PROLAPsE Of subMucOus LIPOMA Of ThE sIgMOID cOLOn

MICHAEL WILHELMSEN, TOMMIE MyNSTERDepartment of Surgery, Bispebjerg Hospital, Copenhagen, Denmark

Lipomas of the colon are rare and usually presenting in the later ages of life. This case describes and discusses the symptoms and signs of lipomas, recommendations and rationale for treatment. Key words: lipoma, colonic invagination, laparoscopic surgery, case report

POLSKI PRZEGLĄD CHIRURGICZNY 10.2478/v10035-012-0017-02012, 84, 2, 102–104

Submucous lipomas of the intestines are rare benign tumours arising from adipocytes with an estimated incidence of 1/30000 and estimated to be found in 1/1300 abdominal operations (1). The condition was first de-scribed in 1757 (2). Submucous lipomas can be placed in all parts of the gastrointestinal tract such as stomach (3), jejunum (4), ascending colon (5), transverse colon (6), sigmoid colon (5) but are most often localized near the ileoce-cal valve (7).

Histologically 90% are located submucosal-ly and the rest are subserosal (8). They are most often solitaire, but about 10% of the cases are multiple. They seem to present at ages above 50 (2). The ratio between sexes is not clear; most authors suggest equal ratio (1, 2, 7), but some suggest a distribution with more females affected than males, although females has no increased risk for lipomas else-where in the body than males (9).

The tumours often lead to symptoms such as bleeding but may also give symptoms such as abdominal distension, pain, diahrrea, change of bowel habits or intusception. There-by they have clinical presentations that simu-lates more serious conditions as colorectal cancer (CRC) (10). They often remain asymp-tomatic and are found by coincidence in acute operation or by routine endoscopy.

The literature was found via Pubmed.com using search terms “Lipoma” and “Submu-cous.” No limits regarding time were set.

CASE REPORT

A 49 year old female was referred to our department due to polyps seen on rectoscopy of the sigmoid part of the colon. She was oth-erwise healthy, had slightly overweight with a Body Mass Index (BMI) of 29 and with an American Society of Anaesthesiologists (ASA) score of 1.

Several times she experienced a rectal pro-lapse of a tumour which she was able to re-positionate digitally. She had experienced one event of blood in her stool, and a 3 months intermittent left abdominal pain, but no weight loss or changes of stool habits. Preoperative tests were normal including plasma haemo-globin. She had no family history of CRC, but was afraid that she was suffering from a ma-lignant disease.

A colonoscopy revealed a polyp that filled the entire lumen of the sigmoideum 60 cm from the anus. A polypectomy with endoscopic mu-cosal resection (EMR) was planned. At this procedure a penducular lipoma with venous stasis was found but impossible to remove due to the advanced size (fig. 1).

A laparoscopic resection of the sigmoid colon was performed. Peroperatively two large lipo-mas with fibrosation were seen in the resected colon sigmoideum (fig. 2). In addition diver-ticulas were found. The diagnosis lipoma with submucosal origin was confirmed by histo-logic examination where 2 lipomas measuring

103Prolapse of submucous lipoma of the sigmoid colon

40x15x15 mm. and 80x40x25 mm. were found.

The patient unevently left the hospital 2 days after the operation and 3 months later she had a control colonoscopy without signs of other lipomas, but with a metaplastic looking polyp measuring 1 cm. in diameter removed by coagulation. Another colonoscopy is planned within three years.

DISCUSSION

This case story is atypical with regards to the location of the lipomas. Lipomas are most often placed near the ileocecal valve and only 10% are

Fig. 1. Lipomas filling the lumen as seen at endoscopy

multiple (2, 7). This case is unique in reporting of intermittent prolapse of the large lipoma.

Furthermore, the lipomas found in this pa-tient are different with respect to the finding of two large lipomas and the fact that the lipomas filled up almost the entire circumference, but without ileus symptoms. Lipomas are most often found by coincidence or as a finding in a patient presenting with an acute abdomen. Therefore the diagnosis is most often done by either X-ray or CT scan, although some authors suggest ul-trasonography as the most appropriate method for diagnosing these tumours (2, 7, 11).

If seen on X-ray lipomas often lead to dila-tation of the intestines (12) or as a ovoid filling. On CT sharp margins and soft tissue density can be seen (2, 7, 12) and thereby the lipoma mimicks other causes of pathology in the bowel. By endoscopy lipomas are often encoun-tered as yellow spots most often located around the ileocecal valve (2,7).

There seems to be an international consen-sus that surgical treatment is the right treat-ment for these patients. Yet surgery is only recommended if the lipoma is more than 20 mm in size as smaller lipomas often remain asymptomatic and the risk of invagination therefore is insignificant (1, 2, 7, 13). Some authors, however, have reported that these can be treated endoscopically (14). In these cases it should be considered thoroughly as the risk of perforation is large (9,15). In one report of 7 patients 3 patients experienced colonic per-foration when treated endoscopically (15). Presently surgical resection seems to be the method of choice providing the lipomas are symptomatic. If the lipomas are less than 20mm. no evidence for treatment exists. Lipo-mas have not been reported to undergo malig-nant transformation.

In conclusion lipomas have clinical mani-festations that can be very different and may simulate malignant disease. The most impor-tant clinical aspect of lipomas is that they are a differential diagnosis to CRC and that an accurate diagnosis is difficult to achieve pre-operatively.

Fig. 2. The resected specimen with Lipomas (and dye marking) and diverticulas

REFERENCES

1. Rathore MA, Andrabi SI, Mansha M: Adult in-tussusception – a surgical dilemma. J Ayub Med Coll Abbottabad 2006 Jul; 18(3): 3-6.

2. Zhang H, Cong JC, Chen CS et al.: Submucous colon lipoma: a case report and review of the literature. World J Gastroenterol 2005 May 28; 11(20): 3167-69.

104 M. Wilhelmsen, T. Mynster

3. Hart RJ: Submucous lipoma of the stomach presenting as pyloric obstruction. Br J Surg 1967 Feb; 54(2): 157-58.4. Cavanaugh JW, Mills WM: Submucous lipoma of the jejunum; report of a case. J Kans Med Soc 1946 Feb; 47: 51.5. Peet TN, Stannard MW: Sigmoid intussusception of a submucous lipoma. Int Surg 1976 May; 61(5): 304-05.6. Di MP, Bracci F, Colizza S et al.: Submucous lipoma of the transverse colon: report of one case. J Surg Oncol 1983 Dec; 24(4): 274-76.7. Rogy MA, Mirza D, Berlakovich G et al.: Submu-cous large-bowel lipomas – presentation and ma-nagement. An 18-year study. Eur J Surg 1991 Jan; 157(1): 51-55.8. Haller JD, Roberts TW: Lipomas of the colon: a clinicopathologic study of 20 cases. Surgery 1964 Jun; 55: 773-81.9. Khawaja FI: Pedunculated lipoma of the colon: risks of endoscopic removal. South Med J 1987 Sep; 80(9): 1176-79.

10. Falcetto G, Paduos A, Alluminio P: Intestinal invagination caused by submucous pedunculated lipoma of the large intestine. Minerva Chir 1990 Apr 15; 45(7): 523-26.11. Zielke A, Forster R, Klotter HJ et al.: Ileocolic invagination in adults. The sonographic characte-ristics. Dtsch Med Wochenschr 1991 Sep 20; 116(38): 1424-27.12. Parmar JH, Lawrence R, Ridley NT: Submuco-us lipoma of the ileocaecal valve presenting as caecal volvulus. Int J Clin Pract 2004 Apr; 58(4): 424-25.13. Kallie NR, Peters JA: Submucous lipoma of the stomach: a case report. Can J Surg 1976 Jan; 19(1): 42-45.14. Geraci G, Pisello F, Arnone E et al.: Endoscopic Resection of a Large Colonic Lipoma: Case Report and Review of Literature. Case Rep Gastroenterol 2010; 4(1): 6-11.15. Pfeil SA, Weaver MG, bdul-Karim FW et al.: Colonic lipomas: outcome of endoscopic removal. Gastrointest Endosc 1990 Sep; 36(5): 435-38.

Received: 10.01.2012 r. Adress correspondence: Department of Surgery, Bispebjerg Hospital, 2400 Copenhagen, Denmark