In this prospective cohort study we demonstrated that the “loop and let go” technique using the endoloop is an effective endoscopic therapy for large CL. Although there are other studies documenting this technique, our study stands out for being prospective and encompassing a relatively large number of patients. Indeed, we are not aware of any larger study using this technique. Thus, our data add to the existing literature on the utility of endoloop to treat submucosal tumors.
Since its initial development by Hachisu, for prevention of delayed bleeding following snare polypectomy of large polyps with thick stalks, detachable snares have become an important part of the endoscopic armamentarium in a variety of therapeutic procedures . Ligation with detachable snare has been successfully deployed in the arresting and control of bleeding of oesophageal [17, 18], gastric varices , GIST , as well as in the management of the large penduculated submucosal tumors [21–23] and ileal lipoma . Despite these publications the utilisation of endoloop for treating submucosal lesions has been mainly reflected by single case reports or small case series .
Although the term “loop and let go” is a misnomer, since it is the virtue of ligation and not the looping that produces an asymptomatic, slow mechanical transection of the lesion, the term has gained far more acceptance in the literature, than the proper form of “ligate and let go”.
In general, endoloop ligation of gastrointestinal lesions without resection is conceptually simple and has the potential to eliminate the risk of perforation or bleeding inherent to the electrocautery. However, only those lesions capable of resulting in problems and complications should be targeted, whereas lipomas smaller than 2 cm and asymptomatic warrant no treatment .
There are some drawbacks of the ligation technique in regard to the management of large symptomatic colonic lipomas. In order to effectively ligate the lipoma, the stalk needs to be clearly seen, preferably at 5–7 o’clock position. If not, reposition of the patient is required, which may be cumbersome in some situations. Furthermore, the endoscopic ligation should not be attempted in the treatment of broad based or sessile colonic lipomas . In these circumstances, endoscopic or surgical resection may be appropriate. Finally, a potential disadvantage of this technique is that the entire lesion is not recovered for histopathologic evaluation.
There are promising reports of a successful endoscopic resection of large CL [12, 26]. However, we believe that this technique has several potential advantages over exisitng methods of endoscopic removal as the “loop and let go” technique avoids the risks associated with electrocautery, potential less hospital stay and theoretical advantage of less perforation. Specifically, when dealing with fatty tissue and lipomas, any endosocpist has certainly endured the difficult situation of having to apply massive amounts of currents to finally resect this lesions.
Our study has potential limitations. First, it is a relative small number of patients from a single center. However, this study represents one of the largest series using the technique of “loop-and-let-go” reported so far. Second, the threshold limit that we used was 2 cm, since, the data in the literature suggest that polyps larger than this isze are more likely to cause problems . Furthermore, we only included symptomatic patients. Finally, our centre is a tertiary university medical centre and the results may not be reproduced in smaller endoscopy units. However, we believe that any skilled endoscopist should be able to master this technique.