Fidelis C. Okoli
Maimonides Medical Center
Colonic lipomas are the second most common benign tumors in the colon, though they are uncommonly seen in clinical practice. They are typically asymptomatic incidental findings. They can become symptomatic when large and can cause complications. Herein we describe a case of a colonoscopic assisted resection of a sigmoid lipoma that prolapsed through the anus.
An 81-year-old man with multiple medical comorbidities presented with a large prolapsing mass from his anus after straining during defecation. On exam, he was noted to have a 7cm prolapsed mass through his anus that was unable to be reduced with manual manipulation. CT scan of the abdomen and pelvis revealed a prolapsed 7x5 cm sigmoid lipoma with coloanal intussusception (figure 1). The decision was made to attempt to reduce and possibly resect the mass under anesthesia in the OR. He was placed in the dorsal lithotomy position yet the lipoma was still unable to be reduced. A pediatric colonoscope was then inserted and a large stalk was visualized along with prolapsed colon and retroflexion views showed the stalk traversing the anus as well as large hemorrhoids (figure 2). Due to the patient being on Plavix, the decision was made to use Endoloops and a LigaSure device to help transect the stalk to limit bleeding. Two Endoloops were placed by the colorectal surgeon under direct visualization with the colonoscope, as they were pushed into the middle of the stalk within the colon without catching the posterior colonic wall. A third Endoloop was placed at the junction of the mass and its stalk at the anal verge. An Impact LigaSure device was used to slowly transect across the apex of the lesion right at the anal verge with manual pressure to retract the skin, perianal region, and hemorrhoids and rectal mucosa from the LigaSure device (figure 3). The colonoscope was then reinserted and the colon was able to be easily traversed up to 40 cm from the anal verge revealing solid stool and a small stalk in the sigmoid colon with two Endoloops in place with no evidence of bleeding or perforation.
Sigmoid lipoma prolapsing through the anus have been described previously in the literature. Management for symptomatic lesions is either endoscopic or surgical resection. Though there are no standardized evidence-based methods for diagnosis and treatment of colonic lipomas due to paucity of high-quality data, endoscopic assistance may help with safe resection in patients that are high risk for surgery as in our case.
CT scan of the abdomen and pelvis showing the sigmoid lipoma with coloanal intussusception.
Figure 2 showing the large stalk of the lipoma and also internal hemorrhoids.
Figure 3 showing the resected sigmoid colonic lipoma
Fidelis Okoli indicated no relevant financial relationships.
Shmuel Golfeyz indicated no relevant financial relationships.
Anne Mongiu indicated no relevant financial relationships.
Joel Albert indicated no relevant financial relationships.