Large Gastric Mesenteric Cyst: Case Report andLiterature Review

MOHAMMED HASSAN, M.D./+ NICK DOBRILOVIC, M.D.,* JOEL KORELITZ, M.D.*

the '^Departmoit of Surgery, The Jewish Hospital, Cincinnnti, Ohio; fDepartment of Surgery, GoodSamaritmi Hospital, Cincinnati, Ohio

The case is a 33-year-old white female presenting with a 3-day history of abdominal pain. Oninitial examination, she was found to have significant right lower quadrant tenderness. Workupincluded computed tomography, which demonstrated a large cystic mass appearing to be ofovarian origin. The patient required an exploratory laparotomy, at which time she was found lohave a large cyst involving the lesser curvature of her stomach. The cyst was successfully resected,and the patient had a rapid postoperative recovery with complete resolution of symptoms. His-topathologic evaluation of the specimen identified a mesenteric cyst. Mesenteric cysts are un-common; gastric involvement is exceedingly rare. A review of the literature is presented.

M CYSTS ARE RARE LESIONS and Were de-scribed by the Florentine anatomist AntonioBenivieni during the latter years of the I5tb century.They may occur anywhere between the duodenum andrectutn with a frequency of approximately 1 in105.000 hospitalized patients. C^lassically. though,they have been de.scribed to involve the stnall boweltnesentery. Half of all mesenteric cysts involve thesmall bowel. 40 per cent the mesocolon. and 10 percent other sites.' They can present with chronic ab-dominal pain, acute abdomen, or even without pain.Diagnostic strategies include the use of abdominalcomputed totnography (CT) and ultrasonography(US). Management involves surgical resection of thecyst and possibly adjaeent bowel.

Case Report

A 33-year-old white female presenled with right lowerquadrant abdominal pain of 3-day duration. She had a pastmedical history significant for appendectomy and gastro-esophagea! reflux disease. Abdominal exam demonstratedexquisite tenderness in the right lower quadrant as well assome distension. Pelvic exam revealed a palpable mass onthe right side.

Laboratory studies revealed multiple Gram-positive or-ganisms in the patient's urine and a slightly elevated CA-

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125 (41 lU/mL). Her p-HCG was negative and other studiesunremarkahle.

Ultrasonography of the abdomen and pelvis demonstrateda large, .septated. complex, eystie mass measuring 18 em x14 em visualized within the mid to lower abdomen andextending well into the pelvis. An abdcmiinal CT sean(Fig. 1) confirmed US findings demonstrating additionalanatomic detail of septations within the cystic structure andsuggesting the right ovary as the source.

At the time of laparotomy through a low midline incision.a large blue/blaek-colored eystie structure was identified.As the suspeeled source, the right ovary was examined firstbut found to be normal in appearance. Because the rightovary was not involved as had been initially suspected, themidline incision was extended superiorly. This allowed forexposure of the entire eystie structure measuring approxi-mately 25 cm X 10 cm X 10 cm in si/e. The cyst appearedentirely filled with tluid and was attached to the inferiorportion of the lesser curvature of the stomach, just proximalto the pylorus. A 2-cm pedicle was the only structure con-necting the cyst to the stomach (Figs. 2 and 3). The pediclewas splayed out and carefully examined and revealed nomaior blood vessels within the pedicle. The pedicle wasclamped, ligated, and the cyst excised. Postoperatively. thepatient had an uneventful recovery and was discharged 3days alter surgery.

Discussion

Mesenteric cysts are uncommon, and gastric in-volvement is exceedingly rare. Some have reportedthat mesenteric cysts occur twice as frequently inwomen as in men.- whereas others suggest equal in-cidence.-'"^ The majority of cysts occur in the stiiallbowel mesentery, and 40 per cent involve the meso-colon. tnost commonly sigmoid.' Bearhs et al. classify

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572 THE AMERICAN SURGEON July 2005 Vol. 71

[-HI, Abdominal CT scan FIG, 3. Cyst removal.

the mesenieric L-ysts into four eliologic groups: em-bryologic. developmental, traumatic, and degenera-tive.''''

Mesenteric cy.sts can appear in .single or multiplenumbers. Fluid volume within a mesenteric cyst varieswidely, ranging from a few millihters to 8 L.'-^'^According to Moynihan. fluid can be serous, chylous.or bloody.*^ Cysts with seroas contents are character-istic of mesocolon cysts, while chylous cysts tend tobe characteristic of small bowel mesentery. !n the casepresented, involving gastric mesentery, fluid was se-rous.

Examination of a cyst's inner surface has provedespecially useful for purposes of pathologic classifi-cation.'" Histologic classifications include simplemesenteric cyst, lymphangioma. pseudocyst (nonpan-creatic). enteric duplication cyst, enteric cyst, and me-sothelial cyst.''

In the case presented, sectioning of the specimenrevealed several encapsulated cystic structures filledwith yellow-tan material with a smooth lining to the

inner cy.st wall. By histopathologic evaluation, find-ings were highly suggestive of a simple mesentericcyst based on cyst wall composition: loosely struc-tured and moderately inflamed fibrous tissue contain-ing small foci of organizing hemorrhage. No neoplas-tic process was appreciated. Immunohistochemicalstaining for factor VIII and vimentin were negative(Fig. 4) which are markers for cystic lymphangiomasand mesothelial cysts, respectively.

Clinically, mesenteric cysts can present withchronic abdominal pain, acute abdomen, or no symp-toms at all. Acute abdomen occurs in one third of theadult population as opposed to two thirds in the pedi-atric population.'- Presenting symptoms include pain(8l7r). palpable mass (58%). nausea and vomiting(45%). constipalion (27%). and diarrhea (6%).'-^ Theabdominal pain most likely results from traction andstretching on the root of the mesentery and perito-neum. Acute symptoms are secondary to complica-tions of obstruction, rupture, hemorrhage, or infec-tion.'-7-

FIG. 2. Cy.st with pedicle. Fin, 4, Hematoxylin and eosin, x2(X).

No. 7 LARGE GASTRIC MESENTERIC CYST Hassan et al. 573

Palpation of an abdominal mass is the most com-mon finding on physical examination. Hypertympa-nism can often be detected over the area of the cyst. Asthe cyst enlarges, chance for misdiagnosis increases asphysical findings begin to resemble those of ascites,including detection of a positive fluid wave.'"^

Diagnostic tests include small bowel series, intra-venous pyelogram radiography (IVP). and bariumenema that rule out cysts of gastrointestinal or geni-tourinary origin. Abdominal CT. ultrasound, andmagnetic resonance imaging (MRI) are noninvasivestudies able to accurately identify cystic structures.Ultrasound appears to yield the most information forthe least expense."^ ^ ''^ ^ '*' Although often performed,angiography is usually of little additional value. Dif-ferential diagnoses include ovarian cyst, pancreaticpseudocyst within the gastrocolic mesentery, pedun-cLilated uterine fibroid, and omental cyst.'-''

There are several treatment methods for mesentericcysts, Enucleation is the treatment of choice for mes-enteric cysts yielding low recurrence. A larger scaleresection of the cyst and adjacent bowel should beconsidered if the cyst is close to bowel. Another formof treatment is marsupialization. which can result in achronic drainage sinus. Although the risk of infectionis increased, internal drainage is an option for cysts ofmore difficult exposure such as sigmoid mesocoloncysts. Simple aspiration has been assessed, but theinfection and recurrence rates have been prohibitive.Finally, the cyst could be partially excised, with cau-terization or phenolization of the residual portions ofcyst tissue, which remain near the root of the mesen-tery.'"'-'"

Mortalities of the late 1940s and 1950s have rangedfrom 4 per cent to 60 per cent. With improved tech-nology, the present mortality rate ranges from 0 percent to 8 per cent with enucleation and 3 per cent to 15per cent with excision and resection of adjacentbowel.- Burnett reported a mortality rate of 4 per centwith marsupialization, 60 per cent with drainage, 33per cent with aspiration. 16 per cent with resection,and 7 per cent with enucleation.'''

The case presented describes a large gastric mesen-teric cyst. This is an exceedingly rare finding. The

patient was successfully treated by complete excision.She experienced a rapid recovery with complete reso-lution of symptoms.

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