Mediastinal duplication of the gut

Case of split notochord syndrome: a neonate with thoracic neuroenteric cyst, abdominal duodenal duplication cyst, malrotation and vertebral anomalies

The authors describe a case of a male neonate with split notochord syndrome presenting with cervico-thoracic deformity, thoracic neuroenteric cyst, separate abdominal duodenal duplication cyst and concurrent intestinal malrotation. This combination of abnormalities is very rare. When these lesions are suspected, patients must be investigated carefully.This case is presented not only to recount an infrequent combination of structural abnormalities but also to raise awareness of the signs that should point to clinical suspicion and prompt diagnosis.Following surgical excision of the thoracic neuroenteric cyst, the patient has made a good recovery.

Giant presacral neurenteric cyst with anomalous sacrum in an adult patient

A rare case of an adult patient with a giant neuro-enteric cyst in a presacral location is reported. It had unique histological features of a stratified squamous epithelial lining with neuro-epithelial and smooth muscle components. There was associated sacral dysgenesis with spina bifida. The possible pathogenesis of this entity is discussed.

Notochord-gut failure of detachment and intestinal atresia

A spectrum of congenital anomalies have been described in an adriamycin-treated model with common features to the human pattern. Multiple intestinal atresias was part of this spectrum occurring in 25% of full-term experimental rat fetuses. The aim of this study was to examine the underlying developmental mechanism that results in intestinal atresia. Virgin timed-pregnant Sprague-Dawley rats were injected with Adriamycin i.p. at a dose of 2 mg/kg on days 6-9 of gestation. Embryos were removed on different gestational days during organogenesis and serial transverse histologic sections were examined and compared with control specimens. In experimental embryos, hindgut atresia was seen in day 12 embryos. Attachment of the intestine with the notochord was obvious observation resulting in abnormal position of the intestine. In some specimens the atretic intestine was splitting the dorsal aorta or even located behind the dorsal aorta. It is concluded that in the adriamycin-animal model, notochord-intestinal failure of detachment resulted in intestinal atresia during the beginning of organogenesis period. The possible underlying mechanisms are pinching of some endodermal cells as well as interference with normal intestinal circulation resulting in ischemic necrosis.

Isolated lumbosacral neurenteric cyst with partial sacral agenesis: case report

A case of an isolated intraspinal lumbosacral neurenteric cyst in a 5-year-old girl with partial sacral agenesis is reported. The cyst wall contained transitional epithelium and smooth muscle characteristic of the urinary bladder, suggesting a possible cloacal origin of the cyst. No prior cases of concomitant neurenteric cysts with partial or complete sacral agenesis have been reported, and the occurrence of an isolated intradural extramedullary sacral neurenteric cyst is rare. The possible pathogenesis of this lesion is described.

Neurenteric cyst: surgery and diagnostic imaging

Neurenteric cysts are rare, with fewer than 30 cases noted in the literature. We report the case of a newborn infant with respiratory distress caused by a large neurenteric cyst that was identified by prenatal ultrasound. Treatment consisted of excision of the mass through a right posterolateral thoracotomy. The cyst adhered to the spine at the level of the first thoracic vertebra and communicated with the jejunum through a posterior diaphragmatic defect. Postoperative studies with magnetic resonance imaging (MRI) and computed tomography (CT) disclosed an anterior meningocele and tethering of the spinal column. This is the second reported case of a neurenteric cyst demonstrated by prenatal ultrasound. The presence of an intrathoracic cyst associated with spinal abnormalities is characteristic of this anomaly. With imaging techniques such as MRI and CT, we may detect residual intraspinal disease associated with neurenteric cysts.

Neurenteric cysts--a spectrum

This review encompasses seven patients with clinically important cystic lesions of the gastrointestinal (GI) tract, exhibiting a wide range of vertebral anomalies and connections to the neural canal. Three patients had mediastinal masses connected to lower cervical and upper thoracic anomalous vertebrae with intraspinal extensions. In addition, one of these patients had a separate, juxtapancreatic intestinal duplication cyst. One infant with colonic duplication had a lumbar vertebral anomaly and an epithelial-lined tract between the two. Another patient had a presacral cystic mass which was the site of recurrent infections and meningitis until a connection with the rectum was divided. A newborn baby had a completely split notochord syndrome with a large dorsal enteric fistula. Finally, one patient had a dorsal enteric cyst with a direct intraspinal connection. Four of the seven patients had associated significant congenital anomalies, two of whom died early in the neonatal period. The rest of the patients did well. This broad range of enteric lesions with associated vertebral and intraspinal abnormalities suggests that the clinical spectrum of neurenteric cystic lesions is much wider than is generally appreciated.

Cystic duplications of the esophagus and neurenteric cysts

This paper reviews the past 25 years of experience with these lesions at The Hospital for Sick Children, Toronto, during which 19 infants and children were treated. There were 8 females and 11 males. Nine of these patients were under 1 year of age at presentation, 5 were between the ages of 1 and 10 years, 5 were older than 10 years. Eleven presented with symptoms referrable to the chest, and six with predominantly neurological symptoms. Two asymptomatic children were referred because of chest masses found incidentally on chest x-rays. Fifteen chest masses were noted; the other four had neurological symptoms only. Fourteen of these 19 lesions had associated vertebral anomalies. Nine patients underwent myelograms and 8 abnormalities were demonstrated, 2 of which were neurologically asymptomatic. Four patients had both myelographic abnormalities and mediastinal masses. Two out of three technetium scans were positive. Fourteen thoracotomies and six laminectomies were carried out. Nine of the 15 chest masses contained gastric mucosa including 2 which had perforated. None of the intraspinal masses contained gastric mucosa. The long-term survival was 95%. In this series, intraspinal anomalies co-existed with mediastinal masses in almost 25% of patients and were often initially asymptomatic. It is recommended that myelography be carried out in all patients with cystic duplications of the esophagus who have vertebral anomalies. Technetium scans may be useful if the diagnosis is obscure.

Enteric thoracoabdominal duplications in children

The clinical and pathological findings of two children with thoracoabdominal enteric duplications are described in detail. In addition, 23 case reports are reviewed. The majority of duplications communicated with the gastrointestinal tract below the diaphragm, but in one case, reported here, the duplication communicated with the cervical esophagus. In infants these duplications most often present with respiratory symptoms, whereas older children more typically have pain and melena. If possible the entire duplication should be removed during one operation.

Thoracic enteric cysts and diverticulae

Six cases of thoracic enteric cysts and diverticulae are described to illustrate a manifestation of the split notochord syndrome. The varied clinical, radiological, and operative picture in these cases is emphasized, the common triad being respiratory symptoms, a posterior mediastinal mass, and a vertebral anomaly. The symptoms may, however, be entirely gastrointestinal in the form of abdominal enlargement or gastro-intestinal haemorrhage. Because of the diversity of presentation these patients may come under the domain of the paediatric surgeon, the thoracic surgeon, or the neurosurgeon, and occasionally a combined team approach may be required to obtain satisfactory results in surgical treatment, which is mandatory.