Post written by Bing Hu, MD, and Toshio Uraoka, MD, PhD, from the Department of Gastroenterology, West China Hospital, Sichuan University, China.

This video presents a case in which EGD showed a huge mass in the duodenum. There was a Forrest-type 2B ulcer at the distal end. CT and EUS characteristics were consistent for lipoma. On EGD, the location was from the second portion to the third portion of duodenum. The base of the lesion was wide. The lesion was en bloc resected by ESD without any complications.

Duodenal ESD is more difficult than that of the esophagus or stomach, and it has a high risk of perforation and postoperative bleeding. Endoscopic resection of a giant duodenal lipoma is feasible, but an ability to control the endoscopy and exposure is needed.

Gastrointestinal (GI) lipomas are slow-growing submucosa tumors found throughout the GI tract, and they account for 4% of all benign GI tumors. Of all the GI lipomas, colonic lipomas are the most common (64%), while only 4% are duodenal lipomas. Duodenal lipoma usually presents as a round or ovoid mass, with regular or lobulated contours. They are soft, which can be confirmed by touching it using a biopsy forceps. The surface mucosa of the lipoma is usually normal.  Erosion or ulceration can be found in few cases. Most GI lipomas are submucosal origin. There is a definite boundary between lipomas and the muscularis propria. The lesion is yellow, and it is relatively recognizable in the ESD process. CT scan can facilitate the preoperative diagnosis of lipoma based on low-attenuation signals of -50 to -100 Hounsfield units. Endoscopic ultrasound (EUS) can also make a correct diagnosis for lipoma, with features of hyperechoic and homogenous mass within the submucosal layer. EUS can also show the depth and invasion of the lesion.

The majority of GI lipomas are found incidentally, and most patients are asymptomatic. The clinical symptoms include abdominal pain, intussusception, and, rarely, GI bleeding. Asymptomatic duodenal lipoma may be monitored, but symptomatic duodenal lipomas warrant intervention. Surgery was traditionally the treatment for large symptomatic lipomas; however, endoscopic treatment is now becoming increasingly favored due to less invasiveness and morbidity. The endoscopic treatment methods used depend on the shape and size of the lesion and the technique of the endoscopists. Endoscopic techniques such as snare polypectomy, ESD, and endoloop have been reported, but these techniques are typically limited to duodenal lipomas much smaller then 10cm. Our report showed endoscopic resection of a giant duodenal lipoma is feasible. This complex technique should be performed by experienced endoscopists in a tertiary hospital due to high risks of perforation and post-operative complications.

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