Accepted Manuscript Chylous mesentric cyst (unusual presentation, unusual management) Dr. Ahmed Eshiba, Mohamed Ali, George Metias, Basma Shalaby, Basma Atef, Rana Essameldin, Mohamed Wahdan PII:
S2213-5766(17)30096-9
DOI:
10.1016/j.epsc.2017.05.007
Reference:
EPSC 751
To appear in:
Journal of Pediatric Surgery Case Reports
Received Date: 6 April 2017 Revised Date:
8 May 2017
Accepted Date: 15 May 2017
Please cite this article as: Eshiba A, Ali M, Metias G, Shalaby B, Atef B, Essameldin R, Wahdan M, Chylous mesentric cyst (unusual presentation, unusual management), Journal of Pediatric Surgery Case Reports (2017), doi: 10.1016/j.epsc.2017.05.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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CHYLOUS MESENTRIC CYST(UNUSUAL PRESENTATION, UNUSUAL MANAGEMENT) Ahmed Eshiba, Mohamed Ali, George Metias, Basma Shalaby, Basma Atef, Rana Essameldin, Mohamed Wahdan.
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Department of Pediatric Surgery, Faculty of Medicine Alexandria University Hospitals, Alexandria, Egypt
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Correspondence address and reprint request to: Dr. Ahmed Eshiba , El Shatbi University Hospital, Shatbi, and Alexandria, Egypt. Tel: 00201063280816 Email:
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[email protected]
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CHYLOUS MESENTRIC CYST(UNUSUAL PRESENTATION, UNUSUAL MANAGEMENT)
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Ahmed Eshiba, Mohamed Ali, George Metias, Basma Shalaby, Basma Atef, Rana Essameldin, Mohamed Wahdan.
Department of Pediatric Surgery, Faculty of Medicine Alexandria University Hospitals,
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Alexandria, Egypt
Correspondence address and reprint request to: Dr. Ahmed Eshiba , El Shatbi
[email protected]
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University Hospital, Shatbi, and Alexandria, Egypt. Tel: 00201063280816 Email:
Abstract: Mesenteric and omental cysts are very rare conditions in pediatric age that occurs in any part of GIT covered by mesentry or omentum. The condition is discovered accidentely mainly with non clear etiology but the most accepted theory is benign proliferation of ectopic lymphatics in the mesentery. In this case study, the patient was 2 months old female baby presented with mild distended and tender abdomen. ULTRASOUND showed multiple
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loculated collections with edematous bowel wall reactions. Midline abdominal exploration
Key Words: Chylous Cyst, mesenteric cyst, omental cyst.
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Introduction: Mesenteric cyst is a benign intra-abdominal cystic swelling with prevelance of 1 case per 20,000 and more common in males than females. Mesenteric cyst is defined as any cyst located in the mesentery, may or may not extend to the retro peritoneum, and has
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endothelial and mesothelial linings. (1-4) Omental cyst is with the same histologic features but is confined to the lesser or greater omentum. The most accepted theory for the development of these cysts is benign proliferation of ectopic lymphatics in the mesentery that lack communication with the remainder of lymphatic system. Ileal mesenteric cyst is the most common one where as sigmoid colonic cyst is the second most common one. It was first discovered in 1907 by the Italian Anatomist Benevieni who first reported it after autopsy of 8 years old girl. In 1842, von Rokitansky described a chylous mesenteric cyst
(5)
. Due to its
vague non specific symptoms and signs, it is discovered mainly incidentally during abdominal exploration for any other reason. It is presented mainly with acute abdominal distention and pain with or without palpable masses.
(6, 7)
The most common mode of acute presentation in
children is small bowel obstruction sometimes associated with volvolus and intestinal
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(6-9)
Abdominal ultrasonography is the investigation of choice showing a well
defined thin walled, fluid filled cystic structure that usually contained thin internal septi. Abdominal CT with oral contrast can show the relation of the bowel to the cyst. The goal of surgery is complete excision of the mass. Omental cysts are easily removed and almost never require bowel resection. (10) Omental cysts can be excised using laparoscopic techniques. The preferred treatment of mesenteric cysts is enucleation, however, bowel resection is frequently
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required to totally eradicate the mass and ensure that the blood supply to the bowel is not compromised. Case Report
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Two months old female baby, presented to the emergency pediatric surgery department with mild distended and slightly tender abdomen since five days without any symptoms or signs of intestinal obstruction. There was no history of similar attacks. Abdominal examination
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showed mild distended and tender abdomen. In PR examination, stool passed. Laboratory investigations showed high CRP of 96 mg/L, Hemoglobin 7.6 g/dl, WBC 3.6x10ଽ cells, normal stool analysis with no worm, no pus cells and negative occult blood test. No growth in blood culture and sensitivity test. The pediatrician asked for ultrasound abdomen and pelvis. ULTRASOUND abdomen and pelvis showed multiple pockets of intra peritoneal loculated fluid collections, showing turbid fluid contents and internal septation between bowel loops.
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Largest two pockets in the greater sac and right subhepatic region with dimensions of 4x3 cm and 3x2 cm (Figure 1) , associated with diffuse congested mesentery and thickening peritoneal reactions . No obstructive bowel changes or intussusception is seen. Normal Liver size and texture, patent portal vein, CBD. Normal pancreas, spleen, both kidneys and urinary
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bladder. No evidence of adnexal masses or uterine abnormality.
Figure 1: Ultrasound abdomen and pelvis.
ACCEPTED MANUSCRIPT The Decision was to taken to perform abdominal exploration with the suspicion of intrabdominal abscess for any reason. The child was prepared for the operation. Through Midline exploratory laparotomy, which revealed multiple chylous mesenteric cysts with severely extended from the proximal jejunum till the mid ileum, and from the terminal ileum till the mid transverse colon (Figure 2) also ruptured one was found with
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milky collection in the abdomen aspirated for cellular examination. The cysts were large and closely adherent to the mesentery. Trial of excision lead to rupture one of these cysts and injury to the mesentery closely adherent. The decision was to close again without proceeding to surgical excision. Abdominal wash and intrabdominal drain was inserted and closure of all abdominal layers. The patient was re-admitted to the ICU to complete the conservative
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treatment. The Cytology results showed reddish milky white aspirate with opaque aspect with high Protein content 3.88 g/dl and high LDH 2048 U/L with no growth in the fluid after seven
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days extended culture.
Figure 2: Multiple chylous mesentric cysts from the DJ junction till the transverse colon.
The patient started again to receive conservative treatment and started oral feeding after 4 days with fat free milk after consultation with gastroenterology pediatrician. The general condition of the baby improved and discharged from our unit after 7 days. Follow up will be with regular ultrasound every a month and regular visits for clinical examination is discussed with the parents. The follow up Ultrasound results in the next month revealed, persistence of multiple loculated fluid collections. The largest one was in the right sub-hepatic region with dimensions of 3.7x1.7 cm and the other one at the perisplenic region with dimensions of
ACCEPTED MANUSCRIPT 2.2x1.6 cm. All of them were seen with turbid content showing loci of hyper-echoic matter, fat globules and separated by avascular septations. They are seen dispersed between the mesentry, otherwise no interval changes. Regular follow up ultrasound abdomen and pelvis will be done monthly till complete regression of the size. Discussion
retro peritoneum, and has endothelial and mesothelial linings. (1-4)
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Mesenteric cyst is defined as any cyst located in the mesentery, may or may not extend to the
Most of the cases reported previously in the literatures were discovered incidentally during abdominal exploration or presented with acute intestinal obstruction or intestinal volvulus but in this case, it was a two months female baby presented with mild distended, slightly
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(5-7)
tender abdomen, no signs or symptoms of intestinal obstruction, high laboratory sepsis
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markers (CRP). Also most of the cases reported previously were older age than this case. Ultrsonography was the investigation of choice in this case; it helped to localize the cysts distribution all over the abdomen and also helped in the postoperative follow up. (9) Most of cases reported previously were managed by enucleation and some times bowel resection may be needed,
(3, 4)
however in this case due to multiple extensions from the
jejunum till the colon the trial of enucleation lead to mesenteric injury and rupture one of
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these cysts so the decision was to stop and not to proceed in more trials of excision. This decision was attributed to the distribution of the cysts all over the small and large bowel that this equal distribution was never to cause intestinal volvulus.
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References
1. O’Brien MF, Winter DC, Lee G, Fitzgerald EJ, O’Sullivan GC. Mesenteric cysts. A series of six cases with a review of the literature. Irish J Med Sci. 1999; 168: 233-36.
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2. Kurtz RJ, Heimann TM, Holt J, Beck AR. Mesenteric and retroperitoneal cysts. Ann Surg. 1986; 203: 109-12.
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4. Kwan E, Lau H, Yuen WK. Laparoscopic resection of a mesenteric cyst. Gastrointest Endosc. 2004; 59: 154-56.
5. Levison CG, Wolfssohn M. A mesenteric chylous cyst. Cal West Med. 1926; 24:48082. 6. Feins NR, Raffensperger JG. Cystic hygroma, lymphangioma, and lymphedema. In: Raffensperger JG, ed. Swenson’s Pediatric Surgery. 5th ed. Norwalk, Conn: Appleton & Lange; 1990: 172-73.
ACCEPTED MANUSCRIPT 7. Lockhart C, Kennedy A, Ali S, McManus D, Johnston SD. Mesenteric cysts: a rare cause of abdominal pain. Ulster Med J. 2005; 74: 60-62. 8. Prasad KK, Jain M, Gupta RK. Omental cyst in children presenting as pseudoascites: report of two cases and review of the literature. Indian J Pathol Microbiol. 2001; 44:153-55.
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9. Ricketts RR. Mesenteric and omental cysts. In: Pediatric Surgery. 5th ed. St. Louis,
10. Covarelli P, Arena S, Badolato M, Canonico S, Rondelli F, Luzi G, et al. Mesenteric
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chylous cysts simulating a pelvic disease: a case report. Chir Ital 2008; 60:319-22.
ACCEPTED MANUSCRIPT Highlights
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Chylous mesenteric cyst is very rare abdominal swelling , mostly discovered incidently during abdominal exploration or may present with acute intestinal obstruction. In this case 2 months female baby presented with abnormal presentation, early presentation and high sepsis markers without any signs or symptoms of intestinal obstruction. During abdominal exploration, multiple extensions all over the bowel made the surgical intervention very difficult so the closure and conservative treatment was the solution.
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