Esophageal lipoma presenting as a paraesophageal omental hernia in a 68-year-old man：Report of a case

Yong Han, Qiang Lu, Zhongping Gu, Xiaoping Wang, Xiaofei Li*
Department of thoracic surgery, Tangdu hospital of The Fourth Military Medical University Xi’an Shaanxi 710038 China

*Corresponding author. Xiaofei Li MD Present address: Department of thoracic surgery Tangdu hospital The fourth Military Medical University Xi’an 710038 China Phone: Tel 86-29 84777436 Fax: 86-29 84777436 Email: lxfchest@fmmu.edu.cn

Key Words: Esophagus lipoma omental hernia

Abstract

A case of esophageal lipoma resembling a paraesophageal omental herniation is described herein. A 68-year-old male with symptoms of epigastric gas pains was noted. A barium swallow examination showed a large mass in the lower esophagus, which could move up and down along the esophagus easily and intermittently. Computed tomography scan of the chest and upper abdomen demonstrated a mass with fatty like density at the lower thoracic esophagus. A left posterior-lateral thoracotomy was performed. Histological examination revealed large mature lipocytes and lipoma of the esophagus was diagnosed. Diagnosis and treatment of lipoma of the esophagus were discussed.

Lipomas of the esophagus are extremely rare benign tumors with an overall incidence of only 0.4%[1].The leading clinical presentations of esophageal lipoma included dysphagia, mass regurgitation and signs of compression of the tumor.Preoperative diagnosis can be confirmed by CT, magnetic resonance imaging (MRI) and endoscopic ultrasonography. The present report describes a patient who suffered from an esophageal lipoma with symptoms of epigastric gas pains with a burning retrosternal sensation, which resembling a paraesophageal omental herniation. We also discuss the associated diagnosis and treatment of lipoma of the esophagus.

Case Report

A 68-year-old male was admitted to our hospital because of an intermittent epigastric gas pain with a burning retrosternal sensation, persistent nausea. He suffered from intermittent epigastric gas pains in the last year, and the pain was aggravated after eating, which was increasingly worsened in the last 2 month, however his weight had been maintained.


On upper GI endoscopy clearly demonstrated an esophageal submucosal lump mass originating from the left wall of the lower esophagus 33-39 cm under the fore-tooth. The mass was covered by normal esophageal mucosa therefore biopsies were not taken. The stomach and the duodenum appeared to be normal.


A barium swallow examination showed a large mass in the lower esophagus with intact overlying mucosa and could easily and intermittently move up and down along the esophagus. (Fig1).Computed tomography scan of the chest and upper abdomen demonstrated a mass with fatty like density at the lower thoracic esophagus, which resembled paraesophageal omental herniation as air could be seen beside the mass (Fig 2), so an omental herniation was suggested for this patient.

Figure 1 Barium swallow of patient showing a paraesophageal hernia

 

Figure 2 Computed tomogram appearance of patient showing extraluminal mass with a lipoma-like density in the lower esophagus.


A left posterior-lateral thoracotomy was performed, a dilated lower thoracic esophagus with edematous muscle wall layers was found. After a longitudinal incision just above the mass, a lipoma like tumor which seemed to be originated from the muscle layer of the left esophageal wall was found. A local resection of the tumor was performed as the esophageal mucosa was intact. The esophageal muscle layers incision was closed with interrupted sutures.
Macroscopically the tumor was a well circumscribed encapsulated mass, which was measured 12 cm×6cm×3cm. The cut surface was soft and bright yellow, resembling lipoma. Histological examination revealed large mature lipocytes and lipoma of the esophagus was diagnosed.


The post-operative course was uneventful and the patient was discharged 10 days later after tolerating a general diet. Symptoms of the patient were resolved after operation, and he has been followed up for 10 month after surgery without any signs of recurrence.

Discussion


Lipoma of the alimentary tract is uncommon, with an overall incidence of 4.1%, but that of the esophagus is extremely rare with an incidence of only 0.4%[1,2]. The most common location is the colon, followed by the small intestine. The clinical symptoms of esophageal lipomatous tumors include progressive dysphagia, regurgitation, retrosternal pain, respiratory distress, and the location of most tumors is the upper esophagus,[3,4,5] however it was located in the lower segment of esophagus in our patient. The diagnosis depends on endoscopic examination and computed tomography to evaluate the origin, extent, surface and consistency of the mass. In our case the CT appearance of patient showed an esophageal mass with a low Hounsfield value and a little gas, which suggested the diagnosis of a paraesophageal omental hernia, especially when the mass could move up and down intermittently along the esophagus. So the differentiation of omental hernia and lipomatous tumor was very important for making a correct preoperative diagnosis. Angiographic findings can provide decisive evidence as to whether or not a fatty mass contains omental vessels[6].


Surgical treatment is the preferred treatment of esophageal lipoma, and varies from simple enucleation or endoscopic resection to partial or total esophagectomy or transthoracic, transgastric resections[7,8]. We proceeded to tumour enucleation in this case without opening the esophageal mucosa during the procedure which is the preferred treatment of esophageal lipoma avoiding esophageal resection. By surgical removal and histologic examination, an esophageal lipoma was diagnosed. Since lipoma is very difficult to be differentiated from well-differentiated liposarcoma of esophagus[9] and recurs might appear even after resection in these patients, so he was followed up for 10 months to now after operation.


In conclusion, we proceeded to tumour enucleation for this patient of esophageal limpoma with a satisfied result. Clinical examination of this patient could not always concord each other. A esophageal lipoma could not be diagnosed easily, and should be differentiated from other diseases especially omental hernia and hiatal hernia.

Reference

  1. Mayo CW, Pagtalunan RJG, Brown DJ. Lipoma of alimentary tract. Surgery 1963;53:598–603.
  2. Sossai P, De Bernardin M, Bissoli E, Barbazza R. Lipomas of the esophagus: a new case. Digestion 1996;57:210–2.
  3. Zschiedrich M, Neuhaus P. Pedunculated giant lipoma of the esophagus. Am J Gastroenterol 1990; 85: 1614-6.
  4. Hasan N, Mandhan P. Respiratory obstruction caused by lipoma of the esophagus. J Pediatr Surg 1994; 29: 1565-6
  5. Algin C, Hacioğlu A, Aydin T, Ihtıyar E. Esophagectomy in esophageal lipoma: Report of a case. Turk J Gastroenterol. 2006;17(2):110-112.
  6. Kubota K, Ohara S, Yoshida S, Nonami Y, Takahashi T. Intrathoracic omental herniation through the esophageal hiatus: a case report. Radiat Med. 2001;19(6):307-11. Review
  7. Wehrmann T, Martchenko K, Nakamura M, Riphaus A, Stergiou N. Endoscopic resection of submucosal esophageal tumors: a prospective case series. Endoscopy. 2004;36(9):802-7
  8. von Rahden BH, Stein HJ, Feussner H, Siewert JR. Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach.Surg Endosc. 2004 Jun;18(6):924-30.
  9. Bak YT, Kim JH, Kim JG, Lee CH, Lee KN, Choi YH, et al. Liposarcoma arising in a giant lipomatous polyp of the esophagus. Korean J Intern Med 1989; 4: 86-9.