Laparoscopic diagnosis of retractile mesenteritis Jeffrey Weiser, MD Barry Salky, MD Alan Slepian, MD Steven Dikman, MD
The mesenteric tumefactions encompass a broad spectrum of pathology ranging from mesenteric lipodystrophy to retractile mesenteritis. Patients are generally asymptomatic but may present with abdominal pain, an abdominal mass, or obstruction. Malignancy is the most common differential diagnosis, which must be ruled out. Heretofore, the diagnosis was made by celiotomy followed by histologic examination. Laparoscopy is the procedure of choice for the diagnosis of diseases involving the peritoneum, which mesenteric tumefactions invariably do. This report demonstrates the efficacy of laparoscopy in the diagnosis of this uncommon problem.
,
.. '
",
Case 1
From the Mount Sinai Medical Center, New York, New York. Reprint requests: Jeffrey Weiser, MD, 306 East 96th Street, #5F, New York, New York 10128. VOLUME 38, NO.5, 1992
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,
CASE REPORTS
A 67-year-old man was admitted to the Mount Sinai Medical Center with an 8-week history of abdominal cramping associated with intermittent diarrhea and tenesmus. Twelve weeks prior to admission the patient noticed pencilthin, non-bloody stools. Over the next several weeks the patient's bowel movements progressed to diarrhea. Four weeks prior to admission the patient developed fever with spikes to 103°F, and was admitted to another institution where he was treated with antibiotics. After 4 weeks, the symptoms did not resolve and the patient was transferred to Mt. Sinai Medical Center. The patient complained of nausea, fatigue, anorexia, and a 20-lb weight loss over the last 8 weeks but denied melena, vomiting, or hematochezia. The patient had no previous history of abdominal complaints, nor did he have any relevant familial history. The patient had no recent travel history. The patient's past medical and surgical history was notable for achalasia treated with dilation 1 year prior to admission and herniorraphy as a child. He did not take any medication regularly and had no known drug allergy. He denied any use of cigarettes or alcohol. Physical examination demonstrated a well-developed white man in no acute distress. Examination of the head, ears, eyes, noae, and throat, heart, and lungs were within normal limits. His abdomen was soft, mildly distended, and with normal bowel sounds. A 10- X 9-cm tender mass was located in the left lower quadrant. Rectal examination was guaiac negative. His hemoglobin/hematocrit was 12.3/38.3, and his WBC was 8.3. Culture of the stool showed normal flora. Barium enema demonstrated an extrinsic narrowing of the sigmoid colon with displacement of adjacent loops of bowel. Obstructive series revealed a partial large bowel obstruction.
.
••
I
. ; ,,' ••
Figure 1. Laparoscopic view toward the pelvis. Retractile mesenteritis involving the sigmoid mesentary is seen in the center of the photograph. Note the marked fat necrosis with exudate. Normal small intestine is seen at the lower right corner. Figure 2. A medium power hematoxylin and eosin-stained photomicrograph of the involved area of the mesentary showing adipose tissue with areas of fibrosis, fat necrosis, and an inflammatory infiltrate with macrophages.
Laparoscopic exploration of the abdomen was performed. This demonstrated a thickened, hard, retracted mesocolon. The pathology extended to the root of the mesentary. The mesentary was yellow with numerous reddish brown plaques (Fig. 1). The colon itself was intrinsically normal with the exception of a dilated segment of proximal sigmoid colon caused by distal compression by the mesentary. Retractile mesenteritis was suspected and was confirmed with biopsy which revealed fibroadipose tissue with fat necrosis and subserosal fibrosis of the mesentary. Three days after laparoscopy, the patient continued to be symptomatic and a diverting transverse loop colostomy was constructed. Over the next 2 weeks the patient's symptoms resolved and the abdominal mass began to decrease in size. The patient was discharged in good condition. Case 2
A 52-year-old woman was admitted with a 3-year history of increasing abdominal girth and discomfort. The patient's presentation was associated with nausea and vomiting but no other change in bowel habits. She was afebrile and denied melena, hematochezia, fatigue, or weight loss. The patient had no previous history of abdominal complaints and had no relevant family history. Past medical history was notable for hiatal hernia, sei615
zures, and a psychiatric disorder. Past surgical history was significant for an abdominal hysterectomy and bilateral salpingo-oophorectomy for a fibroid uterus. She has no known drug allergies and was taking the following medications at the time of admission: dilantin, cogentin, prolixin, librium, and phenobarbital. She denied any ETOH or drug use but admitted to a 5-pack/year smoking history. Physical examination demonstrated a well-developed white woman in no acute distress. Physical findings were limited to the abdomen which was massively distended, soft, non-tender, and with normal bowel sounds. No organomegaly or palpable mass was detected. Rectal examination was guaiac negative. Laboratory findings were significant for a WBC of 12.5, a sodium of 129, a chloride of 80, and CO 2 of 35. Culture of the stool was negative. A kidney, ureter, and bladder film demonstrated a moderately distended colon with a compressed loop of bowel in the left lower quadrant with a nodular indentation suggestive of tumor. The mesenteric border was slightly nodular. Paracentesis of 300 ml demonstrated only sterile ascitic fluid. Laparoscopic examination of the abdomen was performed which demonstrated a mass in the retroperitoneum compressing the colon. This hard, yellowish brown, fatty mass with pink nodules entrapped a distended loop of sigmoid colon. The mass was neovascularized throughout and obliterated the lesser sac. The colon and liver appeared to be normal. The mesocolon was foreshortened. Histologically, the mass consisted of adipose tissue with fat necrosis, fibrosis, and mesothelial hyperplasia (Fig. 2). DISCUSSION
Most authors agree that the mesenteric tumefactions represent a continuum of pathology which begins with mesenteric lipodystrophy and culminates in retraction of the mesentary.l The median age for diagnosis of the mesenteric tumefactions is 60 with a male to female ratio of 3:1. 2 ,3 Children are rarely affected as they have less mesenteric fat in comparison to adults. 4 Most commonly, patients are asymptomatic or present with a non-tender mass in the left lower quadrant. Less commonly, patients present with diarrhea, obstruction, low grade fever, malaise, anorexia, or rectal bleeding. The etiology of the mesenteric tumefactions is unclear with trauma, allergy, infection, autoimmune, and vascular etiologies suggested. Most theories assume that there is a continuum of disease with mesenteric fat necrosis progressing to chronic inflammation and extensive fibrotic tumor growth. 5 In an attempt to clarify the nomenclature, Hartz et al. 6 divided the mesenteric tumefactions into three categories based on histology, anatomical location, symptoms, and prognosis. The term most often used to describe the condition of mesenteric degeneration, the earliest process on the continuum, is "mesenteric lipodystrophy." The degeneration is localized to the mesentary of the small intestine and is histologically characterized by foamy macrophages. Whereas it is usually asymptomatic, the process may occasionally impinge upon mesenteric 616
blood vessels, influencing gastrointestinal function and causing chylous ascites.? No treatment is generally needed as spontaneous recovery is nearly uniform. Three patterns of gross pathology are described: a diffusely thickened base of the mesentary, a single mass located more distally in the mesentary, and multiple, discrete masses located throughout the mesentary. "Mesenteric panniculitis" is the term used most frequently to describe the second stage of the continuum, or inflammation of the mesentary. The inflammatory cell infiltrate is composed primarily of plasma cells, although polymorphonuclear cells, foreign body giant cells, and foamy macrophages are also seen. Grossly, the mesentary appears to be diffusely thickened with a solitary mass or several adherent masses in the mesenteric root causing puckering of the mesenteric surface. 8 Chylous fluid rich in cholesterol is seen within the mesenteric mass. Even though the delineation of normal versus abnormal bowel segments is generally clear, adjacent bowel segments show slight swelling or lymphatic distention. 8 ,9 Symptoms include fever, vague abdominal pain and general malaise. No treatment is generally necessary as the process is usually self-limiting. The final stage, or mesenteric fibrosis, is most often referred to as "retractile mesenteritis." This entity involves the mesentary of both the small and large intestine and may cause obstructive symptoms. Histologically, collagen deposition, fibrosis, and inflammation are seen. Proliferation of myofibroblasts that form hyaline collagen results in scarring and retraction of the mesentary.l This, in turn, results in the formation of an abdominal mass.? The fibrotic reaction may extend through the mesenteric fat, but it is usually most marked in the subperitoneal tissue at the root of the mesentary.1O Although retractile mesenteritis is progressive, it is usually self-limiting with retraction of the mesentary generally being quite mild. Resection of the bowel, although advocated by a few, is generally only appropriate when the disease has markedly progressed. Usually, when obstructive symptoms are present, a diverting colostomy is sufficient treatment. The stoma may be closed if the pathology resolves. As outlined above, the prognosis for all of the mesenteric tumefactions is generally good, with most resolving spontaneously. The time course of resolution, however, is highly variable. A mass may remain palpable for 2 to 11 years. 8 Once the mass has resolved, recurrence of these lesions is rare. l l If treatment is required due to severe obstructive symptoms, a colostomy or ileostomy is indicated. 6 The only medical therapies that have proven efficacious are radiotherapy and corticosteroids.? Traditionally, diagnosis of the mesenteric tumefactions is made by celiotomy in conjunction with biopsy. Laparoscopy is a particularly useful means of diagGASTROINTESTINAL ENDOSCOPY
nosis in this condition given the characteristic appearance of the lesions, and their involvement of the mesenteric peritoneum. Perhaps Ogden, one of the first to recognize the pathology, in the study by Ogden et al. 12 described it best-"The gross appearance of the involved mesentary is at first confusing, but, once seen, the picture is not easily forgotten, and gross diagnosis is not difficult the second time." Biopsy, however, is necessary to rule out malignancy and to verify the diagnosis. 6 As the bowel itself is not biopsied and the samples are taken under direct vision, there should be little risk of bowel perforation. A 3-mm lancet-shaped biopsy forceps is helpful in obtaining tangential biopsies. This further lowers the risk of perforation. Tru-Cut biopsy needles should not be used in this setting. Multiple biopsies of the affected area are required for accurate histologic diagnosis. This should not be difficult as the mesentary in retractile mesenteritis is typically rock hard and mobile. In the authors' experience, the root ofthe mesentary is accessible laparoscopically in greater than 90% of cases. To access this area, second puncture sites are required to retract and visually expose the appropriate areas. Access is further enhanced with use of a tilt table. The advantages of a laparoscopic diagnosis are multiple. The procedure is performed under local anesthesia, negating the potential problems of general anesthesia. The morbidity of exploratory laparotomy, including pain and adhesions, are avoided with lapa-
Gallstone ileus treated by electrohydraulic lithotripsy Naotaka Fujita, MD Yutaka Noda, MD Go Kobayashi, MD Katsumi Kimura, MD Hiromitsu Watanabe, MD Akio Shirane, MD Tokuyoshi Hayasaka, MD Fukuji Mochizuki, MD Tadashi Yamazaki, MD
Gallstone ileus is a relatively rare condition of mechanical small bowel obstruction and stone impaction From the Departments of Gastroenterology and Surgery, Sendai City Medical Center, Sendai, Miyagi, Japan. Reprint requests: Naotaka Fujita, Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai, Miyagi 983, Japan. VOLUME 38, NO.5, 1992
roscopy. Additionally, the procedure may be performed as an outpatient, thereby shortening hospital utilization and decreasing costs. Mesenteric tumefactions are diagnosed by their histology and gross appearance. Thus, laparoscopy in conjunction with histologic verification is the diagnostic procedure of choice for this disease entity. REFERENCES 1. Kelly J, Hwang W. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol 1989;12: 513-21. 2. Monahan D, Poston W, Brown G. Mesenteric panniculitis. Southern Med J 1989;82:782-4. 3. Adachi Y, Mori M, Enjoji M, Ueo H, Sugimachi K. Mesenteric panniculitis of the colon: review of the literature and report of two cases. Dis Colon Rectum 1987;30:962-6. 4. Schwartz S, Shires G, Spenser F. Principles of surgery. 5th ed. New York: McGraw Hill, 1989. 5. Bush R, Hammar S, Rudolph R. Sclerosing mesenteritis: response to cyclophosphamide. Arch Intern Med 1986;146: 503-5. 6. Hartz R, Stryker S, Sparberg M, Poticha S. Mesenteric tumefactions. Am Surg 1980;46:525-9. 7. Kipfer R, Moertel C, Dahlin D. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-8. 8. Durst A, Freund H, Rosenmann E, Birnbaum D. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery 1977;81:203-11. 9. French W, Bale G, Winborn W. Lipodystrophy of mesenteric fat. Surg Gynecol Obstet 1966;122:1046-52. 10. Clemett A, Tracht D. The roentgen diagnosis of retractile mesenteritis. Am J Roentgenol 1969;107:787-90. 11. Han S, Koehler R, Keller F, Ho K, Zornes S. Retractile mesenteritis involving the colon: pathologic and radiologic correlation (case report). AJR 1986;147:268-70. 12. Ogden W, Bradburn D, Rives J. Panniculitis of the mesentery. Ann Surg 1960;151:659-65.
most commonly occurs in the distal ileum. Formerly, most such cases were treated surgically to eliminate this mechanical obstruction. In the past two decades, however, endoscopic surgery has greatly developed and is now widely employed. In cases of large stones in the bile duct, electrohydraulic lithotripsy (EHL) is sometimes applied following endoscopic sphincterotomy or through the percutaneous transhepatic route. A case of gallstone ileus treated successfully by EHL is presented. CASE REPORT
A 60-year-old woman with complaints of nausea and vomiting was diagnosed as suffering from gallstone ileus based on findings of the upper gastrointestinal series and endoscopy at another clinic. She was referred to our department for treatment of this condition. On admission, she was asymptomatic and physical examination showed no remark617
The mesenteric tumefactions encompass a broad spectrum of pathology ranging from mesenteric lipodystrophy to retractile mesenteritis. Patients are generally asymptomatic but may present with abdominal pain, an abdominal mass, or obstruction. Malignancy is the most common differential diagnosis, which must be ruled out. Heretofore, the diagnosis was made by celiotomy followed by histologic examination. Laparoscopy is the procedure of choice for the diagnosis of diseases involving the peritoneum, which mesenteric tumefactions invariably do. This report demonstrates the efficacy of laparoscopy in the diagnosis of this uncommon problem.
,
.. '
",
Case 1
From the Mount Sinai Medical Center, New York, New York. Reprint requests: Jeffrey Weiser, MD, 306 East 96th Street, #5F, New York, New York 10128. VOLUME 38, NO.5, 1992
.•
,
CASE REPORTS
A 67-year-old man was admitted to the Mount Sinai Medical Center with an 8-week history of abdominal cramping associated with intermittent diarrhea and tenesmus. Twelve weeks prior to admission the patient noticed pencilthin, non-bloody stools. Over the next several weeks the patient's bowel movements progressed to diarrhea. Four weeks prior to admission the patient developed fever with spikes to 103°F, and was admitted to another institution where he was treated with antibiotics. After 4 weeks, the symptoms did not resolve and the patient was transferred to Mt. Sinai Medical Center. The patient complained of nausea, fatigue, anorexia, and a 20-lb weight loss over the last 8 weeks but denied melena, vomiting, or hematochezia. The patient had no previous history of abdominal complaints, nor did he have any relevant familial history. The patient had no recent travel history. The patient's past medical and surgical history was notable for achalasia treated with dilation 1 year prior to admission and herniorraphy as a child. He did not take any medication regularly and had no known drug allergy. He denied any use of cigarettes or alcohol. Physical examination demonstrated a well-developed white man in no acute distress. Examination of the head, ears, eyes, noae, and throat, heart, and lungs were within normal limits. His abdomen was soft, mildly distended, and with normal bowel sounds. A 10- X 9-cm tender mass was located in the left lower quadrant. Rectal examination was guaiac negative. His hemoglobin/hematocrit was 12.3/38.3, and his WBC was 8.3. Culture of the stool showed normal flora. Barium enema demonstrated an extrinsic narrowing of the sigmoid colon with displacement of adjacent loops of bowel. Obstructive series revealed a partial large bowel obstruction.
.
••
I
. ; ,,' ••
Figure 1. Laparoscopic view toward the pelvis. Retractile mesenteritis involving the sigmoid mesentary is seen in the center of the photograph. Note the marked fat necrosis with exudate. Normal small intestine is seen at the lower right corner. Figure 2. A medium power hematoxylin and eosin-stained photomicrograph of the involved area of the mesentary showing adipose tissue with areas of fibrosis, fat necrosis, and an inflammatory infiltrate with macrophages.
Laparoscopic exploration of the abdomen was performed. This demonstrated a thickened, hard, retracted mesocolon. The pathology extended to the root of the mesentary. The mesentary was yellow with numerous reddish brown plaques (Fig. 1). The colon itself was intrinsically normal with the exception of a dilated segment of proximal sigmoid colon caused by distal compression by the mesentary. Retractile mesenteritis was suspected and was confirmed with biopsy which revealed fibroadipose tissue with fat necrosis and subserosal fibrosis of the mesentary. Three days after laparoscopy, the patient continued to be symptomatic and a diverting transverse loop colostomy was constructed. Over the next 2 weeks the patient's symptoms resolved and the abdominal mass began to decrease in size. The patient was discharged in good condition. Case 2
A 52-year-old woman was admitted with a 3-year history of increasing abdominal girth and discomfort. The patient's presentation was associated with nausea and vomiting but no other change in bowel habits. She was afebrile and denied melena, hematochezia, fatigue, or weight loss. The patient had no previous history of abdominal complaints and had no relevant family history. Past medical history was notable for hiatal hernia, sei615
zures, and a psychiatric disorder. Past surgical history was significant for an abdominal hysterectomy and bilateral salpingo-oophorectomy for a fibroid uterus. She has no known drug allergies and was taking the following medications at the time of admission: dilantin, cogentin, prolixin, librium, and phenobarbital. She denied any ETOH or drug use but admitted to a 5-pack/year smoking history. Physical examination demonstrated a well-developed white woman in no acute distress. Physical findings were limited to the abdomen which was massively distended, soft, non-tender, and with normal bowel sounds. No organomegaly or palpable mass was detected. Rectal examination was guaiac negative. Laboratory findings were significant for a WBC of 12.5, a sodium of 129, a chloride of 80, and CO 2 of 35. Culture of the stool was negative. A kidney, ureter, and bladder film demonstrated a moderately distended colon with a compressed loop of bowel in the left lower quadrant with a nodular indentation suggestive of tumor. The mesenteric border was slightly nodular. Paracentesis of 300 ml demonstrated only sterile ascitic fluid. Laparoscopic examination of the abdomen was performed which demonstrated a mass in the retroperitoneum compressing the colon. This hard, yellowish brown, fatty mass with pink nodules entrapped a distended loop of sigmoid colon. The mass was neovascularized throughout and obliterated the lesser sac. The colon and liver appeared to be normal. The mesocolon was foreshortened. Histologically, the mass consisted of adipose tissue with fat necrosis, fibrosis, and mesothelial hyperplasia (Fig. 2). DISCUSSION
Most authors agree that the mesenteric tumefactions represent a continuum of pathology which begins with mesenteric lipodystrophy and culminates in retraction of the mesentary.l The median age for diagnosis of the mesenteric tumefactions is 60 with a male to female ratio of 3:1. 2 ,3 Children are rarely affected as they have less mesenteric fat in comparison to adults. 4 Most commonly, patients are asymptomatic or present with a non-tender mass in the left lower quadrant. Less commonly, patients present with diarrhea, obstruction, low grade fever, malaise, anorexia, or rectal bleeding. The etiology of the mesenteric tumefactions is unclear with trauma, allergy, infection, autoimmune, and vascular etiologies suggested. Most theories assume that there is a continuum of disease with mesenteric fat necrosis progressing to chronic inflammation and extensive fibrotic tumor growth. 5 In an attempt to clarify the nomenclature, Hartz et al. 6 divided the mesenteric tumefactions into three categories based on histology, anatomical location, symptoms, and prognosis. The term most often used to describe the condition of mesenteric degeneration, the earliest process on the continuum, is "mesenteric lipodystrophy." The degeneration is localized to the mesentary of the small intestine and is histologically characterized by foamy macrophages. Whereas it is usually asymptomatic, the process may occasionally impinge upon mesenteric 616
blood vessels, influencing gastrointestinal function and causing chylous ascites.? No treatment is generally needed as spontaneous recovery is nearly uniform. Three patterns of gross pathology are described: a diffusely thickened base of the mesentary, a single mass located more distally in the mesentary, and multiple, discrete masses located throughout the mesentary. "Mesenteric panniculitis" is the term used most frequently to describe the second stage of the continuum, or inflammation of the mesentary. The inflammatory cell infiltrate is composed primarily of plasma cells, although polymorphonuclear cells, foreign body giant cells, and foamy macrophages are also seen. Grossly, the mesentary appears to be diffusely thickened with a solitary mass or several adherent masses in the mesenteric root causing puckering of the mesenteric surface. 8 Chylous fluid rich in cholesterol is seen within the mesenteric mass. Even though the delineation of normal versus abnormal bowel segments is generally clear, adjacent bowel segments show slight swelling or lymphatic distention. 8 ,9 Symptoms include fever, vague abdominal pain and general malaise. No treatment is generally necessary as the process is usually self-limiting. The final stage, or mesenteric fibrosis, is most often referred to as "retractile mesenteritis." This entity involves the mesentary of both the small and large intestine and may cause obstructive symptoms. Histologically, collagen deposition, fibrosis, and inflammation are seen. Proliferation of myofibroblasts that form hyaline collagen results in scarring and retraction of the mesentary.l This, in turn, results in the formation of an abdominal mass.? The fibrotic reaction may extend through the mesenteric fat, but it is usually most marked in the subperitoneal tissue at the root of the mesentary.1O Although retractile mesenteritis is progressive, it is usually self-limiting with retraction of the mesentary generally being quite mild. Resection of the bowel, although advocated by a few, is generally only appropriate when the disease has markedly progressed. Usually, when obstructive symptoms are present, a diverting colostomy is sufficient treatment. The stoma may be closed if the pathology resolves. As outlined above, the prognosis for all of the mesenteric tumefactions is generally good, with most resolving spontaneously. The time course of resolution, however, is highly variable. A mass may remain palpable for 2 to 11 years. 8 Once the mass has resolved, recurrence of these lesions is rare. l l If treatment is required due to severe obstructive symptoms, a colostomy or ileostomy is indicated. 6 The only medical therapies that have proven efficacious are radiotherapy and corticosteroids.? Traditionally, diagnosis of the mesenteric tumefactions is made by celiotomy in conjunction with biopsy. Laparoscopy is a particularly useful means of diagGASTROINTESTINAL ENDOSCOPY
nosis in this condition given the characteristic appearance of the lesions, and their involvement of the mesenteric peritoneum. Perhaps Ogden, one of the first to recognize the pathology, in the study by Ogden et al. 12 described it best-"The gross appearance of the involved mesentary is at first confusing, but, once seen, the picture is not easily forgotten, and gross diagnosis is not difficult the second time." Biopsy, however, is necessary to rule out malignancy and to verify the diagnosis. 6 As the bowel itself is not biopsied and the samples are taken under direct vision, there should be little risk of bowel perforation. A 3-mm lancet-shaped biopsy forceps is helpful in obtaining tangential biopsies. This further lowers the risk of perforation. Tru-Cut biopsy needles should not be used in this setting. Multiple biopsies of the affected area are required for accurate histologic diagnosis. This should not be difficult as the mesentary in retractile mesenteritis is typically rock hard and mobile. In the authors' experience, the root ofthe mesentary is accessible laparoscopically in greater than 90% of cases. To access this area, second puncture sites are required to retract and visually expose the appropriate areas. Access is further enhanced with use of a tilt table. The advantages of a laparoscopic diagnosis are multiple. The procedure is performed under local anesthesia, negating the potential problems of general anesthesia. The morbidity of exploratory laparotomy, including pain and adhesions, are avoided with lapa-
Gallstone ileus treated by electrohydraulic lithotripsy Naotaka Fujita, MD Yutaka Noda, MD Go Kobayashi, MD Katsumi Kimura, MD Hiromitsu Watanabe, MD Akio Shirane, MD Tokuyoshi Hayasaka, MD Fukuji Mochizuki, MD Tadashi Yamazaki, MD
Gallstone ileus is a relatively rare condition of mechanical small bowel obstruction and stone impaction From the Departments of Gastroenterology and Surgery, Sendai City Medical Center, Sendai, Miyagi, Japan. Reprint requests: Naotaka Fujita, Department of Gastroenterology, Sendai City Medical Center, 5-22-1, Tsurugaya, Miyagino-ku, Sendai, Miyagi 983, Japan. VOLUME 38, NO.5, 1992
roscopy. Additionally, the procedure may be performed as an outpatient, thereby shortening hospital utilization and decreasing costs. Mesenteric tumefactions are diagnosed by their histology and gross appearance. Thus, laparoscopy in conjunction with histologic verification is the diagnostic procedure of choice for this disease entity. REFERENCES 1. Kelly J, Hwang W. Idiopathic retractile (sclerosing) mesenteritis and its differential diagnosis. Am J Surg Pathol 1989;12: 513-21. 2. Monahan D, Poston W, Brown G. Mesenteric panniculitis. Southern Med J 1989;82:782-4. 3. Adachi Y, Mori M, Enjoji M, Ueo H, Sugimachi K. Mesenteric panniculitis of the colon: review of the literature and report of two cases. Dis Colon Rectum 1987;30:962-6. 4. Schwartz S, Shires G, Spenser F. Principles of surgery. 5th ed. New York: McGraw Hill, 1989. 5. Bush R, Hammar S, Rudolph R. Sclerosing mesenteritis: response to cyclophosphamide. Arch Intern Med 1986;146: 503-5. 6. Hartz R, Stryker S, Sparberg M, Poticha S. Mesenteric tumefactions. Am Surg 1980;46:525-9. 7. Kipfer R, Moertel C, Dahlin D. Mesenteric lipodystrophy. Ann Intern Med 1974;80:582-8. 8. Durst A, Freund H, Rosenmann E, Birnbaum D. Mesenteric panniculitis: review of the literature and presentation of cases. Surgery 1977;81:203-11. 9. French W, Bale G, Winborn W. Lipodystrophy of mesenteric fat. Surg Gynecol Obstet 1966;122:1046-52. 10. Clemett A, Tracht D. The roentgen diagnosis of retractile mesenteritis. Am J Roentgenol 1969;107:787-90. 11. Han S, Koehler R, Keller F, Ho K, Zornes S. Retractile mesenteritis involving the colon: pathologic and radiologic correlation (case report). AJR 1986;147:268-70. 12. Ogden W, Bradburn D, Rives J. Panniculitis of the mesentery. Ann Surg 1960;151:659-65.
most commonly occurs in the distal ileum. Formerly, most such cases were treated surgically to eliminate this mechanical obstruction. In the past two decades, however, endoscopic surgery has greatly developed and is now widely employed. In cases of large stones in the bile duct, electrohydraulic lithotripsy (EHL) is sometimes applied following endoscopic sphincterotomy or through the percutaneous transhepatic route. A case of gallstone ileus treated successfully by EHL is presented. CASE REPORT
A 60-year-old woman with complaints of nausea and vomiting was diagnosed as suffering from gallstone ileus based on findings of the upper gastrointestinal series and endoscopy at another clinic. She was referred to our department for treatment of this condition. On admission, she was asymptomatic and physical examination showed no remark617
