate the mucosal gap. The combination of endoscopic suturing and the use of hemoclips were fully able to close the mucosal defect. Follow-up contrast enhanced CT of the chest illustrated a fine rim of dead space that resulted from the previously resected lipoma and the subsequent defect closure. Follow-up EGD displayed a complete resolution of the mucosal defect with some scar tissue present. There was no narrowing of the lumen after resection of the large esophageal lipoma. Endoscopic removal of a large esophageal lipoma was achieved using a combined endoscopic submucosal dissection and piecemeal resection approach. Closure of the defect was achieved using a combination of the hemoclip application and the endoscopic suturing device producing an excellent clinical outcome. Surgery was traditionally the treatment of choice for large symptomatic esophageal lipomas with high complication rates. This case illustrates the application of ESD as a safe and effective alternative for resection of these lesions.

endoscopic submucosal dissection

giant esophageal lipoma

dysphagia

weight loss

ESD