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| CASE REPORT |
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| Year : 2022 | Volume
: 15
| Issue : 4 | Page : 220-223 |
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A huge mesenteric cyst: A case report and literature review
Maryam Makki1, Rufaida Osman2, Bassem Abou Hussein2, Wessam Hazim Issa2, Omar Al-Marzouqi2
1 Department of General Surgery, Dubai Health Authority, Dubai, United Arab Emirates
2 Department of General Surgery, Rashid Hospital Dubai, Dubai, United Arab Emirates
| Date of Submission | 30-Apr-2022 |
| Date of Decision | 24-Jul-2022 |
| Date of Acceptance | 08-Aug-2022 |
| Date of Web Publication | 22-Dec-2022 |
Correspondence Address:
Omar Al-Marzouqi
Department of General Surgery, Rashid Hospital Dubai, Dubai
United Arab Emirates
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/hmj.hmj_39_22
Rationale: Mesenteric cysts are rare and benign abdominal lesions, located in the mesentry of the bowel, and have different and non specific symptoms which make there diagnosis challenging. The treatment of choice for mesenteric cyst is surgery which can be either done laparoscopic or open depending on the size. Patient Concerns: Here we are presenting a case of a 19 year old gentleman with who presented complaining of abdominal pain and distension, the abdominal distension started 6 months prior to presentation that increased in size gradually. Diagnosis: Computed tomography was done and revealed huge mesenteric cyst 33 cm × 25 cm. Intervention: Exploratory laparotomy was done, and it showed a large solid/cystic mass in the abdomen arising from the root of mesentery; the lesion was pushing the surrounding organs; decompression of the cystic lesion was done and complete excision performed. Outcome: Post-operatively, the patient started on diet gradually; he improved clinically with no more pain and was discharged home on the fifth post operative day in a stable condition.
Keywords: Cyst, lymphangioma, mesentric
How to cite this article:
Makki M, Osman R, Hussein BA, Issa WH, Al-Marzouqi O. A huge mesenteric cyst: A case report and literature review. Hamdan Med J 2022;15:220-3 |
| Introduction | |  |
Mesenteric cysts are rare cysts located in the mesentery of the small bowel or colon; these cysts can remain asymptomatic, until they reach a considerable size. The diagnosis and treatment of mesenteric cysts are challenging due to their rarity, lack of specific symptoms and variability in location and size.[1] We are presenting a case of a 19-year-old gentleman, in whom a huge mesenteric cyst was discovered. Eventually, he was operated on by an exploratory laparotomy and the cyst was totally removed without complications.
| Case Report | | |
A 19-year-old gentleman (basketball player) with no medical or surgical history presented to the accident and emergency department of our hospital complaining of abdominal distension and mild epigastric pain; he started to notice the abdominal distension 6 months prior to presentation. It started to increase in size gradually. He joined the basketbal academy, where he started an excessive workout and exercises 1 month prior to presentation to the hospital, i.e., when the abdominal swelling increased in size significantly, he started to get on-and-off epigastric pain, especially after having food. He also experienced an increased frequency of passing urine and stool. However, there was no nausea, vomiting, constipation and no other complaints.
Examination: he was vitally stable and afebrile.
Abdominal examination revealed a distended abdomen [Figure 1], tense, positive fluid thrill and dull on percussion. No rebound tenderness and Murphy's sign was negative.
Laboratory investigations showed a normal white blood cell count (3.0 10^3/uL) and a normal inflammatory marker level (C-reactive protein: 10 mg/L).
Computed tomography (CT scan) of the abdomen and pelvis showed [Figure 2] a large multi-loculated cystic lesion with fluid content similar to water (14 HU) lies anatomically in the mesentery/peritoneum with no retroperitoneal extension. There were no signs of solid tumour lesions of the omentum or mesentery and no radiologic signs of malignancy. The cystic lesion occupies most of the abdominal cavity and extends down to the pelvic cavity causing mass effect on the intra-abdominal and pelvic structures in the form of left superolateral displacement of small bowel loops with posterior displacement of large bowel loops and both kidneys. Superiorly, it was displacing the liver, but with no signs of an invasion. Inferiorly, urinary bladder and sigmoid are displaced posteriorly.
Exploratory laparotomy was done, and it showed a large solid/cystic mass lesion of 33 cm × 25 cm [Figure 3], in the abdomen arising from the root of mesentery; the lesion was pushing the surrounding organs; it was severely adherent to the retroperitoneal space close to inferior vena cava and aorta, with some peritoneal adhesions to the small bowel; the cyst wall was very thin in some areas; decompression of the cystic lesion was done and around 8 L of turbid dark fluid came out; mobilisation of the large cystic lesion was done; the base of the lesion reached the root of the mesentery, where it was separated without causing vascular injury. A drain was kept in the pelvis and the abdomen was closed.
Histopathologic examination of the specimen showed a fibro-fatty stroma with marked lymphoid cell aggregates and diffuse infiltrate. No evidence of malignancy is identified. (consistent with lymphangioma, cavernous type).
Post-operatively, the patient started on an oral diet that was advanced gradually; he improved clinically with no more pain and was discharged home on the fifth post-operative day in a stable condition with an outpatient clinic appointment for follow-up, where he was seen doing fine with no complaints [Figure 4]. [Figure 5] patient abdomen in clinic follow up visit (scaphoid).
| Discussion | | |
Mesenteric cysts are rare intra-abdominal tumours with a prevalence of 1:100.000 in adults and 1:20.000 in children.[2],[3] Prof. Benevenni (Italian anatomist) was the first to describe this entity performing an autopsy on an 8-year-old boy in 1507.[4]
Aetiology and classification
Although the exact cause of the mesenteric cyst is known, it is believed that the lymph nodes' failure to communicate with the other organs could be a contributing factor. According to Gross, the most common theory is that mesenteric cysts are caused by the proliferation of ectopic lymph nodes that lack communication with the remainder of the lymphatic system.[1],[2]
In 1950, Bearhs divided mesenteric cysts into four groups based on their clinical features and aetiologic characteristics. These included developmental, embryonic, neoplastic, traumatic and acquired. Due to the increasing number of similarities between lymphangiomas and mesotheliomas, the classification of these two conditions was changed.[4],[5]
In 2000, de Perrot proposed a new classification of mesenteric cysts based on the internal epithelium's histopathologic features. This new classification includes six groups: mesothelial, lymphoid, enteric origin, mature cystic teratoma, non-pancreatic pseudocysts and cysts of urogenital origin.[6] Although simple and mesothelial cysts are usually asymptomatic, benign cystic mesotheliomas and lymphangiomas can be invasive and aggressive.[6]
Although mesenteric cysts are usually asymptomatic, they can still cause abdominal pain and other symptoms such as nausea and vomiting. They can also manifest in different ways, such as constipation and diarrhoea. An abdominal mass may be present in up to 60% of patients.[7]
The only type of mesenteric cyst that can carry malignant potential is the malignant cystic mesothelioma. This condition tends to recur after undergoing surgery. If found, this type of tumour can be resected, as it can be benign.
The clinical manifestations of this type of tumour are related to its progression in the abdominal cavity. Some of the common complaints that can be experienced by patients with this condition include abdominal distension, nausea, anorexia and pain. Gastrointestinal complications, such as bowel obstruction, are also sometimes associated with this type of cancer. Due to the nature of the symptoms, many patients with this condition have an advanced disease burden.
Diagnosis of mesenteric cyst
Different diagnostic techniques can be used to determine the presence of mesenteric cysts. However, CT scans and ultrasonography are usually the preferred methods. With the former, they can visualise a hypoechoic mass in the abdomen. They can also show debris, septa and abdominal fluid levels. With the former, a CT scan can visualise the size and origin of the mass. It can also provide a better understanding of the relation between the soft tissues and the mass.[8] On the other hand, with the latter, a magnetic resonance imaging is used to define the dimensions of the cyst and its cystic component.[9]
Management
The treatment of choice for mesenteric cyst is surgery. This procedure can be performed on a complete enucleation. In this case, the tumour is excised en bloc. In addition to this, local resection of the surrounding structures can also be performed to remove the tumour. Simple evacuation and marsupialization are not recommended, because both are associated with unacceptably high recurrence and infection rate.[10],[11],[12]
Depending on the type of mesenteric tumour and its underlying condition, the choice of the procedure can be made. If the tumour is expected to carry a malignant component, laparotomy is usually the surgery of choice. On the other hand, if the tumour is located in an inflammatory or haemorrhagic region, laparotomy might be the preferred option.[13] Moreover, the experience of the surgeon performing the procedure is also taken into account. If the tumour is considered benign, a laparoscopic procedure can be performed. This type of surgery can involve the assessment of the peritoneal cavity and the entire wall of the cyst.
Risk of recurrence
The rate of recurrence of the tumour varies from 0% to 13.6%. Most of these cases are associated with retroperitoneal cysts. Partial excision is also sometimes performed on these patients.[14]
The goal of surgical treatment is to minimise the risk of complications and improve the quality of life for the patients. In contrast, non-surgical treatment options such as steroids and bleomycin can lead to the development of a worse prognosis.[15]
| Conclusion | | |
Mesenteric cysts are extremely rare benign lesions arising from various sites. These cysts present with vague symptoms; there are no specific investigative tools to diagnose these lesions. Surgical excision offers the best curative measure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 14. | Ogita S, Tsuto T, Nakamura K, Deguchi E, Iwai N. OK-432 therapy in 64 patients with lymphangioma. J Pediatr Surg 1994;29:784-5. |
| 15. | Hancock BJ, St-Vil D, Luks FI, Di Lorenzo M, Blanchard H. Complications of lymphangiomas in children. J Pediatr Surg 1992;27:220-4. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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