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

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]).

Fig. 1 Endoscopic image of an ileal submucosal lesion with a normal overlying mucosa. The lesion has prolapsed through the ileocecal valve into the cecum.

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]).

Fig. 2 Endoscopic image showing retraction of the lipoma into the terminal ileum.

Management of a large ileal lipoma by applying the “grasp-to-retract, ligate, unroof, and let-go” technique with a double-channel therapeutic colonoscope.

Fig. 3 Endoscopic image depicting the use of a grasping forceps to pull the lipoma toward the ascending colon, allowing placement of the endoloop.

Fig. 4 Endoscopic image revealing the extrusion of fat – the “naked fat” sign – after endoloop ligation.

Fig. 5 Endoscopic image showing unroofing after snare resection of the top of the tumor for tissue sampling.

Fig. 6 Narrow-band imaging and electronic zoom to 1.2 × magnification reveal a scar with no residual lesion.

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

• 1 Yoshimura H, Murata K, Takase K et al. A case of lipoma of the terminal ileum treated by endoscopic removal. Gastrointest Endosc 1997; 46: 461-463
• 2 Raju GS, Gomez G. Endoloop ligation of a large colonic lipoma: a novel technique. Gastrointest Endosc 2005; 62: 988-990
• 3 Ivekovic H, Rustemovic N, Brkic T et al. Endoscopic ligation (“Loop-And-Let-Go”) is effective treatment for large colonic lipomas: a prospective validation study. BMC Gastroenterol 2014; 14: 122
• 4 Veloso R, Pinho R, Rodrigues A et al. Endoloop ligation (“loop-and-let-go”) of a large ileal lipoma by balloon-assisted enteroscopy. Endoscopy UCTN 2012; 44: E176
• 5 Binmoeller KF, Shah JN, Bhat YM et al. Retract-ligate-unroof-biopsy: a novel approach to the diagnosis and therapy of large nonpedunculated stromal tumors (with video). Gastrointest Endosc 2013; 77: 803-808