P41 Endoscopic management of a symptomatic ileal lipoma facilitated by saline-immersion therapeutic endoscopy at double-balloon enteroscopy

Lipomas of the gastrointestinal (GI) tract are common, benign and usually present as innocuous findings. Larger ones (>2 cm in diameter), particularly those involving the ileum, may present with clinical symptoms such as abdominal pain (caused by intussusception) and iron deficiency anaemia (IDA) or obscure GI bleeding (OGIB) (caused by overlying mucosal ulceration); these cases warrant intervention and often end up being referred for surgery. We describe a minimally invasive endoscopic alternative to surgical resection for the management of these lesions. A 60-year-old man presented with recurrent, cramping abdominal pain and OGIB. A magnetic resonance enterography (MRE) revealed a 2.5 cm submucosal lesion in the distal ileum, in keeping with a large lipoma. In light of these findings and the clinical presentation, we perform a saline-immersion retrograde DBE under conscious sedation, for further evaluation and minimally invasive, definitive endotherapy. At DBE the lesion was identified at around 40 cm proximal to the ileocaecal valve. The endoscopic appearances revealed a 2.5 cm sessile submucosal, lumen-filling lesion with a positive ‘pillow sign’. Although the overlying mucosa appeared mostly unremarkable, a small, healed ulcer (which would account for the patient’s IDA and OGIB) was identified on the medial surface of the lesion. Endotherapy was deemed feasible and this was facilitated by the buoyancy properties provided by SITE. In order to reduce the risk of perforation and bleeding, an endoscopic loop ligating device was first deployed tightly at the base of the lesion. A ball-tip, needle-type endoscopic submucosal dissection (ESD) knife was then used to incise and unroof the lesion. This allowed for exposure and spontaneous extrusion of the lipomatous tissue (already under pressure from the loop-lighting device). Saline-immersion allowed for maintenance of a clear visual field, through avoidance of clouding of the endoscopic lens and flotation of extruded micelles of fatty tissue. A submucosal tattoo and a clip were placed as endoscopic and radiological markers, respectively. The procedure was performed under antibiotic cover. No significant immediate, early or late adverse events were encountered. Histopathological examination of retrieved tissue showed mature adipocytes with fibrofatty submucosal changes, in keeping with a submucosal lipoma. No dysplasia or sarcomatous transformation was identified. The patient’s symptoms have resolved completely post-endotherapy. Our case demonstrates the safety and usefulness of minimally invasive endotherapy of symptomatic large ileal lipomas. The combination of DBE with SITE-facilitated unroofing, after securing the lipoma’s base with a loop-ligation device, allows for safe, spontaneous extrusion of the benign lipomatous tissue and avoids the need for operative surgery in symptomatic patients.