Post written by Takashi Muramoto, MD, PhD, from the Department of Gastrointestinal Endoscopy, NTT Medical Center Tokyo, Tokyo, Japan.

The video describes successful endoscopic submucosal dissection (ESD) for a huge lipoma in the terminal ileum. A 74-year-old man underwent a computed tomography because of intermittent lower-abdominal pain, and the images revealed a tumor in the ileocecal region. The endoscopic examination showed the lesion to be a soft yellowish submucosal tumor measuring 40 mm in diameter located in the terminal ileum. Based on CT and endoscopic findings, we made a diagnosis of lipoma. Since the huge tumor was thought to be the cause of the patient’s intermittent abdominal pain, we decided to remove the tumor by ESD.

The entire procedure is shown in the video. DualKnife (Olympus, Tokyo, Japan) was used as the endo-device, and local injection of hyaluronic acid was administered. First, upon making the incision and dissecting along the ileal side as upstream as possible to the ileocecal valve, the tumor was completely migrated into the cecum without being stuck to the ileum. Since the dissection revealed that the tumor had invaded the muscular layer, it was necessary to partially dissect the muscular layer. The incision was then made circumferential by making an additional incision on the cecal side, and the remaining submucosal layer was dissected, which made it possible to efficiently remove the tumor en bloc. Finally, the ulcer floor after ESD was closed completely with endoclips. The procedure time was 40 minutes, without adverse events, and the specimen measured 38×27×25 mm in size. He was discharged 4 days postoperatively and histological examination confirmed the diagnosis of lipoma without malignancy.

Previously, such tumors were treated surgically, but if endoscopic resection is possible, the physical burden on the patient is reduced. ESD was selected as the method of endoscopic resection instead of endoscopic unroofing or endoscopic mucosal resection because the tumor was huge and fully occupied the ileal lumen, and there was not enough space to deploy a snare at the place.

There have been no previous reports accompanied by a video that clearly show the strategies for safely and efficiently removing this tumor. We consider that there are 2 important points in the treatment of our patients. First, since there was not enough space for treatment in the ileum, all of the procedures should be performed in the cecum with space. Second, incision and adequate dissection on the ileal side were performed first in order to prevent the lesion from becoming stuck in the ileum during the procedure.

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