Introduction

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A lipoma is a benign, adipose tumour that can appear throughout the whole gastrointestinal tract. Most commonly, they are found at the level of the colon (64%), ileum and jejunum (26%). Only 4% of all gastrointestinal lipomas are found in the duodenum. They present as a single and slow-growing tumour and are most often found in the second part of the duodenum or descending duodenum [1]. It is a neoplasm of mesenchymal origin. Other mesenchymal tumours include leiomyomas, leiomyoblastomas, haemangiomas, fibroids, neurofibroma-like tumours, schwannomas, gangliomas and lymphangiomas [2]. Duodenal lipoma can present itself as a sessile or a pedunculated mass, often incidentally diagnosed on endoscopy, computed tomography (CT) or during surgery. 

Small lipomas (diameter < 2 cm) tend to be asymptomatic. When exceeding a diameter of 2 cm, it can cause a wide range of vague symptoms and therefore an easily missed diagnosis in daily practice. Epigastric pain, fullness, nausea, vomiting, obstruction and rarely intussusception have been described [1,3-7]. Gastrointestinal tract bleeding can occur from overlying ulcerated mucosa, causing anemia and melena or occult gastrointestinal bleeding [3,8-16]. Rare symptoms are obstructive jaundice and pancreatitis [17,18]. 

To our knowledge, there are no clear guidelines concerning the treatment of duodenal lipoma. Our aim was to review possible treatment strategies since we encountered a patient with a symptomatic giant duodenal lipoma ourselves. Therefore, a literature search on PubMed was performed for published cases of duodenal lipoma and their treatment strategy. All case reports published in English from 2001 until 2024 were included (table 1).

Case Report

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A 79-year-old male patient presented with anorexia, nausea, unintentional weight loss of 2 kg and constipation. There is a medical history of splenectomy, rectal adenocarcinoma (pT3N0M0, Dukes b) treated with open total mesorectal excision and few years later an incisional hernia treated with open ventral hernia mesh repair. Active medication included calcium channel blockers. Upon clinical examination, there was no recurrence of the ventral hernia. Upper gastrointestinal endoscopy showed an extensive submucosal mass in the second part of the duodenum, easily passable with a scope, over a length of 10 cm, suggestive of a duodenal lipoma.

Computed tomography (CT) of the abdomen confirmed the presence of a duodenal lipoma extending from the 2^nd to 4^th part of the duodenum, measuring 95 mm x 30 mm (Figure 1 - 3).

Figure 1

Figure 2

Figure 3

Due to his surgical history, laparoscopy was not found to be a safe surgical approach. We performed a redo midline, upper abdomen, laparotomy. After extensive adhesiolysis and identification of the Treitz ligament, no mass could be palpated at this level. Proceeding with mobilization of the duodenum by performing the Kocher manoeuvre, a large mass could be palpated in the descending part of the duodenum(D2). Longitudinal duodenotomy at the level of D2 revealed a pedunculated mass originating from the posterior wall of the duodenum (Figure 4-6).

Resection was performed using a powered stapler (EchelonTM flex 60 mm), positioned at the base of the stalk of this pedunculated mass after luxating it through the duodenotomy and checking for safe distance from Vater’s ampulla. After primary transverse closure of the duodenotomy, a Blake drain was placed alongside the duodenum. 

The postoperative period was uneventful. Upper gastrointestinal contrast series on the third postoperative day showed no signs of contrast leakage, normal duodenal appearance and stomach emptying. Oral intake was resumed, and the drain was removed successfully. The patient was discharged home on day 6. 

Histopathological diagnosis confirmed a submucosal lipoma with no signs of malignancy. At the one-month post surgery follow-up, the patient had no residual complaints of nausea, good oral intake without any postprandial discomfort and a stable body weight. 

Figure 4

Figure 5

Figure 6

Materials and Methods

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There are no clear guidelines concerning the treatment of duodenal lipoma to our knowledge. Our aim was to review possible treatment strategies since we encountered a patient with a symptomatic giant duodenal lipoma for the first time.

A literature review was performed using the search term “duodenal lipoma” in PubMed. This search generated 157 articles published from 2001 until May 2024, of which 51 case reports of duodenal lipoma published in English and 2 retrospective studies. The retrospective study by Yang et al. was included since all patient characteristics and treatment details were available per individual patient. Xiang et al. did not provide individual information and thus was not included in our review. Case reports of gastric and jejunal lipoma were excluded. 

Results

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We included 51 case reports and one retrospective study representing 75 patients diagnosed with duodenal lipoma over a time span of 24 years (table 1). There were five cases of multiple lipomas; 44 patients were diagnosed with a single lipoma, of which one was multilobulated, two case reports and the retrospective study by Yang et al. did not mention specific spatial information (26 patients). The size varied between 10 mm and 115 mm. Twenty-three patients were treated surgically of which 4 robot-assisted procedures. Three cases described a combined surgical and endoscopic approach [19-21]. Forty-seven patients were treated endoscopically. In two patients the lipoma was not resected. One case report by Mariani et al. reporting a duodenal lipoma obstructing a biliary stent which was not resected and in the case reported by Talaat et al. stenting of the common bile duct for obstructive jaundice was preferred over resection of the duodenal lipoma [17,18].

One retrospective study was published in 2021 by Yang et al. comparing endoscopic submucosal dissection (ESD) and endoscopic full thickness resection (EFTR) depending on how the lesion was relating to the muscularis propria layer on endoscopic ultrasound.

The literature search showed only one systematic review by Pei et al. discussing all published cases of duodenal lipoma from 1948 until 2016 in addition to their own encountered patient with duodenal lipoma [22]. There are no clinical trials or meta-analysis published.

Figure 7

Figure 8

Discussion

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From 2001 until 2024, the majority of reported cases (24 patients, 32%) including all patients of a retrospective study by Yang et al. were diagnosed with duodenal lipoma in their 7th decade of life. We found no diagnosis before the age of 15 or above the age of 85 (table 1, figure 7). Thirty-eight female (51%) and thirty-four male (45%) patients were diagnosed, 2 case reports (3 patients, 4%) did not mention patient gender or age. The majority of lipoma were found in the second part of the duodenum (figure 8).

Symptoms

Duodenal lipoma can cause vague abdominal symptoms such as epigastric fullness and postprandial discomfort. Unintentional weight loss, gastric outlet obstruction with nausea and (projectile) vomiting are also reported. Intussusception is described with the lipoma acting as the leading point causing duodeno-duodenal intussusception [7]. 

Symptoms of upper gastrointestinal bleeding (hematemesis, melena, anemia, fatigue) can be associated because of ulceration of the overlying mucosa, often seen upon endoscopy. Some rare symptoms, such as obstructive jaundice and (recurrent)pancreatitis, have been described in 3 case reports [17,18,20]. 

Large lipomas tend to cause symptoms more often, whereas small lipomas are frequently found by coincidence on CT scan, during endoscopy or intraoperatively. The literature review by Pei et al. stated that 80% of symptomatic lipomas have a diameter of >2 cm [22].  Other authors mention that lipomas <1 cm are usually asymptomatic and lipomas of> 4 cm are more likely to cause obstruction, intussusception or bleeding [2]. The cut-off diameter for large or giant lipoma differs depending on the author.

Diagnosis

Duodenal lipomas are often found by accident during endoscopy and endoscopic ultrasonography (EUS). They have a characteristic appearance because of their fat content and their submucosal location in the enteric wall. During endoscopy a lipoma can appear as a round yellowish elevated lesion. A positive ‘Pillow sign’, consisting of a visible indentation when palpating the lesion with closed forceps, is described as a typical endoscopic feature for a lipoma [23]. Characteristic presentation during EUS consists of an intense, homogeneous, hyperechoic lesion originating from the submucosa [23,24]. Endoscopy with EUS is the most accurate imaging modality for morphological features (sessile, pedunculated) and defining the exact location of the lipoma establishing its distance to the ampulla of Vater. These features are determining in selecting the right treatment option.

Differential diagnosis consists of other hyperechoic lesions, e.g. renal cell carcinoma metastasis, ampullary carcinoma, hamartomatous duodenal polyp and gangliocytic paraganglioma[25]. Other duodenal lesions to keep in mind are gastrointestinal stromal tumours, carcinoids, solitary Peutz-Jeghers polyp and adenoma [23]. Yang et al. describes a possible risk of malignancy especially when the duodenal lipoma exceeds 5cm, referring to the UK guidelines for management of soft tissue sarcoma’s [26,27]. Reviewing these guidelines ourselves we found no specific statements on visceral or duodenal lipoma in particular. Gaspar et al. and the systematic review by Pei et al. report no malignant transformation [22,23].

Computed tomography (CT) has grown in popularity for diagnostic purposes in the last decade. Lipomas are easily and reliably identified on CT because of their appearance as a smooth margined mass combined with a characteristic low uniform (fat density) attenuation with a low Hounsfield Unit (HU) count from -70 to -120 HU [28-30].

Combining information from EUS and CT, the diagnosis of duodenal lipoma can easily be confirmed because of its characteristic features on both imaging modalities. When the diagnosis remains uncertain, EUS with biopsy is an option to differentiate from possible malignant lesions.

In addition, lipomas have specific characteristics on magnetic resonance imaging (MRI). They show a high signal intensity on a T1-weighted image and an iso-signal intensity on T2-weighted images [30,31]. 

Figure 9

Treatment

Duodenal lipomas come in different sizes and shapes, as do their treatment options. The majority of patients was treated endoscopically (62%), 31% was treated surgically and 4% underwent a hybrid treatment strategy combining both (figure 9). Important features to consider are size, location in the duodenum (relation to the ampulla of Vater) and patient-specific characteristics. The most determining factor is clinical presentation. Lipoma is a lesion of benign nature. In the retrospective study by Yang et al, the authors are concerned about possible malignancy whereas the systematic review by Pei et al. state that malignant change of duodenal lipoma is unheard of and they consider these lesions as benign [22,26]. We found no reports of malignancy or malignant deterioration of duodenal lipoma from 2001 until present.

Given its benign nature, treatment is recommended when patients are symptomatic. A pedunculated duodenal lipoma lends itself to endoscopic management when not too bulky. Large and sessile lipomas are often better managed with surgical intervention.

The majority of patients (47 patients; 62%) were treated endoscopically (figure 10). This high number can partially be explained by the included retrospective study which only reviewed endoscopic treated patients in their hospital. In this study a remarkedly large number of asymptomatic patients were treated claiming resection of the lipoma was the patients’ wish (8 patients). Several endoscopic techniques are described: SNARE polypectomy (17 patients), unroofing technique (2 patients), endoscopic submucosal dissection (ESD, 21 patients) and endoscopic full thickness resection (EFTR, 4 patients). For three patients the endoscopic technique was not specified. In 36% of all endoscopic treated patients, the SNARE technique using a two-channel scope was used. One channel is used for the introduction of an electrocautery snare, and the other channel for grasping forceps pulling the lipoma through the loop of the [4,8,12,15,16,32-42]. The unroofing technique used in 2 patients (4% of all endoscopic treated patients) consisted of cutting the upper half of the lipoma and extruding the remaining adipose tissue from this open surface. It is considered a simple technique with minimal risk of perforation. The main disadvantage is the fragmented resection [24,43]. Yang et al. compares the use of ESD to endoscopic full resection (EFTR), choosing EFTR when the lesion was near the muscularis propria layer. In those patients the nearby muscularis propria and serosa were also resected, closing the defect in the duodenal wall with purse-string sutures using endoloops and clips. This technique is accompanied with the need for pneumoperitoneum desufflation during and after procedure and a gastro-intestinal tube was left behind at level of the resection site. Hospital stay in this study was rather long for both techniques from 5 days until 16 days hospital stay which is longer than the hospital stay of our patient treated with open surgical excision [26].

The most used endoscopic technique, accounting for 21 patients (45% of all endoscopic treated patients) is the endoscopic submucosal dissection (ESD) frequently mentioned as the preferred approach for resection. With increasing lipoma diameter, the endoscopic intervention becomes increasingly challenging with a higher risk of perforation and more fragmentated tissue for histo-pathological examination. Another large disadvantage is the long intervention time reported up to 4 hours in this literature search. Therefore, this technique is not suitable for every patient nor every lesion [19,26,44,45].

Two case reports did not resect the duodenal lipoma causing obstructive jaundice. One lipoma was lifted out of a present biliary stent with the tip of the endoscope without resection[18]. In the second case, endoscopic bare metal stenting was preferred to treat the jaundice without resection of the responsible lipoma [17].

Figure 10

Surgical management was described in 23 patients (31%). Surgical access options are laparotomy (13 patients) or minimally invasive via laparoscopy (4 patients) or robot-assisted surgery as described in 4 patients (figure 10). The access was not specified in two patients.

Different useful surgical techniques are duodenotomy with excision/enucleation of the lipoma and primary closure (12 patients), a pancreas sparing duodenectomy (PSD) with end-to-end or side-to-side duodenojejunostomy (8 patients), PSD with the need for Roux-en-Y reconstruction (1 patient) and Whipple procedure (no reported cases) all summarized in figure 10 [1,5-7,10,11,13,14,31,46–58]. The resection technique was not further specified in two patients [31,55]. Three patients underwent a hybrid approach combining endoscopy and surgical techniques. One patient had multiple intestinal lipomas resected via laparotomy with resection of each palpated (jejunal) lipoma combined with ESD for the one duodenal lipoma[19]. One patient was treated with ESD but needed laparoscopic removal of the specimen [20]. And one patient underwent a hybrid laparoscopic endoscopic collaborative surgery (LECS) procedure in which ESD was performed with en bloc resection of the lipoma followed by laparoscopic suturing of a mucosal defect [21].

Figure 11

Based on reviewed literature we propose a practical flow-chart useful in daily practice when encountering a patient with duodenal lipoma (figure 11). When large and bulky, surgical excision is a more appropriate course of action. No clear cut-off diameter is established in the literature from which surgery is preferred over endoscopic resection. Several authors describe large lipoma as being too difficult for endoscopic resection, especially when located in D2 and near Vaters’ ampulla. The systematic review by Mao Wei Pei et al. (2017) mentions large and sessile lesions as difficult to manage endoscopically because of the increasing risk of perforation and bleeding with increasing lesion size, but a size cut off favoring surgical treatment was not discussed. Kato Motohiko et al.(2019) published a retrospective study identifying lesion size >40mm, lesion location in duodenal flexure and occupied circumference >50% as characteristics associated with technical difficulties during ESD. [59] Therefore 40mm could be a possible size cut-off from which surgery should be considered over endoscopic treatment. Criteria in favor of surgery are location near Vater’s ampulla, sessile and large lipoma and no clear diagnosis of benign nature since endoscopic resection often results in fragmented and sometimes incomplete resection. Future research is needed to establishing a clear size cut-off from which surgery is preferred over endoscopic management. This could result in more evidence-based guidelines supporting gastroenterologist and surgeons in daily practice.

Laparoscopic and robotic approaches are technically feasible and have been described in several cases. Patient history and location of the lipoma in the duodenum are important factors in determining if your patient can be considered for minimally invasive surgery. 

In our case, laparotomy was preferred given the patients’ surgical history and extensive adhesions were to be expected. Additionally, the duodenal lipoma was located at the posterior wall of the descending duodenum, a location difficult to access laparoscopically.

Several good treatment options and techniques have been described for symptomatic duodenal lipoma. In summary, there is endoscopy (SNARE, unroofing technique, ESD, EFTR), laparoscopy and laparotomy (duodenotomy with excision/enucleation, PSD with or without Roux-en-Y reconstruction), robotic assisted procedures and hybrid approach.

There is a need for larger studies with long term follow up of patients to assess outcomes of all the different treatment modalities. This will contribute to more evidence-based guidelines concerning the management of duodenal lipoma to better support and guide gastroenterologists and abdominal surgeons when encountering this rare pathology in their daily practice.

Conclusion

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Duodenal lipoma is a difficult and rare diagnosis. Therefore, it is important to keep this benign tumour in mind when investigating a patient with vague abdominal, nonspecific complaints. 

A CT scan and MRI can confirm the diagnosis based on the imaging characteristics of a lipoma but are less accurate in exact localization. Endoscopic ultrasound is more accurate in determining the precise location of the duodenal lipoma in relation to Vaters’ ampulla and evaluating its morphology and spatial features (sessile, pedunculated). 

Dealing with a benign disease, always consider the least invasive technique seen fit for each patient. Watchful waiting is considered a safe option for asymptomatic duodenal lipoma. When symptomatic, excision is recommended endoscopically or surgically depending on the characteristics of the patient and the lesion.

The best treatment option is the technique most suited for your specific patient taken medical history and characteristics of the lipoma into account. Spatial characteristics of the lipoma such as size, morphology and location, are important factors in determining the appropriate treatment access and technique.

There are no treatment guidelines available. Individual assessment is needed but clear evidence-based guidelines are mandatory in further improving the care for patients diagnosed with duodenal lipoma. Therefor larger studies are needed, assessing long-term outcomes of all different treatment strategies, contributing to evidence-based guidelines.

Acknowledgements

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Not applicable

Declarations

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No funding was received for this article. The authors report there are no competing interests to declare. The patient gave consent for publication.

All data generated or analysed during this study are included in this published article and its supplementary information files.

Author Contributions

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Potums L. acted as writer of the original draft of the article, performing the literature search and review included.

Huysentruyt F., D’hooge P. and Delvaux P. were major contributors throughout the writing and re-writing process of the manuscript, proofreading and help in re-writing the discussion section.

All the authors have read and approved the final manuscript.

Appendix – Additional information

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Table 1

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