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.
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