Endoscopic Resection of Large Duodenal Lipoma

Experienced teaching points

Clinical Pearls

Performing a straight hot snare resection on a lipoma is highly dangerous: adipose tissue has high electrical resistance, increasing the risk of thermal injury, perforation, and the snare becoming stuck to the greasy tissue.
For safe resection, pre-inject the base and perform a hemi- or complete circumferential mucosal incision ('pre-cutting') before using the snare.
When finally snaring the lipoma, use pure cutting current rather than coagulation to prevent the snare from adhering to the fat.
Due to the thin duodenal wall and high vascularity, prophylactic closure of the mucosectomy site with clips is mandatory to prevent delayed perforation or catastrophic post-resection bleeding.

The lesion has characteristic findings of a lipoma: a) yellowish color, b) submucosal location, c) upon applying the tip of closed biopsy forceps the lesions was soft, d) the overlying mucosa was intact (Panel A, B). The latter finding is not always present in lipomas, as these may ulcerate and bleed (1, 2). As large lipomas like these ones can result in obstruction, intussusception, gastric outlet obstruction, bleeding and ulceration a decision was taken to resect it (2, 3).

Key aspects when resecting a duodenal lipoma:

Carefully characterize the lesion endoscopically. Evaluate its location in relation to the papilla. Apply air (CO₂) and observe its mobility. Use water to determine the location. Examine the base of the lesion. In this case it was semi pedunculated (Panel C).

Performing straight hot snare resection for lipomas is risky, as the fat tissue decreases electrical, conduction, thus creating resistance to the cutting electrical currents, increasing the chances of burning and perforation. Also, there is a risk of the snare getting stuck or glued to the partially cauterized, greasy lesion (4). For these reasons we like to pre-inject the base of the lesion (Panel D) and then perform a hemi- or complete circumferential mucosal and submucosal incision (Panel E).

Once the hemi circumferential incision and cutting (“pre-cutting”) was accomplished, a snare was then used to resect the lipoma using pure cutting currents (yellow pedal) (Panel F). Do not use coagulation current, as this increases the chances of the snare getting stuck to the greasy polyp.

The resection site was clean without evidence of deep damage. However, in the duodenum it is always imperative to close the wound using several clips. The duodenum is highly vascularized, and the chances of post-resection bleeding are very high. In addition, the wall of the duodenum is thin and delayed post- resection perforation may occur, which can be catastrophic. For these reasons I ALWAYS close the mucosectomy sites in the duodenum.

References

Ouwerkerk HM, Raber, Freling G, Klaase JM. Duodenal Lipoma as a Rare Cause of Upper Gastrointestinal Bleeding. Gastroenterology Res. 2010 Dec;3(6):290-292. doi: 10.4021/gr260w. Epub 2010 Nov 20. PMID: 27942311; PMCID: PMC5139859.

Pei MW, Hu MR, Chen WB, Qin C. Diagnosis and Treatment of Duodenal Lipoma: A Systematic Review and a Case Report. J Clin Diagn Res. 2017 Jul;11(7):PE01-PE05. doi: 10.7860/JCDR/2017/27748.10322. Epub 2017 Jul 1. PMID: 28892976; PMCID: PMC5583857.Parsi MA, Yerian LM. Iron ulcers. Clin Gastroenterol Hepatol. 2009 Oct;7(10):A22. doi: 10.1016/j.cgh.2009.01.005. Epub 2009 Jan 24. PMID: 19558995.

Tjandra, Douglas BBiomed, MD1; Knowles, Brett BSc, MBCh B, FRACS2,3; Simkin, Paul MBBS, FRANZCR3,4; Kranz, Sevastjan MBBS, FRACP5; Metz, Andrew MBBS, FRACP1,3. Duodenal Lipoma Causing Intussusception and Gastric Outlet Obstruction. ACG Case Reports Journal 6(11):p e00157, November 2019. | DOI: 10.14309/crj.0000000000000157

Phatharacharukul P, Wajid M, Fatima H. Delayed Removal of Entrapped Snare in Colonoscopic Polypectomy. ACG Case Rep J. 2021;8(1):e00535. Published 2021 Jan 27. doi:10.14309/crj.0000000000000535

About the author

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE

Editor-in-Chief, The Practicing Endoscopist

Professor of Medicine, Carilion Memorial Hospital / Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA

Klaus Mönkemüller, MD, PhD, FASGE, FJGES, FESGE, is the editor-in-chief of The Practicing Endoscopist and the founder of EndoCollab. He is Professor of Medicine at Virginia Tech Carilion School of Medicine and a practicing endoscopist at Carilion Memorial Hospital in Roanoke, Virginia.

Dr. Mönkemüller has published extensively on endoscopic techniques and devices, with a particular focus on therapeutic endoscopy, foreign body removal, GI bleeding, and the use of caps and accessories in everyday practice. He lectures internationally and has contributed to multiple GI endoscopy textbooks and atlases.

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