Managing large duodenal lipoma by duodenoscope

Dr. Yong PangYong  Pang, MD, and colleagues from the General Hospital of Chengdu Military Region of PLA in China report on this video case “Unroofing and grasp-and-snare techniques in the management of large duodenal lipoma by duodenoscope combined with double-channel endoscope.”

In this video, we describe a new combined method for endoscopic resection of large duodenal lipoma. Initially, a duodenoscope  was used to apply the unroofing technique which involves snaring at the base of the mass and resecting its upper half. Then the 2-channel therapeutic endoscope  was exchanged and the grasp-and-snare technique was applied to resect the residual fatty tissue. Finally the large defect was closed by hemoclips. The patient was discharged home with no adverse events and the symptom of post-prandial upper abdominal pain disappeared completely at one month follow up.

Because the duodenal wall is a thin and highly vascular structure, standard endoscopic snare cautery of lipomas 2cm or larger has been associated with a higher risk of perforation and bleeding. Looping of lipomas has been widely accepted as a safe therapeutic option. But there are a few aspects to be considered in this method. The main limitation of endolooping is the possibility of loop loosening. Another limitation of endolooping is specimen retrieval because it is difficult to estimate whether the tumor has been transected completely. For historical confirmation, an endoloop-assisted unroofing technique has been developed. However, unroofing the upper half of the mass may increase the risk of loop loosening. Endoscopic management of large duodenal lipoma is still challenging.

We combined two endoscopic techniques for safe and complete resection of a large duodenal lipoma. The upper greater half of the mass was first transected with unroofing technique to reduce the risk of perforation. Then the grasp-and-snare technique was adopted to eliminate residual fat tissues.

We choose two types of endoscopes to perform unroofing and grasp-and-snare technique, respectively. Since the lesion was located on the anterior wall of the duodenum, a side-viewing instrument was optimal as this gives the best en face access to the lesion. The duodenoscope was initially used to apply the unroofing technique. The grasp-and-snare technique can only be accomplished by using the 2-channel therapeutic endoscope.

As for the clip closure, larger defects may require placement of clips starting from both ends of the wound and proceeding to the center. Another key point is the rotator function of the device, which enables control of the direction of the clip, and was very useful for neatly suturing the wound. Air insufflation was kept to a minimum and air was suctioned just before the clip release to let both edges close.

Figure 1Figure 1. A 2.5-cm submucosal bulge in the second portion of the duodenum occupying one-third of the lumen.

Given that the lesion was a lipoma, was complete resection of the base necessary? Although CT imaging, EUS, and endoscopic examination findings were all consistent with duodenal lipoma before endoscopic resection, histological confirmation has yet not been achieved. The possibility of intestinal liposarcoma cannot been completely excluded, so complete resection of the base is still necessary. On the other hand, after unroofing the upper half of the mass, the residual yellow adipose tissue is exposed and visible. We are familiar with grasp-and-snare technique and in this setting, this method was taken naturally and residual fat tissue was eliminated successfully.

Watch the video here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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