Extraction to caecum can facilitate endoscopic resection of terminal ileal lipomas : Tongue out technique

Aims Ileal lipoma is a benign gastrointestinal subepithelial lesion that arises from the submucosa. Although most lipomas are asymptomatic, large lipomas over 2 cm in the ileum can cause symptoms, requiring resection. However, endoscopic treatment in small intestines is one of the most difficult areas to treat owing to its narrow lumen, thin wall, and its abundant mucosal blood supply. There have been previous reports of perforation during resection, as well as other reports of symptom recurrences due to incomplete resection. The high technical expertise required, and the high rate of adverse events have left surgical resection as the mainstay of treatment. We aim to assess the feasibility and technical aspects of endoscopic resection of the ileal lipoma at our hospital.

Methods We retrospectively analysed seven cases of terminal ileal lipoma endoscopically resected at NTT medical centre Tokyo, between January 2010 – October 2023. Technical success rate, resection methods, procedure time, adverse events and recurrence rate were evaluated. A novel endoscopic technique was applied for endoscopic resection of the lipoma. The technique involved extracting the lesion – either spontaneously or endoscopically – into the caecum, allowing sufficient workspace and better view. From the appearance of the lesion protruding out from the ileocecal valve, we have named this “tongue out technique” as it resembled a tongue sticking out of a mouth.

Results Median age of the patients was 74 (50-75) years old and the median size was 31 (14-55) mm in diameter. Only one case had symptoms, and the rest were resected prophylactically. “Tongue out technique” was applied on all seven cases, with all lesions being resected in the caecum, either by endoscopic extraction or by spontaneous protrusion. Three cases were resected with endoscopic mucosal resection (EMR), while endoscopic submucosal dissection (ESD) was performed on the other four. Median procedure time was 6 (4-14) minutes and 35 (10-40) minutes respectively. ESD was chosen as the treatment method when safe snare deployment around the base was not feasible due to the wide base of the lesion. For seven lesions that returned into the ileum upon insufflation, clip and band traction was applied to stabilise the lesion within the caecum. Technical success was 100% (7/7) and en bloc resection was achieved in all cases. There was one case of delayed post EMR bleeding, which was attributable to clip dislodgement. There were no perforations. No recurrence of the lipoma or associated symptoms have been observed. [1] [2] [3] [4]

Conclusions Extraction to caecum by “tongue out technique” is a feasible method to perform endoscopic en bloc resection of terminal ileal lipomas. We believe this new technique will facilitate the procedure allowing more ileal lipomas to be treated with minimally invasive and organ preserving endoscopic procedures.

Conflicts of interest

Authors do not have any conflict of interest to disclose.

• References

• 1 Noda H, Ogasawara N, Tamura Y, Kondo Y, Izawa S, Ebi M. et al. Successful Endoscopic Submucosal Dissection of a Large Terminal Ileal Lipoma. Case Rep Gastroenterol 2016; 10 (03) 506-11
• 2 Muramoto T, Negishi R, Takita M, Minato Y, Ohata K.. Successful endoscopic submucosal dissection for a huge lipoma in the terminal ileum. VideoGIE 2020; 5 (11) 575-6
• 3 Bronswijk M, Vandenbroucke AM, Bossuyt P.. Endoscopic treatment of large symptomatic colon lipomas: A systematic review of efficacy and safety. United European. Gastroenterol J 2020; 8 (10) 1147-54
• 4 Farkas N, Wong J, Bethel J, Monib S, Frampton A, Thomson S.. A systematic review of symptomatic small bowel lipomas of the jejunum and ileum. Ann Med Surg (Lond) 2020; 58: 52-67

Publication History

Article published online:
15 April 2024