Laparoscopic excision for small intestinal mesenteric tumour diagnosed Schloffer tumour.

This report presents a case of Schloffer tumour at the small intestinal mesentery, mimicking a malignant tumour, treated laparoscopically. Six years prior, a 57-year-old woman underwent laparoscopic salpingo-oophorectomy for a benign, cystic, ovarian tumour, but she had no history of malignancy. She was treated at an outpatient clinic for gastrointestinal complaints and was relieved of these symptoms. Abdominal computed tomography showed an incidental mesenteric tumour of the small intestine, tending toward growth. Due to the tumour's malignant potential, laparoscopic examination was performed. A spherical tumour with a base in the jejunum mesentery was observed. It was removed without damage. The post-operative course was uneventful, and the patient was discharged 3 days after the operation without complications. Histological diagnosis showed this to be a Schloffer tumour, but no malignancy was observed. Unidentified intraperitoneal tumours in patients with surgical histories may be Schloffer tumours, and this should be kept in mind.

INTRODUCTION

Schloffer tumours have initially been reported as inflammatory tumours occurring after hernioplasty and have been described as foreign-body granulomas, irritating the area near the abdominal scar. There have also been reports of suspected local malignancy recurrence at a port site or in the abdominal cavity after radical surgery for malignant tumours, with Schloffer tumours being diagnosed during reoperation. This report presents a case of Schloffer tumour in a patient with no history of malignant tumours and no foreign-body irritation.

CASE REPORT

A 57-year-old woman presented with a history of bloody stool due to ischemic colitis. The patient's intestinal condition improved, but abdominal computed tomography (CT) revealed a 32 mm tumour, with a regular surface, in the small intestinal mesentery of the left upper abdomen. She had no history of abdominal injury and had not received any drugs. However, she had undergone laparoscopic salpingo-oophorectomy for a cystic tumour of the ovary 6 years prior. Seven months after the patient's initial presentation, during the follow-up, abdominal enhanced CT showed that the tumour appeared to be growing, reaching a diameter of 43 mm performed [Figure 1]. Based on the findings of the clinical course and imaging, surgery was planned to obtain a diagnosis and rule out the possibility of malignancy. During surgery, five trocars were inserted and a spherical tumour with its base in the jejunal mesentery near the Treitz ligament, was observed [Figure 2a]. The jejunal artery and vein, branching from the superior mesenteric artery and vein, was the main feeder [Figure 2b]. The tumour was removed from the abdominal cavity without damage. The operation time was 201 min and the blood loss was 0 ml. The maximum tumour diameter was 50 mm. The patient was discharged on post-operative day 3 without any complications. The histopathological diagnosis showed fat cells with cholesterol deposition in the centre of the tumour. The tumour composed of thin fibrous capsule and necrotic contents. The foamy macrophages were observed around the necrotic tissues. Consequently, the tumour was diagnosed as a Schloffer tumour without malignancy.

Figure 1

Abdominal computed tomography showed the spherical tumour

Figure 2

(a) A spherical tumour (arrow heads) near the Treitz ligament (arrow) was observed. (b) The jejunal artery and vein was the main feeder (arrow)

DISCUSSION

The term 'Schloffer tumor' often refers to tumours in which granulomas have formed due to chronic inflammation from a foreign-body accompanying surgery, such as a suture. On the other hand, an inflammatory mass that occurs in the omentum is called a Braun mass and is distinguished from a Schloffer tumour. Previous cases have reported foreign-body formation – so-called granuloma formation – and it is presumed that Schloffer tumors have been included in the reported cases up to now. In the present instance, the patient had a past medical history: laparoscopic salpingo-oophorectomy for a cystic ovarian tumor six years prior. According to the operative records, no intraperitoneal adhesions were found; the ovarian arteries and veins were treated using a vessel sealing system without a foreign-body (such as a clipping device) and the resected ovary was removed without destroying the tumour.

Therefore, the possibility of iatrogenic foreign bodies and inflammation of the pelvic organs was ruled out based on the patient's medical history and the operative findings. Schloffer tumours are found incidentally in the abdominal wall;[1] however, in this case, the tumour occurred in the mesentery, and this disease in the abdominal cavity is rare. From a literature search of the PubMed database (using the keywords 'Schloffer tumor'), three similar cases have been reported in English.[123] The patients in these cases had histories of laparotomy, but only one case involved a foreign body.[2]

Previous studies have demonstrated that Schloffer tumours looked like lymph node malignancy recurrence after surgery for gastric cancer and required the dissection of the lymph nodes near the anastomosis.[4] Another case required pancreaticoduodenectomy after ascending colon cancer because the Schloffer tumour resembled malignancy relapse.[5] Therefore, distinguishing post-operative recurrence from Schloffer tumours is difficult when a growing mass is observed at the previous surgical site. In fact, there have been no reports of Schloffer tumours being diagnosed before surgery except for the abdominal wall, further highlighting the difficulty of pre-operative diagnosis.

CONCLUSION

Schloffer tumours should be considered as a differential diagnosis when a growing tumour is observed in the abdominal cavity.

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Conflicts of interest

There are no conflicts of interest.