Endoscopic submucosal dissection followed by laparoscopic collection of a giant duodenal lipoma causing repeated pancreatitis

A 53-year-old woman underwent laparoscopic cholecystectomy for suspected gallstone pancreatitis. However, pancreatitis occurred every few months even after cholecystectomy. Fluoroscopic and endoscopic images showed a giant submucosal tumor approximately 6 cm in size. The stalk originated from the para-ampulla in the second portion of the duodenum and the tumor head was located in the proximal jejunum over the ligament of Treitz ([Fig. 1], [Fig. 2]). Computed tomography revealed a giant lipoma extending from the third portion of the duodenum to the proximal jejunum, and the ampulla and pancreas head were pulled and deviated to the third portion by the giant lipoma ([Fig. 3]). We suspected that the repeated pancreatitis might be caused by the mechanical traction of the giant duodenal lipoma.

Fig. 1 Fluoroscopic image of a giant duodenal lipoma. Arrowheads indicate a giant tumor approximately 6 cm in size, which was present in the third portion of the duodenum and proximal jejunum.

Fig. 2 Endoscopic images revealing an elongated giant submucosal tumor with the stalk (*) originating from the para-ampulla of Vater (arrow).

Fig. 3 Computed tomography showing a giant duodenal lipoma (*) with a high fat density extending from the third portion of the duodenum to the proximal jejunum. The ampulla (arrow) and pancreas head were mechanically pulled to the third portion because of the giant lipoma.

The giant lipoma was successfully resected en bloc with endoscopic submucosal dissection (ESD) using a DualKnife J (Olympus, Tokyo, Japan) in 60 minutes ([Fig. 4], [Video 1]). The resected tumor was laparoscopically removed from the jejunum through a port site ([Fig. 5]). The patient was discharged without any adverse events on postoperative Day 8. No recurrence was observed thereafter.

Fig. 4 Endoscopic image after tumor resection. The stalk of the giant lipoma was successfully resected with endoscopic submucosal dissection.

Video 1 Endoscopic submucosal dissection followed by laparoscopic collection of a giant duodenal lipoma causing repeated pancreatitis.

Fig. 5 Resected specimen. The resected submucosal tumor was a duodenal lipoma, 6 cm in size.

To our knowledge, this is the first case with repeated pancreatitis caused by mechanical traction of a giant duodenal lipoma. Some duodenal lipomas can be resected with conventional polypectomy and endoscopic mucosal resection, as described in previous reports [1] [2] [3]. ESD is a useful method that enables en bloc resection even with large tumors; however, duodenal ESD is challenging due to the technical difficulty and frequent complications. Only one previous case report has described a giant duodenal lipoma being resected with ESD; however, the majority of the resected specimen could not be retrieved due to its large size [4]. The current case describes a novel and noninvasive technique involving ESD followed by laparoscopic per-jejunal tumor collection for a giant duodenal lipoma causing repeated pancreatitis.

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• References

• 1 Gnanapandithan K, Aslanian HR, Jamidar PA. et al. Endoscopic resection of a giant duodenal lipoma. ACG Case Rep J 2020; 7: e00327
• 2 Lee KJ, Kim GH, Park DY. et al. Endoscopic resection of gastrointestinal lipomas: a single-center experience. Surg Endosc 2014; 28: 185-192
• 3 Thorlacius H, Weiber H, Ljungberg O. et al. Endoscopic diagnosis and treatment of a giant duodenal lipoma presenting with gastrointestinal bleeding. Endoscopy 2013; 45: E385-386
• 4 Wu C, Yang JF, Tan Q. et al. En bloc resection of a large symptomatic duodenal lipoma by endoscopic submucosal dissection. VideoGIE 2017; 2: 182-184