An 82-year-old female patient was referred for consideration of endoscopic treatment of an estimated 30-mm subepithelial lesion in the descending duodenum presumed to represent a lipoma. Epigastric discomfort did not benefit from proton pump inhibition and other medications under the assumption of functional dyspepsia. The patient finally consented to endoscopic treatment with a loop-and-let-go technique devised for this benign condition with a questionable symptom correlation. Endoscopy recapitulated a soft elongated lesion with yellowish appearance with a naked fat sign after forceps biopsy at the tip ([Fig. 1A]). Endoloop placement at the base was uncomplicated; however, loop dysfunction resulted in circumferential avulsion of mucosal covering, leaving behind a central stalk with feeding vessels ([Fig. 1B]). Rescue clipping of the lesion was intended using two 16-mm clips as indicated by figures, providing the stalk and the mucosal defect, respectively. This was accomplished without difficulty ([Fig. 1C]) with repeat endoscopy the following day indicating complete necrosis of the lesion ([Fig. 1D]). While the further clinical course was uncomplicated, providing minor symptomatic improvement, final endoscopic assessment after 3 weeks demonstrated complete eradication and healing with one clip still in situ ([Fig. 1E]).
Fig. 1 (A) Estimated 3-cm, finger-like duodenal lipoma with the naked fat sign exposed at the tip after forceps manipulation. (B) Mucosal detachment with the vessel pedicle and lipoma tissue exposed after endoloop misdeployment. (1, 2: intended clip positioning to rescue failure in the loop-and-let-go technique). (C) Two hemoclips applied at pedicle to induce tissue necrosis (clip-and-let-go bailout) and at mucosal tear. (D) Complete lipoma necrosis at day 1. (E) Final result with complete lipoma eradication at day 21.
This is the first description of a clip-and-let-go as an endoscopic bailout for failure of the loop-and-let-go concept due to ligation misdeployment for a small-based lipoma.[1]
