Small intestinal lipomas are benign tumors that usually do not cause clinical symptoms. However, large intestinal lipomas can occasionally cause repeated intussusception, intestinal obstruction, and gastrointestinal bleeding, leading to more serious clinical consequences. Most small intestinal lipomas are treated surgically, but there are also some researchers who try to use endoscopic resection (Table 1). Endoscopic submucosal dissection (ESD) is a newer endoscopic treatment technology. As ESD technology develops, it plays an increasingly important role in treating early cancers and benign tumors of the digestive tract. Some researchers have used gastroscopy and colonoscopy to perform ESD to treat duodenal and ileal lipomas[3,4]. However, application of ESD technology in the deep small intestine is rarely reported owing to the special anatomical structure of the small intestine, medical equipment limitations, and the lack of relevant experience among endoscopists. This study explored the clinical feasibility of ESD treatment for deep intestinal lipomas under single-balloon enteroscopy (SBE). The methods and cases are reported herein.
Cases and methods
Inclusion criteria: The inclusion criteria were: (1) Patients with small intestinal lipoma(s) admitted to the department of gastroenterology, Air Force Characteristic Medical Center of the PLA from November 2015 to September 2019; (2) Patients who had clinical symptoms such as repeated abdominal pain, abdominal distension, obstruction, and hemorrhage as well as patients in remission; (3) Lipoma base diameter was ≥ 1.5 cm, and the risks due to endoscopic mucosal resection (EMR) were expected to be high and (4) The patients and their families agreed to ESD treatment and provided informed consent.
Exclusion criteria: The exclusion criteria were: (1) Patients with severe basic diseases who could not tolerate anesthesia or endoscopic examination; (2) Complete intestinal obstruction made intestinal preparation impossible; (3) Presence of lipoma hemorrhage with hemorrhagic shock or extraluminal lipomas; (4) No consent to ESD treatment was provided; and (5) Diameter of the lipoma base was < 1.5 cm, and the risks due to EMR were expected to be low (could be treated by EMR and regular follow-up).
Equipment information: The following equipment was used: SBE (SIF-0260, Olympus), outer thimble (ST-SB1, Olympus), IT knife (KD-612U, Olympus), dual knife (KD-650U, Olympus), transparent cap (D-201-11804, Olympus), endoscopic injector (WS-2423PN, Wilson), argon plasma coagulation (APC2, ERBE), high-frequency electric knife (VID 300S, ERBE), hemostatic forceps (FD-411UR, Olympus), disposable metal clip (ROCC-D-26-230, Micro-Tech; Nanjing Co.), and instrument channel adaptor (MAJ-1606, Olympus; used to connect to the biopsy channel to temporarily replace the auxiliary water supply function of the balloon-assisted endoscopy as it does not have a special channel for the water supply).
Steps and key techniques of ESD with SBE for treating intestinal lipomas: Preoperative assessment: The general condition of the patients should be comprehensively evaluated, and the coagulation function should be corrected before treatment in patients with coagulation disorders.
As with routine SBE, once the SBE reaches the lesion, the outer thimble should be moved to the top and then pulled back with the SBE after inflating the balloon so that the lens can freely approach the lesion. After completing these steps, the endoscopist can begin the ESD as the assistant fixes the outer thimble.
Lesion marking: Marking is unnecessary if the lesion is prominent, and the basal area has a clear boundary; however, boundaries that are unclear or undetermined post injection should be marked accordingly.
Submucosal injections are performed with 1:4 diluted sodium hyaluronate. After sufficient submucosal injection, the mucosa is incised after being well elevated.
Mucosal incision and lipoma dissection: The mucosa is cut in an arc as close to the tumor edge as possible, with the gravity-side mucosa being incised first to enable more easily exposing the yellowish mass under the mucosa. During dissection, a clear field of vision must be maintained as far as possible to pretreat the large blood vessels as far as possible to avoid perioperative bleeding. Multiple submucosal injections can ensure sufficient separation of the lesion and muscle layer. Dissection should not be performed too quickly.
Postoperative wound management: After completely removing the tumor, the wound surface should be carefully examined. For visible bleeding or tiny blood vessels, coagulation treatments, such as argon plasma coagulation and thermal tweezers, can be used. If the muscle layer is damaged or perforated during the operation, the wound surface must be closed with metal clips. Postoperative perforation or bleeding is difficult to correct endoscopically because of the anatomy of the small intestine; therefore, the wound surface should be sutured as much as possible.