\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[T2A]{fontenc}
\usepackage[polish,ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Mesenteric Lipoma revealed by chronic abdominal pain: A rare challenging
diagnosis}



\author[1]{kais fourati}%
\author[2]{Abderrahmen Masmoudi}%
\author[2]{Amine Zouari}%
\author[2]{Rami Zouari}%
\author[2]{jawhar Bradai}%
\author[2]{Najmeddine Hentati}%
\author[1]{Salah Boujelbene}%
\affil[1]{University of Sfax Faculty of Medecine of Sfax}%
\affil[2]{Habib Bourguiba Hospital}%


\vspace{-1em}



  
  \date{May 21, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Mesenteric Lipoma is very rare. Diagnosis is challenging because of
nonspecific clinical presentation. Complete resection of the lipoma is
proposed to relieve pain, and prevent complications. We report a case of
mesenteric lipoma revealed by chronic abdominal pain and we performed a
litterature review regarding this rare condition.%
\end{abstract}%



\sloppy


\textbf{Title: Mesenteric Lipoma revealed by chronic abdominal pain: A
rare challenging diagnosis}

\textbf{Authors:} Kais Fourati \textsuperscript{1}, Abderrahmen
Masmoudi\textsuperscript{1}, Amine Zouari \textsuperscript{1}, Rami
Zouari\textsuperscript{1} , Jawhar Bradai \textsuperscript{2} ,
Najmeddine Hentati \textsuperscript{1},Salah Boujelbene
\textsuperscript{1}

\textsuperscript{1 General surgery Department, Habib Bourguiba Hospital,
Sfax, TN 3089}

\textsuperscript{2 Radiology Department, Habib Bourguiba Hospital, Sfax,
TN 30893}

\textbf{Correspondance:} Kais Fourati,Department of surgery, Habib
Bourguiba Hospital, Sfax, Tunisia General Surgery Department
Habib~Bourguiba~Hospital University of~Sfax~ 0.5 km~Sfax, TN 3021

E-mail:\emph{kaisfourati51@gmail.com}Num~: 58084298

\textbf{Consent statement}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\textbf{Mesenteric Lipoma revealed by chronic abdominal pain: A rare
challenging diagnosis}

\textbf{Key Clinical Message} :

Mesenteric localization of lipoma is extremely rare. It may be
considered in patient presenting with chronic abdominal pain. Complete
resection of the tumor is indicated to relieve the pain and prevent
complications.

\textbf{Key Words:} Mesenteric Lipoma, Abdominal Pain, surgery

\section*{Introduction}

{\label{introduction}}

Lipoma is a rare benign lesion of mature adipose tissue and commonly
occur in the cephalic part of the body (1,2). Its localization in the
mesentery is extremely rare (1). Few cases of mesenteric lipomas have
been reported in the literature (2).The course is usually asymptomatic
and the clinical findings depend on the size of the lipoma, its location
and the rapidity of growth of the tumor (1). We report a case of
mesenteric lipoma revealed by chronic abdominal pain along with a
litterature review regarding this rare condition.

\section*{Case report}

{\label{case-report}}

A 22-year-old Tunisian man without a medical history presented to the
hospital with abdominal pain located in the right iliac fossa. The pain
began 2 years ago with a paroxysmal evolution, but it has worsened over
the last 6 months. The patient also complained of chronic abdominal
discomfort. There was no signs of bowel obstruction. Physical
examination found tenderness of the right iliac fossa without a palpable
mass (Figure 1). Biology tests showed no abnormalities, in particular,
C-reactive protein was within the normal range. We performed an
abdominal ultrasound which showed a well-defined, homogenous mass of the
right iliac fossa of 10 x 8 cm.

The abdominal scan showed a well-defined mass in the mesentery measuring
12 x 9 cm with fat density surrounded by a thin capsule. This mass did
not enhance after injection of contrast product with no septum or
calcification. There was no lymphadenopathy or invasion of neighboring
organs. The CT scan images were most consistent with a mesenteric lipoma
(Figure 2). Therefore, surgery was decided. Exploration of the abdomen
by midline laparotomy revealed an encapsulated, mobile and yellowish
mass originating from the ileal mesentery without any adhesions to other
organs. There were no necrosis or hemorrhage within the mass. Complete
excision of the lesion was performed with a clear plan of cleavage
between the tumor and the ileal mesentery (Figure 3,4). The mesenteric
bed was kept intact with its vascular structures (Figure 5). The
pathology of the specimen was consistent with benign lipoma. The
postoperative period was uneventful, and the patient was discharged on
the third postoperative day. Upon follow up, the patient was followed up
regularly for more than 2 years. No recurrence has been diagnosed.

\section*{Discussion}

{\label{discussion}}

Lipomas are the most common soft tissue tumours of adipocytes. They are
commonly located in proximal extremities and the trunk (1). Among all
small bowel lipomas, mesenteric location accounted for only 4.8\% of all
cases (1).

It usually occurs in adults in the fourth to sixth decades of life (2).
They are rarer in children and young people as in the case of our
patient (1,3). There is an increased incidence of lipomas in patients
with obesity ,diabetes mellitus, hypercholesterolemia, genetic
predisposition and radiation therapy (3,4).However, our patient was thin
and none of these factors was found in.

Mesenteric lipomas have generally a slow growth without invasion of
surrounding organs (5). Besides, due to their soft consistency, most
patients are asymptomatic with a chance discovery during abdominal
laparotomy or CT scan done for other indications (1,6). The onset of
symptoms depends on the size, rapidity of growth, and location of the
tumor (1). An acute abdomen can reveal lipomas as they can lead to
intestinal obstruction or volvulus(1,5). Less frequently, they can be
revealed by chronic abdominal pain as in the case of our patient.

As the first-line investigation tool for abdominal pain due to its low
cost, ultrasound shows homogenous or heterogenous well-limited and
encapsulated intraperitoneal mass which may be confused with the
mesenteric fat (1,7). Computed tomography (CT) scan of the abdomen is
the gold standard imaging technique and plays a crucial role in the
diagnosis of mesenteric lipoma (1). It allows the analyse of the nature
and the density of the lesion, its exact location, its size and its
extent. It typically shows an intraperitoneal and encapsulated mass with
fatty attenuation with no lobulations, septations, or cystic
organization (1,8). Mesenteric lipomas are often located in the ileal
mesentery as in our case (1) .The first differential diagnosis to be
suspected are liposarcomas. They are heterogeneous and contain thick
septa with tumor extension to adjacent organs (9). Other rare
differential diagnoses should be suggested, in particular lipoblastoma,
cystic lymphangioma, lymphangiolipoma and neuroblastoma, but their
radiological aspects are different from those of lipomas (5).

Magnetic resonance imaging (MRI) is also very performant to describe in
detail the characteristics of the mass. She shows a hypointensity on
T1-weighted and T2-weighted images without modification of the signal
after injection of gadolinium (1). It confirms the fatty nature of the
tumor and differentiates giant lipomas from well-differentiated
liposarcomas (2). It prevents from doing invasive diagnostic techniques
such as biopsy before surgery (2).

Therapeutic management of mesenteric lipoma is not consensual and it is
based on the experience of the different teams. A small lipoma in a
asymptomatic patient can be left in place (1). In the absence of signs
of malignancy , complete surgical resection with, or if possible
without, the affected intestinal loop is the treatment of choice due to
the risk of intestinal obstruction by compression or volvulus (1,5).
Laparotomy was the most used management strategy often with resection of
the involved bowel followed by end-to-end anastomosis (1). Laparoscopy
may be indicated particularly in cases of small lipoma with a clear
plane of cleavage between the tumor and the adjacent small intestine,
thus allowing enucleation of the mass (2). In our case, CT scan showed a
typical benign mesenteric lipoma. Therefore, after an exploratory
laparotomy, we performed a complete resection of the mass while
conserving the intestine.

The recurrence rate of all lipomas after surgery is less than 5\%, and
is usually due to incomplete excision (6).

\section*{Conclusion}

{\label{conclusion}}

Mesenteric lipoma is a rare condition reported in the literature.
However, it should be considered in the differential diagnosis of
unexplained chronic abdominal pain. Contrast-enhanced computed
tomography is the gold standard diagnostic procedure. Treatment is based
on complete surgical resection with or without the affected intestinal
loop, particularly, in case of symptomatic and / or large lipoma to
prevent the risk of complications.

\section*{Summary}

{\label{summary}}

This report describes a rare case of mesenteric lipoma revealed by
chronic abdominal pain in 22-year-old Tunisian man.

Diagnosis is challenging because of nonspecific clinical presentation
and in the absence of risk factor. The CT scan images were most
consistent with a lipoma and shows no signs of malignancy. Complete
excision of the lesion was performed with a clear plan of cleavage
between the tumour and the ileal mesentery.

Histopathologic examination showed benign lipoma. The postoperative
period was uneventful and no recurrence has been diagnosed.

\section*{Funding}

{\label{funding}}

None

\section*{Acknowledgements}

{\label{acknowledgements}}

None declared

\section*{Conflicts of interest}

{\label{conflicts-of-interest}}

None declared

\section*{Ethic Statement:~}

{\label{ethic-statement}}

Personal data~have been respected

\section*{Consent statement}

{\label{consent-statement}}

Written informed consent was obtained from the patient to publish this
report in accordance with the journal's patient consent policy

\section*{Authors' contribution}

{\label{authors-contribution}}

Kais Fourati writing --review and editing ; Masmoudi Abderrahmen :
Writing -- review and editing ;Amine Zouari: Writing -- review and
editing ; Rami Zouari : review and editing (equal); Bradai Jawhar:
Conceptualization; Najmeddine Hentati: Validation- Supervision; Salah
Boujelbene: Validation- Supervision.

All authors read and approved the final manuscript.

\section*{Data Availability Statement}

{\label{data-availability-statement}}

Personal data of the patient were respected. No data is available for
this submission.

\section*{Abbreviations}

{\label{abbreviations}}

\section*{References}

{\label{references}}

1. Vijayan N, Thekkeveettil M, Sundaram S, Krishnadas S. Giant
Mesenteric Lipoma in an Adult. ACG Case Rep J. janv 2022;9(1):e00728.

2. Abtar HK, Abdallah FK, Lakkis RS, Terro JJ, Ismail NH, Al Raishouni
MA, et al. Giant Adult Mesenteric Lipoma: A Rare Cause of Chronic
Abdominal Distention and Discomfort. Case Rep Surg. 2020;2020:6010757.

3. Ilhan H, Tokar B, I\selectlanguage{polish}ş\selectlanguage{english}iksoy S, Koku N, Pasaoglu O. Giant mesenteric
lipoma. J Pediatr Surg. avr 1999;34(4):639-40.

4. Enyinnah MO, Umezurike CC. Mesenteric lipoma causing recurrent
intestinal obstruction. Niger J Clin Pract. d\selectlanguage{ngerman}éc 2013;16(4):551\selectlanguage{english}-3.

5. Cha JM, Lee JI, Joo KR, Choe JW, Jung SW, Shin HP, et al. Giant
Mesenteric Lipoma As an Unusual Cause of Abdominal Pain: A Case Report
and a Review of the Literature. J Korean Med Sci. avr 2009;24(2):333\selectlanguage{english}-6.

6. Ahmed I, Singh S, Rawat JD. Chronic Abdominal Pain in a Child. Saudi
J Gastroenterol. 2011;17(4):295\selectlanguage{english}-6.

7. Kaniklides C, Frykberg T, Lundkvist K. Paediatric mesenteric lipoma,
an unusual cause of repeated abdominal pain. A case report. Acta Radiol.
nov 1998;39(6):695\selectlanguage{english}-7.

8. Tayeh C, Mneimneh S, El-Masri R, Daoud N, Rajab M (2015) Giant
mesenteric lipoma: a case report and a review of the literature. J
Pediatr SurCase Rep 3(4):166--170

9. Ozel SK, Apak S, Ozercan IH, Kazez A. Giant mesenteric lipoma as a
rare cause of ileus in a child: report of a case. Surg Today.
2004;34(5):470\selectlanguage{english}-2.

10. Nathan VMRS, Rabi MM (2020) A large mesenteric lipoma: an uncommon
etiology of small bowel obstruction. Malays J Med Health Sci
16(3):319--321

\section*{Figures}

{\label{figures}}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1:} Preoperative image of the abdomen\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2:} Abdominopelvic CT scan showing mesenteric lipoma in
the right iliac fossa\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 3:} Intraoperative imaging of the lipoma: dashed lines
show the clivage plan between the lipoma (blue arrow) and the mesentere\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}

\textbf{Figure 4 :} Operative specimen\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}

\textbf{Figure 5 :} Intraoperative imaging after resection of the lipoma
with the mesenteric bed kept intact (dashed lines).

\selectlanguage{english}
\FloatBarrier
\end{document}

