Mesenteric Cysts

By:

Mohamed Tag El-din MohamedResident of General Surgery

Sohag university hospital

Introduction

A mesenteric cyst is formed of fluid

collection between the 2 layers of

small bowel mesentery

Introduction (conc.)

• Mesenteric cysts can be simple or multiple,

unilocular or multilocular, and they may

contain hemorrhagic, serous, chylous, or

infected fluid.

(Egozi et al, 1997)

Introduction (conc.)

• The fluid is serous in ileal and colonic cysts and

is chylous in jejunal cysts.

• They can range in size from a few millimeters to

40 cm in diameter.

(Egozi EI et al, 1997)

Incidence

• Mesenteric cyst is one of the rarest abdominal

masses.

• The incidence varies from 1 per 100,000 to 1 per

250,000 admissions

• Approximately one third of cases are diagnosed

before the age of 15.(Egozi EI et al, 1997)

Types and Etiology

1)False mesenteric cyst:• Blood cyst due to trauma.• Tuberculous mesenteric cold

abscess due to caseating tuberculous mesenteric adentitis.

2) True mesenteric cyst:• Chylolymphatic cyst “the commonest” due to:

– benign proliferations of ectopic lymphatics . (Bliss DP Jr et al, 1997)

– Obstructed lymphatic drainage.

• Enterogenous cyst due to:– failure of the leaves of the mesentery to fuse.– Sequestrated intestinal epithelium or from duplicated

intestine.

• Treatomatous dermoid cyst• Hydatid cyst

( kasr el-aini introduction to surgery, 8th edition, 2014)

Large mesenteric cyst arising from the small-

bowel mesentery.

Multiple mesenteric cysts, some filled with chyle, arising from the jejunal mesentery.

Huge mesenteric cyst arising from the transverse colon mesentery .

Multiple jejunal mesenteric cysts surrounding a loop of jejunum.

Presentation

• Mesenteric cysts mostly discovered incidentally

• Symptoms

– Abdominal distention

– vague abdominal pain

– Mass may be palpable .

(Lockhart C et al, 2005)

Presentation(conc.)

• Approximately 10% of patients with mesenteric

cysts present with an acute abdominal

emergency, the most common picture is small-

bowel obstruction, which may be associated

with intestinal volvulus or infarction.(Kosir MA et al, 1991)

Investigations

Ultrasonography

• Ultrasonography reveals

fluid-filled cystic structures,

commonly with thin internal

septi and sometimes with

internal echoes from debris,

hemorrhage, or infection.(Wootton-Gorges SL et al,

2005)

Investigations (conc.)

CT scanning

• Abdominal CT scanning adds minimal

information, onlt ti ensure that cyst not

arising from another organ such as the kidney,

pancreas, or ovary.(Nakano T et al, 2007)

Investigations (conc.)

Radiography (rare)

• Plain abdominal radiography may reveal a gasless,

homogeneous, water-dense mass that displaces bowel loops

laterally or anteriorly in the presence of a mesenteric cyst.

Fine calcifications can sometimes be observed within the cyst

wall.

(Wootton-Gorges SL et al, 2005)

Treatment

A.Medical Therapy

Anti-tuberculous drugs in case of ceasating tuberculous mesenteric cysts

Treatment (conc.)

B.Surgical Treatment

1. Enucleation: The preferred treatment of

mesenteric cysts.(Hebra A et al, 1993)

Treatment (conc.)

2. Excision and intestinal resection:– is frequently required to ensure that the

remaining bowel is viable.– Bowel resection may be required in 50-60%

of children with mesenteric cysts, whereas resection is necessary in about 30% of adults.

Treatment (conc.)

3. partial excision with marsupialization:

• If enucleation or resection is not possible because of the size

of the cyst or because of its location deep within the root of

the mesentery

• the cyst lining should be sclerosed with 10% glucose solution,

electrocautery, or tincture of iodine to minimize recurrence.

(Ricketts RR, Pediatric Surgery. 5th ed. 1998)

Treatment (conc.)

4. Current apporaches

• Laparoscopic management: could be used to

localize the cysts, and resection could be

performed through a small laparotomy or via

an extended umbilical incision.

(Bhandarwar AH et al, 2013)

Treatment (conc.)

• Ultrasound-guided drainage has also

reported to be successful.

(Ma A et al, 2012).

Postoperative

• Depend on the intraoperative decision

• If enculation done: the patient is maintained

nothing by mouth (NPO) with intravenous fluids

until bowel function returns(mostly 24 hours).

• If intestinal resection done: follow up until

anastmosis is good.

Follow-up

• Routine postoperative follow-up care 2-3 weeks after discharge

from the hospital is indicated.

• The child's family should be warned about the potential for

intestinal obstruction from adhesions.

• If the patient was treated with marsupialization, closer follow-up

for possible recurrence should be instituted.

• Otherwise, long-term results for simple excision are favorable.

(Chang TS et al, 2011)

Outcome and Prognosis

• Overall results are favorable. The recurrence rate ranges

from 0-13.6%.

• Most recurrences occur in patients with retroperitoneal

cysts or those who had only a partial excision.

• Essentially, no mortality is associated with mesenteric cyst ;

only one pediatric death has been reported since 1950.

(Wong SW et al, 1998)

Future

• With the widespread use of ultrasonography,

mesenteric cysts are being diagnosed earlier, so

intervention during early infancy is indicated to

prevent potential complications such as

intestinal obstruction and volvulus.

(Polat C et al, 2004)