key: cord-0923885-y4tcdomk authors: Bouali, M.; Sylvestre, K.; ElBakouri, A.; El Hattabi, K.; Bensardi, F.Z.; Fadil, A. title: Mesenteric lipoma with small bowel volvulus: A rare cause of upper gastrointestinal obstruction (a case report and literature review) date: 2022-02-25 journal: Int J Surg Case Rep DOI: 10.1016/j.ijscr.2022.106875 sha: bec84c2383041e70106e365874bdbc0e8c709501 doc_id: 923885 cord_uid: y4tcdomk INTRODUCTION: Small bowel volvulus due to mesenteric lipoma is a rare clinical entity. It poses both a diagnostic and therapeutic challenge. Small bowel mesenteric lipoma is a rare cause of small bowel obstruction. We present the case of a patient admitted to our emergency department for a small bowel volvulus due to a mesenteric lipoma with small intestine obstruction. PATIENT AND METHOD: A 61 years old man, with diabetes since 25 years with antidiabetics oral medication, vaccinated against Covid 19 (two doses) who presented with peri-umbilical pain for two months, constipation and melaena, complicated 3 days before his admission by obstructive symptoms and vomiting with apyrexia and overall health state alteration. The physical examination noticed abdomen distension and the abdominal CT scan revealed a large fatty mass of the hypochondrium and left flank, roughly oval with regular borders, well limited measuring 124 × 86 mm of height of 126 mm thought to be a liposarcoma. The patient underwent enbloc resection of 20 cm of small bowel with the mass and end to end anastomosis of the ileo-ileum. The postoperative course was uneventful and he was been discharged from hospital on day 5. DISCUSSION: Mesenteric lipomas are diagnosed incidentally after laparoscopy or laparatomy. Ultrasound shows a well defined homogenous echogenic mass, and so can distinguish it from a mesenteric cyst. Computed Tomography (CT) is the standard imaging of diagnosis and shows homogenous tumor of adipose tissue. The treatment is surgery and the prognosis is better. CONCLUSION: The mesenteric is an uncommon location of lipoma. When there is small bowel obstruction with intra-abdominal mass, the mesenteric lipoma could be recalled. Lipomas are benign neoplasms of adipose tissue that can occur almost anywhere [1] . Small bowel lipomas are rare and uncommon while small bowel obstructions are due essentially to the band after surgery; the occlusion of small bowel occlusion after strangulation due to mesenteric lipomas is very rare [2] . Here, we present a case of a small intestine volvulus caused by a giant small bowel mesenteric lipoma, which was successfully managed by small bowel resection through laparotomy. The aim of our study is describe a rare case of small bowel obstruction due to mesenteric lipoma. This case is presented in line with scare check list 2020 [3] . The patient was a 61 years old man, treated for diabetic since 25 years with oral antidiabetics medication, vaccinated against Covid 19 (two doses) who presented 2 months ago with peri-umbilical pain, constipation and melaena, worsened 3 days before his admission by obstructive symptoms and vomiting with apyrexia and overall health alteration. The physical examination noticed a conscious patient with pressure of 18/09, respiratory rate of 19 cycles, pulse of 86 beats per minute. Abdomen distended and tympanic. Non intraperitoneal mass found. The hernial area and lymph node examination were free. Rectal exam was normal. The rest of physical examination was unremarkable. Abdomino-pelvic CT scan show dilation of small intestine measuring of 33 mm in diameter with aeric-fluid levels upstream of a transitional level located at the umbilicus. Absence of defect of wall enhancement or pneumatosis. Peritoneal effusion in the left iliac fossa. A large fatty mass of the left hypochondrium and flank, oval with regular limits, measuring 124 × 86 × 126 mm. This mass makes a compression to the colon and is in contact to the abdominal wall without invasion (Fig. 1 ). Multiple nodes, coelio mesenteric, lumbar and aortic. The biology assessment is shown in Table 1 . He underwent in emergency the resection of 20 cm of small bowel enbloc with the mass through laparotomy approach. An end to end anastomosis of the ileum was performed. The exploration found a fatty mass, mobile attached at the side of the mesenteric side of the small bowel of 10 cm located at 1 m 60 cm from the duodenojejunal angle associated with a small intestine volvulus of two rounds counterclockwise spiral and dilation of proximal portion of small intestine of 3.5 cm, without complications signs (Figs. 2 and 3). The postoperative was uneventful and the patient was discharged from hospital at D5 with oral feed allowed at D4. The specimen analysis showed a proliferative adipose tissue cells with confirmation of lipoma on immunohistochemistry. A lipoma is a benign tumor of mature adipocytes which can develop almost at any part of the body especially the trunk, extremities, or intraperitoneal. The differential diagnosis is liposarcoma, which has a high degree of malignancy and recurrence rate [2] . Small bowel volvulus is rare and only few cases have been reported worldwide. Volvulus of the small bowel accounts for less than 7% of all cases of small bowel obstruction and can be attributed to primary or secondary causes. Primary volvulus occurs without anatomic abnormalities while the secondary volvulus is due to anatomical abnormalities and the most common is an incomplete common mesentery [4] . The small bowel obstruction after volvulus due to a mesenteric lipoma is extremely rare. By the way, the small bowel is not a common location of lipoma even the intraperitoneal cavity. The site of location, the number and the size of lipomas in the intraperitoneal cavity are largely different and present with a variety of symptoms without specificity. According to the site, they are mesenteric, antimesenteric and submucosa lipoma while for the number, isolated lipoma, multiple circumscribed lipomas, diffuse nodular lipomatosis, and diffuse adipose tissue infiltration of the submucosa without tumor formation are described in literature [5] . They occur in adults between fortieth and sixtieth years and rarely in children under ten years. The factors that predispose to lipoma are obesity, diabetes mellitus, hypercholesterolemia, familial tendency, trauma, radiation therapy and chromosomal translocation. They either occur in the root of the mesentery or at the luminal edge of the mesentery [6] . These lipomas are usually asymptomatic because most allow passage of small bowel as the lipomas are soft and mobile masses which do not infiltrate surrounding structures. Mesenteric lipomas are diagnosed incidentally after laparoscopy or laparatomy. The common symptoms are vague abdominal pain, distension, anorexia and weight loss. Rarely, patients present with intestinal obstruction, and this is usually due to small bowel volvulus or intussusception caused by the lipoma. Mesenteric lipomas are usually asymptomatic, but larger lipomas can twist around their pedicle, leading to volvulus and ischemia and infarction. In case of torsion, patient present acute abdomen with onset of pain and imaging may show inflammatory changes, such as edema and fat stranding. Few cases of mesenteric lipomas complicated with torsion are described in the literature [7] . Ultrasound shows a well defined homogenous echogenic mass, and so can distinguish it from a mesenteric cyst. Computed Tomography (CT) is the standard imaging of diagnosis and shows homogenous tumor of adipose tissue. Also gives information about effect on the small bowel, whether there is evidence of ischemia and may demonstrate the typical whirl like pattern of a volvulus. Liposarcoma, lymphangioma, lymphangiolipoma, neuroblastoma and lymphoma are important differential diagnosis of mesenteric lipoma that should be considered [8] . Treatment of large or symptomatic mesenteric lipomas involves surgical resection of the lipoma with the adjacent small bowel and end-to-end anastomosis. However, enucleation of tumor from has been reported. Laparoscopic approach has also been reported. Although mesenteric lipomas are rare, they must be considered for diagnostic in cases of long standing abdominal pain, with intraperitoneal fat tissue mass on imaging. The treatment involves laparatomy with enbloc resection the segment of the bowel [6, 9] . The mesenteric lipomas are uncommon localisation. The small bowel volvulus is a life threatening pathology with rapid complications such as necrosis. The small bowel obstruction due to mesenteric lipoma volvulation is unusual. Although lipomas are benign, they can lead to severe complications and mighty be treated when diagnosed. Not commissioned, externally peer-reviewed. Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. The study is exempt from ethical approval in our institution. No funding for research. Kabura Sylvestre. None. Mounir Bouali: designed the study, wrote the protocol and the first draft of the manuscript Sylvestre KABURA: designed the study, wrote the protocol and the first draft of the manuscript ElBakouri Abdelillah: managed the analyses, and the correction of the manuscript Khalid ElHattabi: managed the analyses, and the correction of the manuscript Fatima Zahra Bensardi: managed the analyses, and the correction of the manuscript Fadil Abdelaziz: managed the analyses, and the correction of the manuscript. Multiple duodenal lipomas as a rare cause of upper gastrointestinal obstruction: case report and literature review A small intestine volvulus caused by strangulation of a mesenteric lipoma: a case report The SCARE 2020 guideline: updating consensus Surgical CAse REport (SCARE) guidelines Volvulus of ileum: a rare cause of small bowel obstruction Acute intestinal infarction due to diffuse jejunoileal and mesenteric lipomatosis in a 39-year-old woman Giant mesenteric lipoma causing small bowel volvulus: a case report Torsion of a giant antimesenteric lipoma of the sigmoid: a rare cause of acute abdomen Small bowel volvulus due to a large intestinal lipoma: a rare case report Safe techniques for endoscopic resection of gastrointestinal lipomas All authors read and approved the final manuscript. No conflicts of interest.