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Successful endoscopic management of adult ileocecal intussusception secondary to a large ileal lipoma

A 90-year-old man presented to our hospital with abdominal pain, nausea, and loss of appetite that started the day before arrival. Initial CT revealed a target sign with a lowdensity mass at the center located in the terminal ileum (Fig. 1). Although a severely distended small bowel and ascites were present, physical and serum laboratory findings were not suggestive of peritonitis. From the CT findings, the patient was diagnosed with adult intussusception secondary to a lipoma. Because vital signs were stable and abdominal pain was under control without administration of anesthetics, we attempted endoscopic reduction under fluoroscopic guidance (Video 1, available online at www.VideoGIE.org).


ENDOSCOPIC REDUCTION
A colonoscope (CF-HQ290L/I; Olympus Medical Systems, Tokyo, Japan) and CO 2 gas insufflation were used during the procedure. The patient did not receive a bowel preparation, and 3 mg of midazolam was administered for conscious sedation. A 20-mm red, smooth, protruding mass formed an intussusception at the ileocecal valve (Fig. 2). The mass was repositioned into the ileum by Figure 1. CT scan showed a target sign at the terminal ileum, and the responsible tumor showed a homogeneous low density. The patient was diagnosed with adult intussusception secondary to a lipoma in the ileum.  insufflating air at cecum (Figs. 3 and 4). Immediately after the procedure, the patient recovered from bowel distention by passing a large amount of watery stool.

ENDOSCOPIC RESECTION OF LIPOMA
On day 4, follow-up CT scan revealed dissipation of ileal dilation and ascites. After administering magnesium citrate for bowel preparation, polypectomy was attempted. We assumed that the lesion was a benign lipoma, and given that the elderly patient was on multiple anticoagulants because of a history of cerebral infarction, we aimed for an incomplete resection of the submucosal tumor instead of attempting a high-risk complete resection (Fig. 5).
The lesion was grasped toward its bottom using a bipolar snare (26 mm Dragonare BSDH-217, Zeon Medical, Tokyo, Japan), and an electrosurgical unit (VIO 300D; ERBE Elektromedizin, Tübingen, Germany) was used at the following power settings: AUTO CUT effect 4, 30W, FORCED COAG effect 2, 20W. Because the surface of the lesion was severely carbonized with both mode settings, the initial attempt at resection was unsuccessful.
Subsequently, we replaced the snare with a monopolar snare (SnareMaster, Olympus Medical Systems, Tokyo Japan), and the lesion was successfully resected with    ENDOCUT Q effect 3 settings. The cut section of the tumor was yellow, fat-like tissue, which was confirmed to be a lipoma on pathologic analysis (Fig. 6). No adverse events occurred during or after the resection. A clear scar without any signs of recurrence was confirmed on follow-up colonoscopy performed 4 months after the resection (Fig. 7).

DISCUSSION
Adult intussusception accounts for only 1% to 5% of all bowel obstruction, and 75% to 80% are located in the small intestine. 1 In general, a radiologically homogeneous lowdensity mass can be diagnosed as a lipoma. 2 Although surgical resection has been the most common approach to treat intussusception, reports regarding endoscopic reduction and resection have increased over the last 2 decades. As a result, several endoscopic methods to remove lipomas have been developed, including standard polypectomy, 3 endoloop polypectomy, 4 endoscopic unroofing, 5,6 endoscopic mucosal resection, 7 and endoscopic submucosal dissection. 8 To date, there is no consensus on treatment methods, and whether to complete resection is necessary remains controversial. However, given that resection of colonic lipomas 2 cm or larger is associated with a higher risk of perforation and bleeding, it is important to consider the risk and benefit for each patient. 9 Our case demonstrates that it is feasible to reduce an intussusception and resect the responsible lesion endoscopically. Although the lesion was located in the ileum, where care should be taken to avoid perforation, it is important to select a monopolar snare instead of a bipolar snare when a lipoma is suspected. Short-term follow-up suggested that an incomplete resection is acceptable, especially among elderly patients. Endoscopic treatment is less invasive, and long-term adverse events related to surgical treatment can be avoided.

DISCLOSURE
All authors disclosed no financial relationships.