Gastrointestinal
Radiology
Gastrointest Radiol 4, 191-193 (1979)
Recurrent Retroperitoneal Mesenteric Cyst A Case Report and Review Suvimol Chirathivat and Dennis Shermeta Department of Pediatric Radiology and Pediatric Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
Abstract. A m e s e n t e r i c cyst is a n u n c o m m o n
cause of a palpable abdominal mass. A correct preoperative d i a g n o s i s c a n be m a d e b y the c o m b i n e d use o f rad i o g r a p h i c a n d s o n o g r a p h i c e x a m i n a t i o n s in c o n j u n c tion with the clinical features. A patient with a retrop e r i t o n e a l cyst e x t e n d i n g i n t o the leaves o f t h e m e s e n tery is p r e s e n t e d . T h e cyst r e c u r r e d 4 y e a r s a f t e r surgery.
Key Words: M e s e n t e r i c C y s t -
Retroperitoneal cyst
U l t r a s o u n d , cyst.
T h e first r e p o r t o f a m e s e n t e r i c c y s t a p p e a r s to h a v e b e e n m a d e in 1507 by B e n e v i e n e , a F l o r e n t i n e a n a t o m i s t , w h e r e a s s u r g i c a l e x c i s i o n o f a cyst was first d o n e in 1880 by T i l l a u x [1]. T h e r e h a v e b e e n m a n y r e p o r t s in t h e l i t e r a t u r e o f m e s e n t e r i c c y s t s ; h o w e v e r , t h e r e t r o p e r i t o n e a l v a r i e t y h a v e b e e n infrequentl3~ r e p o r t e d [2]. W e p r e s e n t a c a s e o f a m e s e n t e r i c cyst w h i c h a r o s e p r i m a r i l y in t h e r e t r o p e r i t o n e a l s p a c e a n d w h i c h rec*urred 4 y e a r s a f t e r surgery.
Case Report A 12-year-old asymptomatic black boy, who was having a routine physical examination prior to a meatotomy, was found to have a large, freely movable mid-abdominal mass. There was no evidence of hepatosplenomegaly and there were no other pertinent physical findings. An intravenous urogram demonstrated upward and lateral displacement of the left kidney and lateral displacement of the left ureter (Fig. 1). The kidneys themselves appeared intrinsically normal. Ultrasound examination revealed a 20 x 7 • 12 cm cystic mass in the mid-abdomen extending down into the pelvis. No septa were present within the mass. A second multiseptated cystic mass measuring 20 x 12 x 9 cm was identified arising in the left upper Address reprint requests to: Dr. S. Chirathivat, Department of Radiology (R130), University of Miami School of Medicine, P.O. Box 016960, Miami, FLA 33101, USA
quadrant. The barium enema showed marked displacement of the sigmoid and descending colon anteriorly and to the right, by a large soft tissue mass (Fig. 2). There was no evidence of calcification within the mass. At surgery, a large cystic mass was found in the left retroperitoneal area extending into the root of the mesentery. The cyst had multiple loculations. A number of smaller isolated cysts were also found. At surgery, all of the cysts were removed. The pathological findings were compatible with those of a mesenteric cyst. The patient was readmitted to the hospital 4 years later because of abdominal pain and recurrence of the abdominal mass. The intravenous urogram again demonstrated upward and lateral displacement of the left kidney and lateral displacement of the left ureter. Repeat surgery, as before, showed that the cyst arose from the left retroperitoneal space, had invaded the root of the mesentery, and had displaced the left kidney upward and to the left. The cyst could not be excised due to intimate involvement of the aorta and left renal vein, and so the cyst was drained of 400 cc of straw colored fluid. A left flank drain was left in place and postoperatively water-soluble contrast was injected into the cyst to demonstrate its size and extent (Fig. 3). The patient developed left renal vein thrombosis following surgery, but recovery was otherwise uneventful and he was discharged to be followed in the Pediatric Surgery Clinic.
Discussion A l t h o u g h m e s e n t e r i c cysts m a y o c c u r at a n y age, 2 5 % o c c u r b e f o r e the age o f 10 y e a r s [2]. D e s p i t e o u r c a s e r e p o r t , t h e y a r e said to be r a r e in t h e b l a c k p o p u l a t i o n . T h e y m a y be e m b r y o n i c , n e o p l a s t i c , t r a u m a t i c , o r i n f e c t i o u s in o r i g i n [3]. T h e e m b r y o n i c variety is t h o u g h t to be d u e to a b e r r a n t g r o w t h o f l y m p h a t i c tissue w h i c h d e v e l o p s i n t o a cyst l i n e d by c o n n e c t i v e tissue a n d e n d o t h e l i a l cells. It m a y be filled w i t h serous, c h y l o u s , b l o o d y , o r m i x e d f l u i d [1, 3]. The traumatic and infectious variety have no endothelial l i n i n g . M e s e n t e r i c cysts, u n l i k e d u p l i c a t i o n cysts, h a v e n o m u c u s - p r o d u c i n g cells. M e s e n t e r i c cysts m a y be single o r m u l t i p l e a n d u n i - o r m u l t i l o c u l a r . A l t h o u g h c a l c i f i c a t i o n s are said to be rare, t h e y o c c u r r e d in 1 7 % o f the p a t i e n t s in the series o f W a l k e r a n d P u t n a m [1]. T h e y u s u a l l y
9
0 3 6 4 - 2 3 5 6 / 7 9 / 0 0 0 4 - 0 1 9 1 $01.00 1979 S p r i n g e r - V e r l a g N e w Y o r k Inc.
Fig. 1. There is lateral displacement of the left kidney, especially the lower pole, along with lateral displacement of the left ureter. The left psoas margin has been obliterated by a soft tissue mass. The right kidney is poorly seen due to overlying bowel gas. Contrast is seen in the right distal ureter
Fig. 2. The barium enema shows anterior and medial displacement of the descending and sigmoid colon by a soft tissue mass Fig. 3. A Right posterior oblique view of the a b d o m e n following the injection of water-soluble contrast into the cyst via a 1eft flank drain. The irregular margins and extent of the cysts are outlined. B Lateral view of the a b d o m e n with water-soluble contrast in the cyst. The anterior extent of the cyst is seen with anterior displacement of the gas-filled bowel
S. Chirathivat and D. Shermeta: Mesenteric Cyst
develop between the leaves of the mesentery, and may be found anywhere from the duodenum to the rectum. Fifty percent occur in the mesentery of the small bowel and half of these are in the ileomesentery [3, 4]. They present as a mid-abdominal mass that is freely movable from side to side, but less movable in the craniocaudal direction [1]. They can present as a pelvic mass if they arise in the mesentery of the sigmoid colon. Only 5% of mesenteric cysts are retroperitoneal and, due to ther origin, are not usually freely movable [5, 6]. In our case, although the cyst arose from the retroperitoneal area, it did extend into the mesentery and thus was felt as a freely movable midabdominal mass. The c o m m o n e s t mode of presentation, as in our case, is that of an asymptomatic palpable abdominal mass [7]. Other symptoms in decreasing order of frequency include abdominal pain, nausea and vomiting, constipation, and even diarrhea [2]. Symptoms, when present, may be acute or chronic [1]. The acute presentation is usually that of peritonitis due to hemorrhage, infection, torsion, or rupture of the cyst. Small and large bowel obstruction, although uncommon, may occur due to compression by a very large cyst. On abdominal radiographs, a round to oval, homogeneous soft tissue mass with a smooth border is identified within the abdomen. On barium studies, it will be shown to be extrinsic to the gastrointestinal tract. If the cyst involves the small bowel mesentery, the stomach and proximal small bowel are usually displaced upward while the ascending and descending colon are displaced laterally. If the cyst arises from the retroperitoneal space, as in our case, there is anterior displacement of the gastrointestinal tract (Fig. 2). The intravenous urogram may show displacement of the kidney and ureter (Fig. 1). Hydronephrosis is unc o m m o n and occurs only with very large cysts. Sonography will demonstrate a uni- or multilocular cystic structure w i t h smooth walls and no internal echoes unless there is superimposed hemorrhage or infection [8]. It may have a bilobed appearance. On angiography, the blood supply to the cyst is separate from that of the adjacent bowel. The differential diagnosis of a mesenteric cyst includes a duplication cyst, omental cyst, ovarian cyst, fibroma of the mesentery, and pancreatic pseudocyst. If it arises from the retroperitoneum, it has to be
193
considered in the differential diagnosis of other retroperitoneal tumors. Sarcomatous degeneration of a cyst may occur, but it is u n c o m m o n [7]. Although the treatment of choice is total excision of the cyst, this may require excision of a small a m o u n t of adjacent bowel as excision of the cyst may compromise the small bowel's blood supply. As in our case, if the cyst cannot be totally excised, it m a y be treated with marsupialization or partial excision with cauterization of the cyst remnant with 10% glucose. Aspiration of the cyst is not useful, as the fluid reaccumulates and infection may occur [4]. Cyst recurrence following surgery has been reported in 7% of the cases, but the actual recurrence rate is probably even higher [1]. In summary, the diagnosis of a mesenteric cyst can b e made preoperatively by the combined use of radiographic and sonographic examinations in conjunction with the clinical features. These imaging procedures help the clinician in planning the surgical approach as they delineate the site and extent of the cyst. Following surgery, cyst recurrence is not uncommon. Acknowledgments. We would like to thank Dr. John P. Dorst for his encouragement, Mr. Henri Hessels for photographic assistance, and Ms. Hazel Garrett for secretarial help.
References 1. Walker A, P u t n a m P: Omental, mesenteric and retroperitoneal cysts: A clinical study of thirty-three new cases. Ann Surg 178:13 19, 1973 2. Bucher R: Mesenteric cysts. Arc Surg 60.'699-706, 1950 3. Baker A H : Developmental mesenteric cysts. Br J Surg 48:534 540, 1961 4. Sanchez RE, Gordon HE, Passaro E Jr: Mesenteric c y s t s - a review and report of four cases. Am Surg 36:378 382, 1970 5. N o r m a n CH Jr: Retroperitoneal mesenteric cyst. Med Radiogr Photogr 45:26 27, 1969 6. Lahey FH, Eckerson E: Retroperitoneal cysts. Ann Surg 100.'231 237, 1934 7. Hardin W J, Hardy JD: Mesenteric cysts. Am J Surg 119.'640 645, 1970 8. Wicks J, Silver TM, Bree RL: Giant cystic abdominal masses in children and adolescents ultrasonic differential diagnoses. Am J Roentgenol 130.'853 857, 1978
Received: September 20, 1978; accepted: October 16, 1978
Radiology
Gastrointest Radiol 4, 191-193 (1979)
Recurrent Retroperitoneal Mesenteric Cyst A Case Report and Review Suvimol Chirathivat and Dennis Shermeta Department of Pediatric Radiology and Pediatric Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
Abstract. A m e s e n t e r i c cyst is a n u n c o m m o n
cause of a palpable abdominal mass. A correct preoperative d i a g n o s i s c a n be m a d e b y the c o m b i n e d use o f rad i o g r a p h i c a n d s o n o g r a p h i c e x a m i n a t i o n s in c o n j u n c tion with the clinical features. A patient with a retrop e r i t o n e a l cyst e x t e n d i n g i n t o the leaves o f t h e m e s e n tery is p r e s e n t e d . T h e cyst r e c u r r e d 4 y e a r s a f t e r surgery.
Key Words: M e s e n t e r i c C y s t -
Retroperitoneal cyst
U l t r a s o u n d , cyst.
T h e first r e p o r t o f a m e s e n t e r i c c y s t a p p e a r s to h a v e b e e n m a d e in 1507 by B e n e v i e n e , a F l o r e n t i n e a n a t o m i s t , w h e r e a s s u r g i c a l e x c i s i o n o f a cyst was first d o n e in 1880 by T i l l a u x [1]. T h e r e h a v e b e e n m a n y r e p o r t s in t h e l i t e r a t u r e o f m e s e n t e r i c c y s t s ; h o w e v e r , t h e r e t r o p e r i t o n e a l v a r i e t y h a v e b e e n infrequentl3~ r e p o r t e d [2]. W e p r e s e n t a c a s e o f a m e s e n t e r i c cyst w h i c h a r o s e p r i m a r i l y in t h e r e t r o p e r i t o n e a l s p a c e a n d w h i c h rec*urred 4 y e a r s a f t e r surgery.
Case Report A 12-year-old asymptomatic black boy, who was having a routine physical examination prior to a meatotomy, was found to have a large, freely movable mid-abdominal mass. There was no evidence of hepatosplenomegaly and there were no other pertinent physical findings. An intravenous urogram demonstrated upward and lateral displacement of the left kidney and lateral displacement of the left ureter (Fig. 1). The kidneys themselves appeared intrinsically normal. Ultrasound examination revealed a 20 x 7 • 12 cm cystic mass in the mid-abdomen extending down into the pelvis. No septa were present within the mass. A second multiseptated cystic mass measuring 20 x 12 x 9 cm was identified arising in the left upper Address reprint requests to: Dr. S. Chirathivat, Department of Radiology (R130), University of Miami School of Medicine, P.O. Box 016960, Miami, FLA 33101, USA
quadrant. The barium enema showed marked displacement of the sigmoid and descending colon anteriorly and to the right, by a large soft tissue mass (Fig. 2). There was no evidence of calcification within the mass. At surgery, a large cystic mass was found in the left retroperitoneal area extending into the root of the mesentery. The cyst had multiple loculations. A number of smaller isolated cysts were also found. At surgery, all of the cysts were removed. The pathological findings were compatible with those of a mesenteric cyst. The patient was readmitted to the hospital 4 years later because of abdominal pain and recurrence of the abdominal mass. The intravenous urogram again demonstrated upward and lateral displacement of the left kidney and lateral displacement of the left ureter. Repeat surgery, as before, showed that the cyst arose from the left retroperitoneal space, had invaded the root of the mesentery, and had displaced the left kidney upward and to the left. The cyst could not be excised due to intimate involvement of the aorta and left renal vein, and so the cyst was drained of 400 cc of straw colored fluid. A left flank drain was left in place and postoperatively water-soluble contrast was injected into the cyst to demonstrate its size and extent (Fig. 3). The patient developed left renal vein thrombosis following surgery, but recovery was otherwise uneventful and he was discharged to be followed in the Pediatric Surgery Clinic.
Discussion A l t h o u g h m e s e n t e r i c cysts m a y o c c u r at a n y age, 2 5 % o c c u r b e f o r e the age o f 10 y e a r s [2]. D e s p i t e o u r c a s e r e p o r t , t h e y a r e said to be r a r e in t h e b l a c k p o p u l a t i o n . T h e y m a y be e m b r y o n i c , n e o p l a s t i c , t r a u m a t i c , o r i n f e c t i o u s in o r i g i n [3]. T h e e m b r y o n i c variety is t h o u g h t to be d u e to a b e r r a n t g r o w t h o f l y m p h a t i c tissue w h i c h d e v e l o p s i n t o a cyst l i n e d by c o n n e c t i v e tissue a n d e n d o t h e l i a l cells. It m a y be filled w i t h serous, c h y l o u s , b l o o d y , o r m i x e d f l u i d [1, 3]. The traumatic and infectious variety have no endothelial l i n i n g . M e s e n t e r i c cysts, u n l i k e d u p l i c a t i o n cysts, h a v e n o m u c u s - p r o d u c i n g cells. M e s e n t e r i c cysts m a y be single o r m u l t i p l e a n d u n i - o r m u l t i l o c u l a r . A l t h o u g h c a l c i f i c a t i o n s are said to be rare, t h e y o c c u r r e d in 1 7 % o f the p a t i e n t s in the series o f W a l k e r a n d P u t n a m [1]. T h e y u s u a l l y
9
0 3 6 4 - 2 3 5 6 / 7 9 / 0 0 0 4 - 0 1 9 1 $01.00 1979 S p r i n g e r - V e r l a g N e w Y o r k Inc.
Fig. 1. There is lateral displacement of the left kidney, especially the lower pole, along with lateral displacement of the left ureter. The left psoas margin has been obliterated by a soft tissue mass. The right kidney is poorly seen due to overlying bowel gas. Contrast is seen in the right distal ureter
Fig. 2. The barium enema shows anterior and medial displacement of the descending and sigmoid colon by a soft tissue mass Fig. 3. A Right posterior oblique view of the a b d o m e n following the injection of water-soluble contrast into the cyst via a 1eft flank drain. The irregular margins and extent of the cysts are outlined. B Lateral view of the a b d o m e n with water-soluble contrast in the cyst. The anterior extent of the cyst is seen with anterior displacement of the gas-filled bowel
S. Chirathivat and D. Shermeta: Mesenteric Cyst
develop between the leaves of the mesentery, and may be found anywhere from the duodenum to the rectum. Fifty percent occur in the mesentery of the small bowel and half of these are in the ileomesentery [3, 4]. They present as a mid-abdominal mass that is freely movable from side to side, but less movable in the craniocaudal direction [1]. They can present as a pelvic mass if they arise in the mesentery of the sigmoid colon. Only 5% of mesenteric cysts are retroperitoneal and, due to ther origin, are not usually freely movable [5, 6]. In our case, although the cyst arose from the retroperitoneal area, it did extend into the mesentery and thus was felt as a freely movable midabdominal mass. The c o m m o n e s t mode of presentation, as in our case, is that of an asymptomatic palpable abdominal mass [7]. Other symptoms in decreasing order of frequency include abdominal pain, nausea and vomiting, constipation, and even diarrhea [2]. Symptoms, when present, may be acute or chronic [1]. The acute presentation is usually that of peritonitis due to hemorrhage, infection, torsion, or rupture of the cyst. Small and large bowel obstruction, although uncommon, may occur due to compression by a very large cyst. On abdominal radiographs, a round to oval, homogeneous soft tissue mass with a smooth border is identified within the abdomen. On barium studies, it will be shown to be extrinsic to the gastrointestinal tract. If the cyst involves the small bowel mesentery, the stomach and proximal small bowel are usually displaced upward while the ascending and descending colon are displaced laterally. If the cyst arises from the retroperitoneal space, as in our case, there is anterior displacement of the gastrointestinal tract (Fig. 2). The intravenous urogram may show displacement of the kidney and ureter (Fig. 1). Hydronephrosis is unc o m m o n and occurs only with very large cysts. Sonography will demonstrate a uni- or multilocular cystic structure w i t h smooth walls and no internal echoes unless there is superimposed hemorrhage or infection [8]. It may have a bilobed appearance. On angiography, the blood supply to the cyst is separate from that of the adjacent bowel. The differential diagnosis of a mesenteric cyst includes a duplication cyst, omental cyst, ovarian cyst, fibroma of the mesentery, and pancreatic pseudocyst. If it arises from the retroperitoneum, it has to be
193
considered in the differential diagnosis of other retroperitoneal tumors. Sarcomatous degeneration of a cyst may occur, but it is u n c o m m o n [7]. Although the treatment of choice is total excision of the cyst, this may require excision of a small a m o u n t of adjacent bowel as excision of the cyst may compromise the small bowel's blood supply. As in our case, if the cyst cannot be totally excised, it m a y be treated with marsupialization or partial excision with cauterization of the cyst remnant with 10% glucose. Aspiration of the cyst is not useful, as the fluid reaccumulates and infection may occur [4]. Cyst recurrence following surgery has been reported in 7% of the cases, but the actual recurrence rate is probably even higher [1]. In summary, the diagnosis of a mesenteric cyst can b e made preoperatively by the combined use of radiographic and sonographic examinations in conjunction with the clinical features. These imaging procedures help the clinician in planning the surgical approach as they delineate the site and extent of the cyst. Following surgery, cyst recurrence is not uncommon. Acknowledgments. We would like to thank Dr. John P. Dorst for his encouragement, Mr. Henri Hessels for photographic assistance, and Ms. Hazel Garrett for secretarial help.
References 1. Walker A, P u t n a m P: Omental, mesenteric and retroperitoneal cysts: A clinical study of thirty-three new cases. Ann Surg 178:13 19, 1973 2. Bucher R: Mesenteric cysts. Arc Surg 60.'699-706, 1950 3. Baker A H : Developmental mesenteric cysts. Br J Surg 48:534 540, 1961 4. Sanchez RE, Gordon HE, Passaro E Jr: Mesenteric c y s t s - a review and report of four cases. Am Surg 36:378 382, 1970 5. N o r m a n CH Jr: Retroperitoneal mesenteric cyst. Med Radiogr Photogr 45:26 27, 1969 6. Lahey FH, Eckerson E: Retroperitoneal cysts. Ann Surg 100.'231 237, 1934 7. Hardin W J, Hardy JD: Mesenteric cysts. Am J Surg 119.'640 645, 1970 8. Wicks J, Silver TM, Bree RL: Giant cystic abdominal masses in children and adolescents ultrasonic differential diagnoses. Am J Roentgenol 130.'853 857, 1978
Received: September 20, 1978; accepted: October 16, 1978
