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A mesenteric cyst
is defined as any cyst located
in the mesentery; it may or may
not extend into the retroperitoneum, which has a recognizable lining of endothelium
or mesothelial cell. Mesenteric cyst
can occur anywhere in the mesentery
of gastrointestinal tract from duodenum to rectum. A mesenteric cyst
is one of the rarest abdominal tumors, with approximately 822 cases recorded
since 1507. The incidence is between 1 per 100,000 to 1 per 250,000 hospital
admissions. We are presenting a female patient, who was operated for mesenteric
cyst more than 2 years back. She had presented to us with mesenteric dermoid
cyst. She was successfully operated. The patient was followed-up for a long 10
years and she is absolutely normal. But finding two variants of mesenteric
cysts in one individual is extremely rare.
Keywords: Mesenteric cyst, Metachronus, Chylo-lymphatic, Retroperitoneum, Dermoid
INTRODUCTION
Mesenteric
cysts are rare benign intra-abdominal tumours with an incidence of 1 case per
100,000 to 250,000 hospital admission [1-4]. Often they present with abdominal
pain, vomiting and abdominal mass. In-spite of variable and non-specific
clinical symptoms and signs, often they are discovered during abdominal
radiological examination. But sometimes either accidentally they are discovered
during investigations for other reason or during laparotomy for the management
of one of the complications. The aetiology of such cysts remains unknown but
several theories regarding their development exist.
Tillaux
triad named after the French surgeon Paul Jules Tillaux can be seen in cases of
mesenteric cyst. It consists of the following signs are a fluctuating swelling
near the umbilicus, swelling freely mobile in the direction perpendicular to
the attachment of mesentery and with a zone of resonance around the swelling
[5].
Mesenteric
cysts are of 4 variants such as:
1.
Developmental cyst
2.
Traumatic: Blood cysts
3.
Infective: Tuberculous mesenteric cold abscess following
caseation and
4.
Neoplastic: According to the cause.
But
developmental cysts include basically the following 4 types:
1.
Chylo-lymphatic cyst: Most common type, thin wall, lined by flat endothelium,
clear chylous fluid present, separate blood vessels.
2.
Enterogenous cyst: Thick wall, lined by columnar, mucinous fluid present
and common blood supply.
3.
Urogenital remnant cyst
4.
Dermoid cyst (mature cystic teratoma): Contain developmentally mature
skin with its accompanying structures: hair follicles, sweat glands, hair and
often bits of other tissues. They are almost always benign. Dermoid cyst rarely
present as mesenteric cysts [6].
In
2000, some researchers suggested a classification for mesenteric cysts based on
histopathological features:
A.
Cysts lymphatic origin: Simple lymphatic cyst, lymphangioma
B.
Cysts of mesothelial origin: Simple mesothelial cyst, benign
cystic mesothelioma and malignant cystic mesothelioma
A.
Cysts of enteric origin: Enteric cyst and enteric duplication cyst
B.
Cysts of urogenital origin
C.
Mature cystic teratoma: Dermoid cysts
D.
Pseudo-cysts: Infectious, traumatic cysts
Complete surgical excision of the
cyst is the treatment of choice. Due to the rarity of this entity and the lack
of specific symptoms and signs, sometimes correct pre-operative diagnosis is
difficult. Knowledge of these lesions is important due to the various
complications associated with suboptimal or delayed surgical management.
CASE SUMMARY
Mrs. Banabali Mishra,
w/o Mr. RR Kamal Tripathy, 24 years female from Balangir, Orissa got admitted in surgery department,
MIMS, Nellimarla, on 6th December 2006 (MR No. 518277 and IP No.
44978). She had come with the complaint
of abdominal pain, vomiting and constipation for last 2 years but
symptoms were more severe for last 3 months. Abdominal pain was intermittent
type, dull aching in nature, around the umbilicus and left side of the abdomen.
Pain was not related to food and also did not have any diurnal variation. Vomiting
was sometimes associated with abdominal pain. Often associated with
constipation, but pain used to reduce after passing motion. There was no
history of loss of appetite but there was history of loss of weight. Usually
bowel and bladder habits were normal. There was no history of jaundice.
PAST HISTORY
She was suffering from similar type of
abdominal pain during early days of 2004. For which she was investigated and
found to have mesenteric cyst. She underwent operation (exploratory laparotomy
and total excision of the mesenteric cyst) on 19-04-2004 at Medical college
hospital, Burla, Orissa. There was a mass of 4” × 3” from the mesentery
containing serous fluid and chylous in nature. Mass was excised and sent for
HPE. Post-op was uneventful.
Then the HP report was a cyst of 8 × 5 cm was
embedded in the mesentery. Outer wall was smooth with inner wall showing
papillary folds. Microscopically, cyst wall showed fibro collagenous tissue,
adipose tissue, capillaries and contained chyle inside the cyst. Features were
in consistent with chylo-lymphatic mesenteric cyst.
Eight months after surgery, she started
having attacks of severe abdominal pain, around umbilicus, lasting from hours
to days but used to get relief with medical treatment. Since then she has been
treated symptomatically and used to get relief with treatment, with varying
periods of symptom free life.
Then on 29-09-2006, U.S Scan was repeated and
found that there was an oval, hypoechoeic lesion measuring 23 mm × 30 mm × 46
mm (volume:16.4 ml) seen in left para-umblical region, below the umbilicus.
Rest of the abdomino-pelvic scan was normal.
Urine - R & M/E - NAD, ESR - 15 mm/1 h
(Wastergren).
She was advised surgery after the scan, but
patient neglected.
PERSONAL HISTORY
She is a teacher, by profession, married
since 6 months. No H/O menstrual irregularity or whitish discharge, LMP was 20
days back. No H/o allergy. No H/o chronic diseases like DMT /HTN. But she has
lost weight nearly 6 to 7 kg in last 2 years.
GENERAL CONDITION
Average built, weight: 45 kg, BP: 110/80 mm
Hg, pulse: 100/min, temp: N and no lymphadenopathy.
Systemic examination revealed CVS: S1 S2 no
murmurs, resp: NBS, No as P/A: Abdomen was scaphoid, soft. No organomegally.
There was a mass over the supra pubic region and lower abdomen mainly on the
left side. It was well defined, firm, restricted movement with mild tenderness
over left central abdomen (Figure 1).
No ascitis. P/R & P/V: NAD.
INVESTIGATIONS
Urine: R & M/E- NAD, blood: CBC: Hb% -
12.8g%, BT: 1’10”, CT: 2’30”, TC: 8,800/cells/cumm, DC: P-66%, L-29, E-05%,
ESR: 48 mm/1st hour, Serology: HIV-Negative and Hbs Ag-Negative,
RBS: 88 mg% and Blood Grouping and Rh typing-‘O’+ve.
US scan and CECT scan of abdomen (8-12-06)
showed a contrast enhanced soft tissue density mass lesion, with solid and
cystic components, is seen at the level of aortic bifurcation on the left side
measuring 4 × 4 × 5 cm (Figure 2).
Impression: Mesenteric dermoid cyst with
small bowel adherence to the posterior aspect of anterior abdominal wall (Figure 3).
TREATMENT
After preparation, Exploratory Laparotomy was
done on 13-12-2006. Two to three lobulated masses partly cystic and partly
solid mass was present in the mesentery, close to intestinal wall with lots of
omental adhesions and angulations. Hence, excision of mesenteric dermoid cyst
along with adjacent loop of small gut was done. End to end anastomosis of small
intestine was done. Post-op was uneventful. HPE report came as Mesenteric
Dermoid cyst. No evidence of any malignancy (Figures 4 and 5).
DISCUSSION
A mesenteric cyst is defined as a cyst
located in the mesentery lined by endothelial or mesothelial cells; may or may
not extend in to retro-peritoneum. Mesenteric cysts are rare surgical
conditions occurring 1 in 200,000 to 1 in 350,000 hospital admission [7].
Italian Anatomist Benevenni first described mesenteric cyst in an 8 years old
boy in 1507, while performing autopsy. Later on, Rokitansky published a case of
chylous mesenteric cyst with description on 1842 and Tillaux performed the
first surgery on mesenteric cyst successfully in 1880 [8]. Mesenteric cysts can
occur anywhere in the mesentery GIT from duodenum to rectum. In a review of a
series of 162 patients, 60% occurred in small bowel mesentery, 24% in large
bowel mesentery, and 14.5% in the retro-peritoneum and indefinite in 1.5% cases
[9]. Mesenteric cysts can be simple or complex, unilocular or multilocular. The
size varies from few millimeters to few centimeters in diameter. They may
contain serous, hemorrhagic, chylous or infected fluid, hair teeth or pus,
depending on the type of mesenteric cyst [10].
Mesenteric cyst may occur in
patients of any age. Approximately, one-third of cases occur in children
younger than 15 years. The cyst may present either as a non-specific abdominal
feature, as an incidental finding or as an acute abdomen. They are often asymptomatic
and found incidentally while patients are undergoing work-up or receiving
treatment for other conditions, such as appendicitis, small-bowel obstruction,
or diverticulitis.
Exact etiology of mesenteric cyst
has yet to be ascertained, but failure of the lymph nodes to communicate with
the lymphatic or venous systems or blockage of the lymphatic as a result of
trauma, infection and neoplasm are said to be contributing factors [11]. The
most accepted theory, proposed by Gross, is benign proliferation of ectopic
lymphatic in the mesentery that lack communication with the remainder of the
lymphatic system [12].
Although patients may present
with lower abdominal pain, the symptoms are often variable and non-specific and
include pain (82%), nausea and vomiting (45%), constipation (27%) and diarrhea
(6%). An abdominal mass may be palpable in up to 61% of patients [13].
Complications associated with
mesenteric cysts include volvulus, spillage of infective fluid,
intussusceptions, herniation of bowel into an abdominal defect and obstruction
[14].
Mesenteric cyst should be
evaluated with complete history, clinical examination, blood investigations
like CBC, RFT, FBS, LFT and radiological investigations (X-ray abdomen erect,
ultrasound abdomen (USG) and computed tomography (CT) scan (in selected cases)
to reach a provisional diagnosis. The clinical diagnosis may be confirmed by
diagnostic laparoscopy or laparotomy. Of course histopathological examination
of the excised specimen shall finally confirm the diagnosis.
The treatment of choice is
complete excision of the cyst (total cystectomy), to avoid recurrence and
possible malignant transformation. Bowel resection may be necessary in cases
where cysts are close to bowel structures with common blood supply, like enterogenous
cysts or any other cyst involve blood vessels that supply the bowel. Once
removed, mesenteric cysts rarely recur, and patients have an excellent
prognosis. Malignant cysts occur in less than 3% of cases [15]. This can be performed either by
open method or laparoscopically.
CONCLUSION
Mesenteric dermoid cysts are very much
uncommon. Metachronous presentation of chylo-lymphatic and dermoid mesenteric
cysts are extremely rare. Rarely these cysts can become malignant. They can
present asymptomatically or with signs and symptoms suggestive of other
intra-abdominal pathology. Pre-operative diagnosis can be difficult, but can be
made with expert ultra-sonography or contrast CT scanning. Histopathological
examination of the tumor will give accurate diagnosis. Optimal treatment for
definitive management is intact removal of the tumor, wherever possible.
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