Resection of a large ileal lipoma exhibiting ball-valve prolapse into the cecum with a “grasp-to-retract, ligate, unroof, and let-go” technique

 

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A 51-year-old woman was referred to our department for endoscopic resection of a symptomatic ileal lipoma, which had been detected during a previous colonoscopy performed to investigate a 6-month history of intermittent episodes of abdominal pain and diarrhea. Colonoscopy revealed a large, yellowish, pseudo-pedunculated ileal lesion with normal overlying mucosa that was prolapsed through the ileocecal valve into the cecum ([Fig. 1]).

Because of retraction of the lipoma into the terminal ileum with manipulation ([Fig. 2], [Video 1]), a two-channel therapeutic colonoscope (CF-2T160I; Olympus America, Center Valley, Pennsylvania, USA) was used. The lipoma was pulled toward the ascending colon with a grasping forceps while an endoloop (MAJ-254; Olympus), previously placed over the forceps, was positioned and tightened around its base ([Fig. 3], [Video 1]). Endoloop ligation resulted in congestion of the mucosa and the extrusion of fat – the “naked fat” sign ([Fig. 4], [Video 1]). Subsequently, unroofing was accomplished by snare resection of the top of the tumor ([Fig. 5], [Video 1]), histopathologic examination of which confirmed the clinical diagnosis. At follow-up colonoscopy 2 months later, the patient was asymptomatic, and a scar with no residual lesion was found ([Fig. 6]).

Lipomas account for 21.4 % of all benign small-bowel tumors and are located mainly in the terminal ileum [1]. Larger lipomas may result in abdominal pain, constipation, and diarrhea and require resection to avoid complications [1] [2] [3]. Although surgical resection has been used traditionally, the endoscopic removal of lipomas is increasingly being reported [1] [3]. Unlike endoscopic snare cautery of large subepithelial tumors, endoloop has a negligible risk of bowel perforation because it involves the slow mechanical transection of large pedunculated lipomas [2] [3] [4]. Its main pitfalls are the lack of a specimen for examination and the eventual need for additional ligation procedures to complete resection of the lipoma [2] [4] [5]. Nevertheless, the unroofing technique allows spontaneous enucleation of the lesion and tissue sampling [5]. This “grasp-to-retract, ligate, unroof, and let-go” technique constitutes a safe and successful approach to the management of prolapsing ileal lipomas.

Endoscopy_UCTN_Code_TTT_1AQ_2AD

• References

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