World Journal of Colorectal Surgery

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1 World Journal of Colorectal Surgery Volume 4, Issue Article 5 Giant Rectal Lipoma Treated By TEM: Report Of A Case Rutger Franken Daan Moes Sanne Veltkamp Eric Derksen Slotervaart hospital Amsterdam, frankenrj@gmail.com Slotervaart hospital Amstelland hospital Slotervaart hospital Copyright c 2014 The Berkeley Electronic Press. All rights reserved.

2 Giant Rectal Lipoma Treated By TEM: Report Of A Case Rutger Franken, Daan Moes, Sanne Veltkamp, and Eric Derksen Abstract Lipoma of the large intestine is a relatively uncommon finding in clinical practice. Most lipomas remain silent and are found coincidentally. However, lipomas larger than 2 cm could lead to a variety of symptoms. In this case report we describe a patient with a giant rectal lipoma who was suffering from constipation, changed bowel habits and uncomfortable passage sensations during defecation. Consequently, the lipoma was removed by transanal endoscopic microsurgery. To our knowledge, removal of a rectal lipoma by TEM has never been decribed in literature. Presenting this case we add another patient with a rectal lipoma to the small number of cases described in literature. Furthermore, we state that TEM could be an appropriate therapy for the treatment of a rectal lipoma. KEYWORDS: rectum, therapy, TEM, surgery

3 Franken et al.: Giant Rectal Lipoma Treated By TEM: Report Of A Case 1 Introduction Lipoma of the large intestine is a relatively uncommon entity in clinical practice. Most lipomas are found coincidentally during endoscopy or surgery. Lipomas smaller than 2 cm usually remain silent whereas larger lesions can produce a variety of symptoms. Small lesions are most commonly diagnosed during endoscopy and subsequently treated. For larger lesions the treatment of choice is surgery. TEM (Transanal Endoscopic Microsurgery, Richard Wolf Medical Instruments Corporation U.S.) has never been described as a therapeutic option for rectal lipoma. We report on a patient with a giant rectal lipoma who was successfully treated by TEM. Case report A 72-year-old man with the past medical history of atrial fibrillation and thyroiditis was referred to our hospital. He suffered from constipation and changed bowel habits. Furthermore, he had the sensation of something passing through the anus during defecation. The referring clinic performed endoscopy which revealed a yellowish tumour at 10cm from the anal verge. (Fig 1.) Additionally, MR imaging and CT-colography confirmed a bulging mass located between the rectum and the prostate. Endoscopic ultrasonography disclosed extension into the rectal wall. A transanal endoscopic microsurgery (TEM) procedure was performed in our clinic and a weak yellowish mass was successfully removed. (Fig 2.) Its measurements were 6.2 x 5.3 x 3.8 cm. Histological examination confirmed the diagnosis of a lipoma. One day after the procedure the patient was discharged in good health. At the follow-up visits up to 4 months after the procedure, the patient was free of rectal complaints. Discussion In this case report we present the rare finding of a rectal lipoma. Autoptic studies have shown an incidence ranging from %. (1) However, most colonic lipomas remain silent and do not produce symptoms. Lipomas exceeding the size of 2 cm in diameter can produce symptoms including bleeding, constipation, abdominal pain, changing bowel habits, intestinal obstruction or intussusception of the mass. (2;3) Lesions smaller than 2 cm in size are usually asymptomatic. These polyps are usually found coincidentally by endoscopy and subsequently treated.(4;5) Larger lesions are clinically more challenging since they may mimic malignant irregularities. Although less specific, imaging can also contribute to a preoperative diagnosis. In acute patients, computed tomography or 1 Produced by The Berkeley Electronic Press, 2014

World Journal of Colorectal Surgery 2 Vol. 4, Iss. 1 [2014], Art. 5 magnetic imaging seemed to be the preferred diagnostic tool since these imaging findings appear to be both sensitive and specific.

4 World Journal of Colorectal Surgery 2 Vol. 4, Iss. 1 [2014], Art. 5 magnetic imaging seemed to be the preferred diagnostic tool since these imaging findings appear to be both sensitive and specific. (6) Less specifically, barium and water enemas give rise to filling defects suggesting an intraluminal lesion. Ascending colon and sigmoid colon are the most common sites for the colonic lipoma. (7) Rectal lipomas are relatively rare, with only 9 cases described in literature (8;9). Treatment of lesion smaller than 2 cm is usually done by endoscopic snare resection. Endoscopic resection of larger lesions is associated with higher risks of perforation, although some successful procedures are described. (4;10) Jiang et al. concluded that the surgical removal of the lipoma is indicated in the following cases: (1) Lipoma with a diameter of more than 4 cm, with a sessile appearance or limited pedicle; (2) Unclear preoperative diagnosis; (3) Lesions with significant symptoms, especially the appearance of intussusception; (4) Involvement of the muscular layer or serosa, and (5) Lesion can not be resected radically under colonoscopy. (7) To our knowledge, treatment of a rectal lipoma by TEM has never been described. In this report, we add another patient diagnosed with a rectal lipoma to the small number described in literature. Moreover, we state that TEM can be an appropriate treatment for the removal of a rectal lipoma. However, the procedure should be performed by an experienced surgeon, especially concerning larger lesions as these are technically more demanding. Figures Figure 1. Transanal protruding mass 2

Franken et al.: Giant Rectal Lipoma Treated By TEM: Report Of A Case 3 Figure 2. Local resection of the rectal lipoma by TEM References 1. Haller JD, Roberts TW.

5 Franken et al.: Giant Rectal Lipoma Treated By TEM: Report Of A Case 3 Figure 2. Local resection of the rectal lipoma by TEM References 1. Haller JD, Roberts TW. Lipomas of the colon: a clinicopathologic study of 20 cases. Surgery 1964; Franc-Law JM, Begin LR, Vasilevsky CA, et al. The dramatic presentation of colonic lipomata: report of two cases and review of the literature. Am.Surg. 2001;67(5) Vecchio R, Ferrara M, Mosca F, et al. Lipomas of the large bowel. Eur.J.Surg. 1996;162(11) Kim CY, Bandres D, Tio TL, et al. Endoscopic removal of large colonic lipomas. Gastrointest.Endosc. 2002;55(7) Pfeil SA, Weaver MG, Abdul-Karim FW, et al. Colonic lipomas: outcome of endoscopic removal. Gastrointest.Endosc. 1990;36(5) Liessi G, Pavanello M, Cesari S, et al. Large lipomas of the colon: CT and MR findings in three symptomatic cases. Abdom.Imaging 1996;21(2) Jiang L, Jiang LS, Li FY, et al. Giant submucosal lipoma located in the descending colon: a case report and review of the literature. World J.Gastroenterol. 2007;13(42) Produced by The Berkeley Electronic Press, 2014

6 4 World Journal of Colorectal Surgery Vol. 4, Iss. 1 [2014], Art Arora R, Kumar A, Bansal V. Giant rectal lipoma. Abdom.Imaging 2011;36(5) Martellucci J, Civitelli S, Tanzini G. Transanal resection of rectal lipoma mimicking rectal prolapse: description of a case and review of the literature. ISRN.Surg. 2011; Tamura S, Yokoyama Y, Morita T, et al. "Giant" colon lipoma: what kind of findings are necessary for the indication of endoscopic resection? Am.J.Gastroenterol. 2001;96(6)

Colo-Colonic Intussusception Caused by a Submucosal Lipoma

168 Colo-Colonic Intussusception Caused by a Submucosal Lipoma Case Report and Review of the Literature B.A. Twigt S.K. Nagesser D.J.A. Sonneveld Department of Surgery, Diakonessenhuis, Utrecht, The Netherlands