Is endoscopic submucosal dissection really contraindicated for a large submucosal lipoma of the colon?

has recently been developed for endo− scopic treatment of gastrointestinal tu− mors, enabling en bloc resection of even large tumors [1,2]. Although many en− doscopists now perform ESD for early− stage gastric cancer, ESD has yet to be es− tablished as a safe therapy for colonic dis− eases, even in Japan. It is still unclear whether ESD is indicated for submucosal tumors (SMTs), and ESD for colonic dis− eases is still a controversial issue due to the considerable risk of perforation. In the pre−ESD era, SMTs required surgical treatment. Here we describe a unique case of a large submucosal lipoma of the colon which was successfully resected en bloc by ESD. The patient was a 62−year−old woman with a giant SMT in the descending colon. Colonoscopic examination revealed a yel− lowish protruding submucosal tumor ap− proximately 5 cm in diameter, suggesting that it might be totally resectable by ESD (l" Figures 1 a, b). The technical aspects of our ESD proce− dure for this SMT are as follows. The first step was to create a sufficient submucosal fluid cushion to lift the tumor from the muscle layer. The submucosal injection solution was a mixture of 1 % 1900−kDa hyaluronic acid and 10 % glycerin with 5 % fructose plus 0.9 % saline solution, with a small amount of indigo carmine and epinephrine [3]. The next step was to pre− cut the surrounding mucosa and dissect the connective submucosal tissue under the SMT from the anal side while observ− ing the lower surface of the tumor [4] (l" Figures 1 b, c). It was possible to make the giant SMT hang from the colonic wall by controlling the body position of the pa− tient, and this made it easy to preserve the muscular layer (l" Figure 1 d). ESD may be sufficient for en bloc resec− tion of submucosal tumors in selected cases.