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Endoloop-assisted unroofing for the treatment of symptomatic duodenal lipomas
Brief Reports 9. Masci E, Toti G, Mariani A, et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study. Am J Gastroenterol 2001;96:417-23. 10. Paraskevas G, Papaziogas B, Natsis K, et al. Abnormal location of papilla of Vater: a cadaveric study [English abstract]. Folia Morphol 2005;64:51-3. 11. Pereira-Lima J, Pereira-Lima LM, Nestrowski M, et al. Anomalaous location of the papilla of Vater. Am J Surg 1974;128:71-4. 12. Levine MP. Anomalous location of the papilla of Vater. Am Surg 1976; 42:135-7.
Department of Hepato-Gastroenterology (Y-K.T., N-J.L.), Department of Surgery (Y-Y.J.), Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taipei, Taiwan. Reprint requests: Nai-Jen Liu, MD, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan, ROC Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.02.078
Endoloop-assisted unroofing for the treatment of symptomatic duodenal lipomas Wen-Hsin Huang, MD, Cheng-Yuan Peng, MD, PhD, Cheng-Ju Yu, MD, Jen-Wei Chou, MD, Chun-Lung Feng, MD Taichung, Taiwan
Lipomas of the duodenum are relatively uncommon findings that usually are detected incidentally at endoscopy and mostly are asymptomatic. However, duodenal lipomas that increase in size to the extent of 1 to 7 cm in the greatest dimension may cause various symptoms, including discomfort or pain in the upper abdomen, intestinal obstruction, intussusception, or GI bleeding.1-5 Recently, because of advances in techniques and accessories used in endoscopy, endoscopic snare polypectomy has been used for the treatment of large, symptomatic lipomas of the duodenum.2-4 However, standard endoscopic polypectomy is associated with a risk of postpolypectomy hemorrhage and perforation.6,7 We reported on 2 patients who were seen with upper-abdominal fullness after eating. A diagnostic workup revealed clinically significant lipomas in the duodenum. To safely remove the lipomas, the patients underwent the endoloop-assisted unroofing technique for endoscopic removal of the masses. To the best of our knowledge, this is the first report of symptomatic duodenal lipomas excised endoscopically with the assistance of the endoloop and unroofing technique.
CASE REPORTS Case 1 A 46-year-old man came to the hospital because of upperabdominal fullness after eating, which he had experienced over a period of 4 months. An EGD showed a broad-based pedunculated submucosal mass, approximately 2 cm in the greatest dimension, in the duodenal bulb. The mass was adjacent to the pyloric ring and partially obstructed the pylorus. An EUS demonstrated a homogeneous and hyperechoic mass in the submucosal layer of the duodenal wall, which was suggestive of a lipoma of the duodenum. The patient underwent an endoscopic resection of the li1234 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
Figure 1. Endoscopic view of a broad-based polypoid mass with smooth and yellow mucosa in the duodenum. The mass partially covered the main duodenal papilla (arrow).
poma with the unroofing technique, which transected the upper portion of the mass after application of a ligating device (HX-20U-1; Olympus, Tokyo, Japan) to the mass base. The ligating device is composed of a handle and a detachable endoloop (MAJ-254; Olympus). There was no procedurerelated complication. Histopathologic examination of the excised specimen confirmed the diagnosis of a lipoma, which was composed of mature adipose tissue, in the submucosa of the duodenum. A follow-up endoscopy 3 months later showed scarred mucosa, without any residual mass.
Case 2 A 75-year-old woman was referred to the hospital with a 2-month history of postprandial fullness and a duodenal submucosal mass. A duodenoscopy showed a broad-based www.giejournal.org
Brief Reports
Figure 4. Extruding fat was noted after the upper portion of the mass was transected with an electrocautery snare (arrow).
Figure 2. An endosonogram, showing a homogeneous and hyperechoic mass (arrow) with smooth borders in the third duodenal-wall layer.
Figure 3. The duodenal lipoma was ligated with an endoloop (arrow).
polypoid mass, approximately 20 15 15 mm, with a smooth and yellow surface in the second portion of the duodenum (Fig. 1). An EUS demonstrated a homogeneously hyperechoic lesion with smooth borders located in the submucosal layer of duodenal wall (Fig. 2). The patient underwent an endoscopic resection of the lipoma with the endoloop-assisted unroofing technique (Figs. 3 and 4). Extruding fat was observed after the resection of the upper portion of the mass, which coincided with the diagnosis of a duodenal lipoma.
DISCUSSION Lipomas of the GI tract are uncommon, and those of the duodenum are extremely rare. Indeed, the incidence of duwww.giejournal.org
odenal lipoma was only 0.16% among 4000 cases of benign intestinal masses.8 Most of these masses were asymptomatic and were found incidentally at endoscopy, surgery, or autopsy. However, large duodenal lipomas may produce symptoms of dyspepsia, intestinal obstruction, or bleeding.1-5 There are some scattered reports of successful endoscopic removal of symptomatic lipomas of the duodenum when using standard electrosurgical methods.2-4 However, a resection of lipomas 2 cm or larger has been associated with a higher risk of perforation and bleeding.6,9 Recently, many techniques and devices for use in endoscopy were developed to safely remove large and symptomatic lipomas.7,10 The endoloop, which enables endoscopic ligation of the base of an elevated lesion, was first developed by Hachisu11 in 1991. The loop is electrically nonconductive and consists of a heat-treated elliptically shaped nylon thread and a silicone rubber stopper that maintains tightness of the loop. The previous study revealed that bleeding during or after a polypectomy with detachable endoloops occurred significantly less frequently than without the assistance of endoloops.6 In addition, the endoloop may prevent the risk of perforation, because fixing the tumor base by an endoloop before a polypectomy can prevent the serosa from invaginating into the pedicle. Large and broad-based duodenal lipomas are highly vascular structures that carry a greater risk of bleeding when a mass resection is performed. The correct application of the endoloop before a mass resection may reduce the probability of such bleeding and thereby permit the mass to be safely excised. Because the intestinal wall of the duodenum is thin, standard endoscopic snare polypectomy may cause bowel perforation. In addition, a mass with a broad base such as the masses in our patients is a risk factor for bowel perforation.7 The unroofing technique, which was first introduced by Mimura et al12 in 1997, only cuts off the upper half of a submucosal tumor and thus greatly reduces the possibility of bowel Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1235
Brief Reports
perforation. Moreover, a lipoma can be removed completely, without any residual mass after elimination of the remaining adipose tissue. Extruding fat from the cut surface after a polypectomy is always mandatory for the diagnosis of an intestinal lipoma. Thus, endoscopic unroofing may prevent bowel perforation, particularly in cases of intestinal lipomas with broad-based pedicles, as in our patients, and, therefore, a duodenal lipoma can be removed safely and completely. Duodenal lipomas, which are benign submucosal masses, have been reported to possess certain characteristic endoscopic features. A diagnosis of a lipoma cannot be made on the basis of conventional forceps-biopsy specimens. EUS is a diagnostic tool that images the digestive wall as a US 5-layered structure. The characteristic feature of a lipoma on EUS images, which provides diagnostic evidence, is a homogenous hyperechoic mass localized in the submucosal layer.13 In addition, an EUS can precisely assess the location of a lipoma in the submucosa that does not extend into the muscularis propri and can detect the rare instance of a lipoma located in the subserosa. Therefore, endoscopic removal of a duodenal lipoma should be based on the findings of EUS. In summary, it is uncommon for duodenal lipomas to cause clinically significant symptoms. Symptomatic lipomas of the duodenum should be treated by an endoscopic resection after an EUS confirms that the mass is localized in the submucosa. The present cases are the first report of a symptomatic duodenal lipoma excised endoscopically with the unroofing technique and with assistance of an endoloop. The endoloop-assisted unroofing technique is safe and effective for treatment and histologic confirmation of a symptomatic and broad-based pedunculated lipoma of the duodenum.
DISCLOSURE The authors report that there are no disclosures relevant to this publication.
REFERENCES 1. Sarma DP, Weilbaecher TG, Basavaraj A, et al. Symptomatic lipoma of the duodenum. J Surg Oncol 1984;25:133-5. 2. Sou S, Nomura H, Takaki Y, et al. Hemorrhagic duodenal lipoma managed by endoscopic resection. J Gastroenterol Hepatol 2006;21: 479-81. 3. Blanchet MC, Arnal E, Paparel P, et al. Obstructive duodenal lipoma successfully treated by endoscopic polypectomy. Gastrointest Endosc 2003;58:938-9. 4. Tung CF, Chow WK, Peng YC, et al. Bleeding duodenal lipoma successfully treated with endoscopic polypectomy. Gastrointest Endosc 2001; 54:116-7. 5. Hizawa K, Kawasaki M, Kouzuki T, et al. Unroofing technique for the endoscopic resection of a large duodenal lipoma. Gastrointest Endosc 1999;49:391-2. 6. Iishi H, Tatsuta M, Narahara H, et al. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 1996;44:594-7. 7. Kim CY, Bandres D, Tio TL, et al. Endoscopic removal of large colonic lipomas. Gastrointest Endosc 2002;55:929-31. 8. Mayo CW, Pagtaluman RJG, Brown DJ. Lipoma of the alimentary tract. Surgery 1963;53:598-603. 9. Bar-Meir S, Halla A, Baratz M. Endoscopic removal of colonic lipomas. Endoscopy 1981;13:135-6. 10. Murray MA, Kwan V, Williams SJ, et al. Detachable nylon loop assisted removal of large clinically significant colonic lipomas. Gastrointest Endosc 2005;61:756-9. 11. Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 1991;5:70-4. 12. Mimura T, Kuramoto S, Hashimoto M, et al. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997;46:259-63. 13. Nakamura S, Iida M, Suekane H, et al. Endoscopic removal of gastric lipoma: diagnostic value of endoscopic ultrasonography. Am J Gastroenterol 1991;86:619-21.
Current affiliations: Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan. Reprint requests: Wen-Hsin Huang, MD, Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, No 2, Yuh-Der Rd, Taichung 404, Taiwan. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.03.003
Spontaneous perforation of the duodenum by a migrated ureteral stent Ian Wall, DO, Robin Baradarian, MD, Matthew Tangorra, DO, Nison Badalov, MD, Kadirawel Iswara, MD, Jianjun Li, MD, Scott Tenner, MD, MPH Brooklyn, New York, USA
Iatrogenic duodenal perforation is a rare event and typically results from an intraluminal intervention, especially ERCP sphincterotomy. There are isolated reports of duodenal perforations from other forms of endoscopic interven1236 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
tions, such as migrated esophageal stents, gastroduodenal stents, biliary endoprosthestics, and EUS.1-4 Rarely, duodenal perforations result from interventions outside the GI tract, such as with inferior vena cava filter placement.5 www.giejournal.org
Department of Hepato-Gastroenterology (Y-K.T., N-J.L.), Department of Surgery (Y-Y.J.), Chang Gung Memorial Hospital & Chang Gung University College of Medicine, Taipei, Taiwan. Reprint requests: Nai-Jen Liu, MD, 5, Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan, ROC Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.02.078
Endoloop-assisted unroofing for the treatment of symptomatic duodenal lipomas Wen-Hsin Huang, MD, Cheng-Yuan Peng, MD, PhD, Cheng-Ju Yu, MD, Jen-Wei Chou, MD, Chun-Lung Feng, MD Taichung, Taiwan
Lipomas of the duodenum are relatively uncommon findings that usually are detected incidentally at endoscopy and mostly are asymptomatic. However, duodenal lipomas that increase in size to the extent of 1 to 7 cm in the greatest dimension may cause various symptoms, including discomfort or pain in the upper abdomen, intestinal obstruction, intussusception, or GI bleeding.1-5 Recently, because of advances in techniques and accessories used in endoscopy, endoscopic snare polypectomy has been used for the treatment of large, symptomatic lipomas of the duodenum.2-4 However, standard endoscopic polypectomy is associated with a risk of postpolypectomy hemorrhage and perforation.6,7 We reported on 2 patients who were seen with upper-abdominal fullness after eating. A diagnostic workup revealed clinically significant lipomas in the duodenum. To safely remove the lipomas, the patients underwent the endoloop-assisted unroofing technique for endoscopic removal of the masses. To the best of our knowledge, this is the first report of symptomatic duodenal lipomas excised endoscopically with the assistance of the endoloop and unroofing technique.
CASE REPORTS Case 1 A 46-year-old man came to the hospital because of upperabdominal fullness after eating, which he had experienced over a period of 4 months. An EGD showed a broad-based pedunculated submucosal mass, approximately 2 cm in the greatest dimension, in the duodenal bulb. The mass was adjacent to the pyloric ring and partially obstructed the pylorus. An EUS demonstrated a homogeneous and hyperechoic mass in the submucosal layer of the duodenal wall, which was suggestive of a lipoma of the duodenum. The patient underwent an endoscopic resection of the li1234 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
Figure 1. Endoscopic view of a broad-based polypoid mass with smooth and yellow mucosa in the duodenum. The mass partially covered the main duodenal papilla (arrow).
poma with the unroofing technique, which transected the upper portion of the mass after application of a ligating device (HX-20U-1; Olympus, Tokyo, Japan) to the mass base. The ligating device is composed of a handle and a detachable endoloop (MAJ-254; Olympus). There was no procedurerelated complication. Histopathologic examination of the excised specimen confirmed the diagnosis of a lipoma, which was composed of mature adipose tissue, in the submucosa of the duodenum. A follow-up endoscopy 3 months later showed scarred mucosa, without any residual mass.
Case 2 A 75-year-old woman was referred to the hospital with a 2-month history of postprandial fullness and a duodenal submucosal mass. A duodenoscopy showed a broad-based www.giejournal.org
Brief Reports
Figure 4. Extruding fat was noted after the upper portion of the mass was transected with an electrocautery snare (arrow).
Figure 2. An endosonogram, showing a homogeneous and hyperechoic mass (arrow) with smooth borders in the third duodenal-wall layer.
Figure 3. The duodenal lipoma was ligated with an endoloop (arrow).
polypoid mass, approximately 20 15 15 mm, with a smooth and yellow surface in the second portion of the duodenum (Fig. 1). An EUS demonstrated a homogeneously hyperechoic lesion with smooth borders located in the submucosal layer of duodenal wall (Fig. 2). The patient underwent an endoscopic resection of the lipoma with the endoloop-assisted unroofing technique (Figs. 3 and 4). Extruding fat was observed after the resection of the upper portion of the mass, which coincided with the diagnosis of a duodenal lipoma.
DISCUSSION Lipomas of the GI tract are uncommon, and those of the duodenum are extremely rare. Indeed, the incidence of duwww.giejournal.org
odenal lipoma was only 0.16% among 4000 cases of benign intestinal masses.8 Most of these masses were asymptomatic and were found incidentally at endoscopy, surgery, or autopsy. However, large duodenal lipomas may produce symptoms of dyspepsia, intestinal obstruction, or bleeding.1-5 There are some scattered reports of successful endoscopic removal of symptomatic lipomas of the duodenum when using standard electrosurgical methods.2-4 However, a resection of lipomas 2 cm or larger has been associated with a higher risk of perforation and bleeding.6,9 Recently, many techniques and devices for use in endoscopy were developed to safely remove large and symptomatic lipomas.7,10 The endoloop, which enables endoscopic ligation of the base of an elevated lesion, was first developed by Hachisu11 in 1991. The loop is electrically nonconductive and consists of a heat-treated elliptically shaped nylon thread and a silicone rubber stopper that maintains tightness of the loop. The previous study revealed that bleeding during or after a polypectomy with detachable endoloops occurred significantly less frequently than without the assistance of endoloops.6 In addition, the endoloop may prevent the risk of perforation, because fixing the tumor base by an endoloop before a polypectomy can prevent the serosa from invaginating into the pedicle. Large and broad-based duodenal lipomas are highly vascular structures that carry a greater risk of bleeding when a mass resection is performed. The correct application of the endoloop before a mass resection may reduce the probability of such bleeding and thereby permit the mass to be safely excised. Because the intestinal wall of the duodenum is thin, standard endoscopic snare polypectomy may cause bowel perforation. In addition, a mass with a broad base such as the masses in our patients is a risk factor for bowel perforation.7 The unroofing technique, which was first introduced by Mimura et al12 in 1997, only cuts off the upper half of a submucosal tumor and thus greatly reduces the possibility of bowel Volume 68, No. 6 : 2008 GASTROINTESTINAL ENDOSCOPY 1235
Brief Reports
perforation. Moreover, a lipoma can be removed completely, without any residual mass after elimination of the remaining adipose tissue. Extruding fat from the cut surface after a polypectomy is always mandatory for the diagnosis of an intestinal lipoma. Thus, endoscopic unroofing may prevent bowel perforation, particularly in cases of intestinal lipomas with broad-based pedicles, as in our patients, and, therefore, a duodenal lipoma can be removed safely and completely. Duodenal lipomas, which are benign submucosal masses, have been reported to possess certain characteristic endoscopic features. A diagnosis of a lipoma cannot be made on the basis of conventional forceps-biopsy specimens. EUS is a diagnostic tool that images the digestive wall as a US 5-layered structure. The characteristic feature of a lipoma on EUS images, which provides diagnostic evidence, is a homogenous hyperechoic mass localized in the submucosal layer.13 In addition, an EUS can precisely assess the location of a lipoma in the submucosa that does not extend into the muscularis propri and can detect the rare instance of a lipoma located in the subserosa. Therefore, endoscopic removal of a duodenal lipoma should be based on the findings of EUS. In summary, it is uncommon for duodenal lipomas to cause clinically significant symptoms. Symptomatic lipomas of the duodenum should be treated by an endoscopic resection after an EUS confirms that the mass is localized in the submucosa. The present cases are the first report of a symptomatic duodenal lipoma excised endoscopically with the unroofing technique and with assistance of an endoloop. The endoloop-assisted unroofing technique is safe and effective for treatment and histologic confirmation of a symptomatic and broad-based pedunculated lipoma of the duodenum.
DISCLOSURE The authors report that there are no disclosures relevant to this publication.
REFERENCES 1. Sarma DP, Weilbaecher TG, Basavaraj A, et al. Symptomatic lipoma of the duodenum. J Surg Oncol 1984;25:133-5. 2. Sou S, Nomura H, Takaki Y, et al. Hemorrhagic duodenal lipoma managed by endoscopic resection. J Gastroenterol Hepatol 2006;21: 479-81. 3. Blanchet MC, Arnal E, Paparel P, et al. Obstructive duodenal lipoma successfully treated by endoscopic polypectomy. Gastrointest Endosc 2003;58:938-9. 4. Tung CF, Chow WK, Peng YC, et al. Bleeding duodenal lipoma successfully treated with endoscopic polypectomy. Gastrointest Endosc 2001; 54:116-7. 5. Hizawa K, Kawasaki M, Kouzuki T, et al. Unroofing technique for the endoscopic resection of a large duodenal lipoma. Gastrointest Endosc 1999;49:391-2. 6. Iishi H, Tatsuta M, Narahara H, et al. Endoscopic resection of large pedunculated colorectal polyps using a detachable snare. Gastrointest Endosc 1996;44:594-7. 7. Kim CY, Bandres D, Tio TL, et al. Endoscopic removal of large colonic lipomas. Gastrointest Endosc 2002;55:929-31. 8. Mayo CW, Pagtaluman RJG, Brown DJ. Lipoma of the alimentary tract. Surgery 1963;53:598-603. 9. Bar-Meir S, Halla A, Baratz M. Endoscopic removal of colonic lipomas. Endoscopy 1981;13:135-6. 10. Murray MA, Kwan V, Williams SJ, et al. Detachable nylon loop assisted removal of large clinically significant colonic lipomas. Gastrointest Endosc 2005;61:756-9. 11. Hachisu T. A new detachable snare for hemostasis in the removal of large polyps or other elevated lesions. Surg Endosc 1991;5:70-4. 12. Mimura T, Kuramoto S, Hashimoto M, et al. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997;46:259-63. 13. Nakamura S, Iida M, Suekane H, et al. Endoscopic removal of gastric lipoma: diagnostic value of endoscopic ultrasonography. Am J Gastroenterol 1991;86:619-21.
Current affiliations: Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan. Reprint requests: Wen-Hsin Huang, MD, Division of Hepatogastroenterology, Department of Internal Medicine, China Medical University Hospital, No 2, Yuh-Der Rd, Taichung 404, Taiwan. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$34.00 doi:10.1016/j.gie.2008.03.003
Spontaneous perforation of the duodenum by a migrated ureteral stent Ian Wall, DO, Robin Baradarian, MD, Matthew Tangorra, DO, Nison Badalov, MD, Kadirawel Iswara, MD, Jianjun Li, MD, Scott Tenner, MD, MPH Brooklyn, New York, USA
Iatrogenic duodenal perforation is a rare event and typically results from an intraluminal intervention, especially ERCP sphincterotomy. There are isolated reports of duodenal perforations from other forms of endoscopic interven1236 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 6 : 2008
tions, such as migrated esophageal stents, gastroduodenal stents, biliary endoprosthestics, and EUS.1-4 Rarely, duodenal perforations result from interventions outside the GI tract, such as with inferior vena cava filter placement.5 www.giejournal.org