Mesenteric cyst - Journal club

S
JC – MESENTRIC CYST –
REVIEW OF LITERATURE
Dr. Priyadarshan Konar
Post Graduate Trainee
Department of General Surgery
IMS & SUM Hospital
30.06.201
7

“Mesenteric cyst: A rare intra-abdominal
tumour”
A.K. Pithawa, Col, A.S. Bansal, Brig, and S.P.S. Kochar, Brig

Mesenteric cysts are rare benign intra-abdominal tumours.
Incidence: 1per 250,000 hospital admission.
Because of variable and non-specific clinical symptoms and
signs, they are discovered either accidentally during an
abdominal radiological examination 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.
Complete surgical excision of the cyst is the treatment of
choice.
Due to the rarity of this entity and the lack of specific
symptoms, correct pre-operative diagnosis is difficult.
INTRODUCTION

A 7-year-old boy presented with history of dull aching
pain on left side of abdomen of five months duration,
particularly after meals.
A lump was noticed on the left side of the abdomen by the
parents.
No history of fever, vomiting, jaundice, maleana,
haematemesis, bleeding per rectum, dysuria, haematuria,
chronic cough, haemoptysis, bony pains, seizures or worm
infestation.
No such family history.
CASE REPORT

On clinical examination vital parameters were found within
normal limit with no pallor, icterus, pedal oedema,
lymphadenopathy.
Per abdomen examination revealed a well-defined oval
shape, intra-abdominal lump, extending from left
hypochondrium to left iliac fossa, cystic in consistency, non-
tender, with well-defined margins.
It was slightly mobile from side to side.

His laboratory tests eg. CBC, LFT, Amylase, Lipase
and urinalysis were within normal limit.
Chest radiograph showed no infiltration in the lungs.
Ultrasound abdomen revealed an intra-abdominal cystic
mass, measuring11.5 × 7.2 × 6.5 cm in dimension, with
thick fluid of finely granular echogenecity on left side of
abdomen with an enhancing peripheral rim.
Based on clinical features and ultrasound study of abdomen
diagnosis of “Mesenteric Cyst” was made.
CECT was not done due to non availability.

Patient underwent exploratory laparotomy, which
revealed a big lobulated mesenteric cyst in mesentery of
sigmoid, extending in mesentery of descending colon.
Few epicolic and paracolic lymph nodes were slightly
enlarged.
Complete enucleation of cyst carried out leaving the
large intestine intact.
1 each epicolic and paracolic lymph nodes taken out for
HPE.

Mesenteric cyst extending from costal margin to brim of
pelvis

Mesenteric cyst arising from mesentery of sigmoid colon

Mesenteric cyst excised completely

Cut section revealed multi-loculated cyst with varying
wall-thickness, filled with dark brown fluid.
HPE showed that Cyst wall was lined by flattened benign
epithelium with no granuloma or malignant feature, so
opinion was consistent with clinical diagnosis of benign
mesenteric cyst.
HPE of lymph node showed reactive follicles with Sinus
histiocytosis and there was no evidence of metastatic
malignancy or granuloma.

Mesenteric cyst are one of the rare cyst observed
in abdomen.
Frequency: 1/100.000 in adults and 1/20.000-
35.000 in paediatric age group.
Approximately 1/3rd of cases occur in children
younger than 15years.
No differences in sexes in terms of frequency.
First described by Italian anatomist Benevenni in
1507.
Tillaux performed the first successful surgery for a
cystic mass in the mesentery in 1850.

Can occur anywhere in the mesentery of the GI tract
from duodenum to rectum.
It may or may not extend into the retroperitoneum.
It has a recognisable lining of endothelium or
mesothelial cells.
Most frequent localisation is small bowel mesentery
(70%) and within small bowel it is commonly
localised in ileal mesentery (50-60%).

AETIOLOGY:
Aetiology has yet to be ascertained
Several hypothesis
Like failure of lymph nodes to communicate
with the lymphatic or venous system / blockage
of the lymphatics as a result of trauma,
infection and neoplasm are said to be
contributing factors.
The most accepted theory, proposed by Gross,
is benign proliferation of ectopic lymphatics in
the mesentery that lack communication with
the remainder of the lymphatic system.

CLASSIFICATION:
The most common classification is Histo-pathologic
classification, which divides these cyst into 6 groups:
1. Cyst of Lymphatic origin
2. Cyst of mesothelial origin
3. Enteric cyst
4. Cyst of urogenital origin
5. Dermoid cyst
6. Pseudocyst

 Most common variety
 Almost invariably solitary & most often
unilocular
 Probably arising in congenitally misplaced
lymphatic tissue
 Thin walled, composed of connective tissue
lined by flat endothelium.
 Filled with clear lymph or rarely with chyle
 Consistency may vary from watered milk to
cream
Cyst of lymphatic origin:

Cyst of mesothelial origin:
 Includes simple mesothelial cyst, benign
cystic mesothelioma and malignant cystic
mesothelioma.
 Usually small size and multiple in number
 Thin walled, filled with clear or yellowish
fluid or gelatinous material
 Microscopically no mucous is found in
cytoplasm or outside the cells.

Enteric cyst:
 Believed to be derived either from a
diverticulum of Mesenteric border of the
intestine during embryonic life or from a
duplication of the intestine.
 Thick walled
 Lined by ciliated mucous membrane.
 Usually content is mucinous and is either
colourless or yellowish brown as a result of
past haemorrhage.

Cyst of urogenital origin:
 Cyst may be unilocular or multilocular
 These cysts are believed to be derived from a
remnant of the Wolffian duct.
 Often attains large dimension
 Develops in the retroperitonel space.

CLINICAL FEATURES:
May be asymptomatic
Symptomatic ones does not have typical findings.
Abdominal discomfort
Acute / chronic pain
Distension of abdomen
Shock due to rupture or bleeding of cyst
Compression of adjacent structures may lead to
intermittent pain
Can also cause non-specific symptoms i.e. Anorexia,
nausea, vomiting, fatigue and weight loss.

Physical examination may reveal a mass lesion that
is mobile only from the patient’s right to left or left to
right – known as “Tillaux sign”
Tillaux was the first to record this physical findings
and in 1850, the first to successfully remove a
Mesenteric cyst.

INVESTIGATIONS:
X-Ray Abdomen
Ultrasonography
CT Scan
MRI

Ultrasonography:
Things to look in USG
 Unilocular / multilocular
 Size
 Shape
 Internal echoes
 Wall of the cyst
 Any septation
 Whether any blood flow

CT Scan:
CT Scan of Mesenteric cyst. Unilocular appearance
without solid component strongly suggests benign
cyst.

TREATMENT:
When symptomatic, simple Mesenteric cyst are
surgically excised either openly or laparoscopically.
Cyst unroofing or marsupialization is not
recommended because Mesenteric cyst have a high
propensity to recur.
Rarely, adjacent mesentery or bowel may get
adhered to the cyst or Mesenteric vessels must be
sacrificed in order to achieve complete excision.

Mesenteric cyst - Journal club

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