Mesenteric cystic masses: a series of 21 pediatric cases and review of the literature

Surgical Treatment of Mesenteric Lymphatic Malformations in Children: An Observational Cohort study

BACKGROUND

Few studies have analyzed the cyst characteristics and complications of mesenteric lymphatic malformations (ML). This study aimed to compare ML's cyst characteristics and preoperative complications at different locations and suggest a modified ML classification for patients requiring surgery.

METHODS

In total, 157 ML patients underwent surgery at Beijing Children's Hospital between January 2010 and December 2021. The cyst characteristics and preoperative complications were reviewed. The surgical methods for ML were analyzed according to the modified ML classification (Type I, n = 87, involving the intestinal wall; Type II, n = 45, located in the mesenteric boundaries; Type III, n = 16, involving the root of the mesentery; Type IV, n = 7, multicentric ML; Type V, n = 2, involving the upper rectum).

RESULTS

Overall, 111 (70.7%) ML were located at the intestinal mesentery and 44 (28.0%) at the mesocolon. Type I and type II ML mainly involved intestinal mesentery (64.9%) and mesocolon (56.8%), respectively (P < 0.001). Microcystic-type ML and ML with chylous fluid were only located in the intestinal mesentery. Intestinal volvulus was only found in patients with ML in the intestinal mesentery (P < 0.001), whereas ML in the mesocolon were more prone to hemorrhage (P = 0.002) and infection (P = 0.005). ML in the jejunal mesentery was an independent risk factor for intestinal volvulus (OR = 3.5, 95% CI 1.5-8.3, P = 0.003). The surgical methods significantly differed between Type I and type II ML (P < 0.001).

CONCLUSIONS

ML at different locations have different characteristics. For patients requiring surgery, the new ML classification can be used to select an appropriate surgical method.

LEVEL OF EVIDENCE

Level III.

Volvulus Due to Mesenteric Cysts in Infants and Children; A Case Report

Mesenteric cysts are defined as benign intra-abdominal tumors located in the mesentery. It was a rare disease with an incidence of 1:20000 in children. The most common location was in the small bowel mesentery. Most patients with mesenteric cysts are asymptomatic and have unspecific symptoms like dyspepsia, abdominal enlargement, and abdominal pain. The fewer others could present with an acute abdomen. We describe two cases of volvulus due to the mesenteric cyst; one case in an infant and one case in a child. There is a different clinical presentation and histopathology between infants and children. In the infant, it presented with an acute abdomen, while in the child acute abdomen was not present. We found a chylous cyst in the child while the enterogenous cyst was present in the infant. We found a volvulus due to the mesentery cyst in the infant. This comparison of mesenteric cysts between the infant and the child could help to diagnose mesenteric cysts, especially in infants.

Preoperative complications in children with mesenteric lymphatic malformations: Incidence, risk factors and outcomes

BACKGROUND

Preoperative complications of mesenteric lymphatic malformations (ML) in children are various and complex. We aim to analyze the incidences and risk factors of three major preoperative complications (hemorrhage of the cyst, infection of the cyst and intestinal volvulus) in ML patients, and explore their influence on the outcomes.

METHODS

This retrospective cohort study enrolled ML patients undergoing surgery at Beijing Children's Hospital between June 2016 and June 2022 and classified them according to different preoperative complications, preoperative hemorrhage or infection, and preoperative intestinal volvulus. The groups were examined and compared according to sex, age at admission, presenting symptoms, laboratory examinations, imaging examinations, preoperative treatments, cyst characteristics, surgical details, perioperative clinical data, and follow-up. Logistic regression analysis was performed to identify the independent risk factors for preoperative hemorrhage or infection, and preoperative intestinal volvulus.

RESULTS

Of the 104 enrolled ML patients, 27 (26.0%) had preoperative hemorrhage or infection, and 22 (21.2%) had preoperative intestinal volvulus. Univariate analysis showed that patients with preoperative hemorrhage or infection had a higher rate of ML in the mesocolon (44.4 vs. 23.4%, p < 0.038) and larger cysts (10 vs. 8 cm, p = 0.042) than patients without preoperative hemorrhage or infection. Multivariable logistic regression analysis found that the location (OR, 3.1; 95% CI, 1.1-8.6; p = 0.026) and size of the cyst (≥7.5 cm) (OR, 6.2; 95% CI, 1.6-23.4; p = 0.007) were independent risk factors for preoperative hemorrhage or infection. Preoperative intestinal volvulus was only found in ML at the intestinal mesentery. Further analysis showed that ML in the jejunal mesentery was an independent risk factor for preoperative intestinal volvulus (OR, 3.3; 95% CI, 1.1-10.0; p = 0.027). Patients with preoperative hemorrhage or infection spent more on hospitalization costs than patients without preoperative hemorrhage or infection (3,000 vs. 2,674 dollars, p = 0.038).

CONCLUSIONS

ML patients should be treated as soon as possible after diagnosis. The location and size of the cyst were independent risk factors for preoperative hemorrhage or infection. ML in the jejunal mesentery was an independent risk factor for preoperative intestinal volvulus.

Management outcomes of mesenteric cysts in paediatric age group

BACKGROUND

Mesenteric cysts are rare intra-abdominal masses and high index of suspicion is required to clinically suspect this pathology and make a definitive diagnosis. They are most commonly located in the ileal mesentery but can be located anywhere along the gastrointestinal tract mesentery and may extend into the retroperitoneum. The rarity of these anomalies and diversity of clinical picture pose challenges in the diagnosis and operative management. The objective of this study is to determine the demographic pattern, clinicopathological diagnosis and management outcome of mesenteric cysts in our hospital.

MATERIALS AND METHODS

This retrospective study was conducted on children operated for mesenteric cysts from October 2013 to September 2020. Statistical analysis was performed using Open Epi Version 3.01.

RESULTS

Out of 32 children with a diagnosis of mesenteric cyst, 78% were below 5 years of age. Small intestine was affected in 26 cases and large bowel mesentery was the site of origin in six cases. Complete excision of mesenteric cyst was possible in all cases. Bowel resection was required in ten cases (31%) to enable complete excision. Bowel resection was required more often in children operated on emergency than those with elective surgery, and is statistically significant (P = 0.04; confidence interval: 0.05-0.96, odds ratio: 0.23). An uncommon co-existence with ileal atresia and detection of rare chylolymphatic cyst in another infant were also remarkable findings. Histopathology proved the diagnosis in all cases. There was no mortality or recurrence during hospitalisation and follow-up, which ranged from 3 months to 3 years.

CONCLUSIONS

Mesenteric cysts present with diverse clinical features and children below 5 years of age are most commonly affected. Complete surgical excision is the optimal treatment and may require bowel resection in significant number of cases, especially those operated during emergency. Histopathology is the gold standard for diagnosis.

Chylous content might determine the optimal surgical approach for mesenteric lymphatic malformations in childhood

BACKGROUND

Mesenteric lymphatic malformations (LMs) represent rare congenital anomalies that can include chylous or nonchylous content. The pathologic mechanisms explaining this phenomenon are poorly understood and not yet described. Furthermore, the current management approach does not consider the contents of the mesenteric LMs. In the present study, we have defined the relationship between the lymphatic mesenteric cyst content and the histologic evidence of LMs within the bowel wall.

METHODS

We retrospectively investigated all patients with mesenteric LMs treated surgically at our department from 1999 to 2018.

RESULTS

A total of 11 patients (6 girls and 5 boys) were included in our analysis. Seven patients had presented with LMs located in the jejunal mesentery, three in the ileocecal region, and only one in the mesocolon transversum and omentum. Of the 11 children, 7 had had LMs with nonchylous content and 4 had presented with chylous content LMs. Intestinal resection was performed in all 4 patients with chylous content LMs and 4 patients with nonchylous content LMs. Histopathologic evaluation of the surgical specimens determined that only the LMs with chylous content displayed malformed lymphatic channels throughout the bowel wall. The resected small bowel of four patients with nonchylous content showed no LM extension throughout the intestinal wall.

CONCLUSIONS

LMs with chylous content seem to develop from malformed lymphatic channels within the bowel wall. In such cases, segmental intestinal resection is mandatory. In contrast, mesenteric LMs with nonchylous content can potentially be treated without bowel resection if the blood supply can be preserved. This finding is, to the best of our knowledge, reported in the present study for the first time.

Intra-abdominal lymphatic malformation management in light of the updated International Society for the Study of Vascular Anomalies classification

BACKGROUND

The International Society for the Study of Vascular Anomalies (ISSVA) classification distinguishes between common lymphatic malformations and complex lymphatic anomalies. These entities have overlapping features but differing responses to treatment. Surgery has been the mainstream treatment in intra-abdominal lymphatic malformation, with variable reported success in the literature.

OBJECTIVE

The aim of this study was to review the outcome of different treatments for intra-abdominal lymphatic malformations in children.

MATERIALS AND METHODS

We retrospectively reviewed all intra-abdominal lymphatic malformations from 1999 to 2019 in children treated by the surgical team or followed in the vascular anomalies clinic of our institution. Children were classified into one of three groups: group A, isolated intra-abdominal lymphatic malformation; group B, common lymphatic malformation in continuity with other regions; or group C, intra-abdominal involvement as part of a complex lymphatic anomaly or associated syndrome.

RESULTS

Fifty intra-abdominal lymphatic malformations were diagnosed; five of these were excluded. In group A (n=28), the treatment was surgical resection (n=26) or sclerosing treatment (n=1), with one case of spontaneous regression; no recurrence was observed in 25 patients. In group B (n=7), three patients had partial resection and all had recurrence; four had sclerotherapy alone with good response. In group C (n=10), therapeutic options included surgery, sclerosing treatment and pharmacotherapy, with variable outcomes.

CONCLUSION

The management of intra-abdominal malformations requires a team approach. Sclerotherapy is successful in treating macrocystic lymphatic malformation. Surgery is successful in treating isolated intra-abdominal common lymphatic malformation, albeit at times at the cost of intestinal resection, which could be avoided by combining surgery with preoperative sclerotherapy. With surgery there is often limited resectability, and therefore recurrence in intra-abdominal lymphatic malformations that are part of complex lymphatic anomalies associated with syndromes, or in common lymphatic malformations in continuity with other regions. Sclerotherapy is an effective modality in these instances along with pharmacotherapy.

Fetal abdominal tumors and cysts

This article reviews the contemporary diagnosis and management of the most common abdominal neoplasms and cystic lesions diagnosed in the fetus. Fetal tumors discussed include teratomas (sacrococcygeal, cervical or mediastinal), mesoblastic nephroma, nephroblastoma (Wilms' tumor), neuroblastoma, and hepatoblastoma. Fetal abdominal cystic lesions discussed include ovarian cyst, choledochal cyst, intestinal duplication cyst, mesenteric cyst, simple hepatic cyst, and meconium pseudocyst. We discuss the rare indications for fetal intervention or fetal surgery and other perinatal management, including prenatal interventions and fetal surgery for sacrococcygeal teratoma. The lesions reviewed are detected by widespread use of screening ultrasonography during pregnancy. Work-up for these abnormalities may include fetal MRI which enhances the diagnostic accuracy of abdominal tumors and cystic lesions and can aid in characterization of the lesion in relationship to surrounding anatomic structures. Accurate prenatal diagnosis of such lesions permits recommendations for optimal location and timing of delivery, and inclusion of appropriate caregivers and expertise to facilitate postnatal management. Perinatal management of the fetus with a neoplasm requires consideration of the optimal timing and mode of delivery, and pediatric oncology and surgical specialty care. The majority of tumors diagnosed antenatally have good prognosis with current multimodality treatment.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Ultrasonographic diagnosis, classification, and treatment of cervical lymphatic malformation in paediatric patients: a retrospective study

Background

To explore the imaging features, key diagnostic points, classification, treatment, and prognosis of cervical lymphatic malformation.

Methods

Overall, 320 patients diagnosed with cervical lymphatic malformation were retrospectively analysed in our hospital between 1 January 2014 and 31 December 2017. Imaging modalities included colour Doppler ultrasound, magnetic resonance imaging, and contrast-enhanced computed tomography. Cervical lymphatic malformations were classified by cyst diameter. Treatments included interventional therapy, surgery, and expectant treatment.

Results

Cervical lymphatic malformation was identified in 320 of 1192 patients with lymphatic malformation. Four were excluded due to misdiagnosis by ultrasonography. Cervical lymphatic malformation was classified as mixed, macrocystic, and microcystic in 184 (57.5%), 117 (36.56%), and 19 (5.94%) patients, respectively. Sixty-four (20%), ten (3.12%), seven (2.19%), and three (0.94%) patients experienced intracystic haemorrhage, infection, concurrent intracystic haemorrhage and infection, and calcification, respectively. Among 260 (81.25%) patients who underwent interventional sclerotherapy, 163 (50.94%) received it once and 96 (30%) received it two or more times. Twenty-eight (8.75%), five (1.56%), and 27 (8.44%) patients underwent surgical resection, interventional sclerotherapy plus surgery, and expectant management, respectively.

Conclusions

Ultrasonography is useful for diagnosing definite cervical lymphatic malformation. Interventional therapy is the first choice for children with confirmed cervical lymphatic malformation.

Congenital and hereditary cystic diseases of the abdomen

Congenital and hereditary cystic lesions of the abdomen are relatively rare. Correct diagnosis is critical as they may simulate several other benign and malignant acquired diseases of the abdomen. With the correct and appropriate use of imaging, diagnosis may be relatively straightforward and clinical management may be implemented appropriately. The purpose of this article is to describe imaging findings of common and uncommon congenital and hereditary cystic disease of the abdominal organs.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence‐based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence‐based guidelines for the management of vascular anomalies.

Japanese clinical practice guidelines for vascular anomalies 2017

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

A Case of Mesenteric Cyst in a 4-Year-Old Child with Acute Abdominal Pain

Mesenteric cysts are rare intra-abdominal lesions occurring during childhood, which were first described in 1507. Cases of mesenteric cysts have been continuously reported, but these cases were very small in number. They are often asymptomatic and incidentally found while patients are undergoing work-up or receiving treatment for other conditions such as appendicitis, small-bowel obstruction, or diverticulitis; however, patients may still have lower abdominal pain and symptoms that are frequently associated with other abdominal conditions. The symptoms are variable and non-specific, including pain (82%), nausea and vomiting (45%), constipation (27%), and diarrhea (6%). An abdominal mass may be palpable in up to 61% of patients. We are to report the clinical course and literature of a child with mesenteric cysts who complained of acute abdominal pain, distension, and vomiting and were surgically treated after being diagnosed with mesenteric cysts based on radiological examination.

Acute Abdominal Pain Caused by an Infected Mesenteric Cyst in a 24-Year-Old Female

A mesenteric cyst is a rare cause for abdominal pain. This umbrella term includes cystic entities which reside in the mesentery. We present a case of an infected false mesenteric cyst in a 24-year-old female patient without prior surgery or known trauma. Mainstay of treatment involves surgical resection, although less invasive treatments have been described. Prognosis depends on the origin of the cyst.

Clinical features of mesenteric lymphatic malformation in children

BACKGROUND

Mesenteric lymphatic malformations (MLs) are a heterogeneous group of benign diseases of the lymphatic system that present with cystic dilated lymphatics of the mesentery. MLs are rare and represent less than 5% of all lymphatic malformations. The aims of this study were to analyze the characteristics of MLs in children and to suggest a modified classification.

PATIENTS AND METHODS

We investigated 25 patients who underwent ML surgery. The clinical data and pathological findings were reviewed retrospectively. We divided the patients into 4 groups according to the operative findings. Group 1 included patients with MLs involving the intestinal walls. Group 2 included patients with pedicle-type MLs with no relationship to the mesenteric vessels. Group 3 patients presented with MLs located in the mesenteric boundaries near the mesenteric vessels. Group 4 patients had multicentric and diffusely infiltrated MLs.

RESULT

The male-to-female ratio was 11:14, and the median age at diagnosis was 5years of age. The most common symptom was abdominal pain. The jejunal mesentery was the most frequently involved site in this study. Five patients showed the macrocystic type and 20 patients showed the mixed cystic type. With the exception of one patient with a large mixed cystic-type ML who underwent incomplete mass excision, 24 patients underwent complete mass excision. The group 1 patients (n=14) underwent mass excision performed with segmental resection of the bowel. The group 2 patients (n=3) only underwent mass excision surgery. The patients in group 3 (n=7) underwent mass excision with segmental resection of the intestine because ML excision altered the blood supply of the adjacent intestines. The group 4 patients (n=1) presented with MLs involving the entire mesentery and underwent incomplete excision.

CONCLUSION

The relationships between MLs and the neighboring organs determine the surgical strategy, and the size and location of MLs affect the operative methods. The modified classification based on these findings can facilitate effective treatment planning.

Prenatal Imaging of the Gastrointestinal Tract with Postnatal Imaging Correlation

Prenatal detection of a wide variety of anomalies and masses of the gastrointestinal tract is now possible. Prenatal imaging with ultrasonography and in selected cases magnetic resonance imaging provides invaluable information to the referring obstetrician, the maternal fetal medicine specialist, the neonatologist and pediatrician who will care for the child after birth, the surgeons and pediatric specialists who will repair or manage a prenatally detected anomaly, and of course to the parents, allowing them to prepare psychologically and financially for the specific interventions that may be needed for their child. Additional screening for associated anomalies can take place, route of delivery can be decided, and arrangements for delivery in an appropriate setting can be made. Prenatal detection also allows for consideration for pregnancy termination. This article will give a broad overview of anomalies of the gastrointestinal tract that can be detected prenatally and their imaging appearance postnatally.

Cases of atypical lymphangiomas in children

Background. Lymphatic malformations or lymphangiomas are rare benign hamartomas that result from maldevelopment of primitive lymphatic sacs. They are most frequently found in the neck and axilla, while intra-abdominal and mediastinal lymphangiomas are uncommon. These are primarily tumours of infancy and childhood and are successfully treated with surgical excision. Summary of Cases. Five cases of lymphangioma comprising three intra-abdominal lymphangiomas and two unilateral axillary lymphangiomas presenting at one institution in Trinidad W.I. between 2005 and 2012 were examined. The presentations, location, workup, treatment, and outcome of these patients were studied. Conclusion. This paper discusses a range of extracervical lymphangioma cases seen at San Fernando General Hospital, Trinidad W.I. We report three intra-abdominal cases and the most common clinical presentations were abdominal pain and distension. Also two axillary cases were reported, which presented as painless axillary masses. The major concerns for excision of axillary lymphangioma by parents and surgeons were cosmesis and feasibility of complete resection without disruption of developing breast tissue and axillary vessels. We believe that ultrasound scan is very good at detection of the lesion, while CT is better at determining tumour content and planning for the operation. It is our opinion that complete surgical excision can be achieved.

Beyond appendicitis: evaluation and surgical treatment of pediatric acute abdominal pain

PURPOSE OF REVIEW

Evaluation of the child with acute abdominal pain is challenging because of the wide range of potential diagnoses. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging.

RECENT FINDINGS

Intussusception and intestinal malrotation are potentially serious causes of intestinal obstruction, which are best evaluated by ultrasound and upper gastrointestinal series, respectively. Ultrasound has diagnostic importance in the evaluation of multiple diseases, including appendicitis, by potentially decreasing the need for inpatient observation, cholecystitis and complications of gall stones such as pancreatitis, and ovarian diseases. Pelvic inflammatory disease should be considered in evaluation of a teenage girl with lower abdominal pain. Less common causes of acute abdominal pain include ingested foreign bodies, infected congenital anomalies, and perforated peptic ulcer disease.

SUMMARY

Presenting symptoms and physical examination findings can narrow the number of potential diagnoses in pediatric acute abdominal pain and thereby guide diagnostic imaging selection. Abdominal/pelvic ultrasound, rather than computed tomography scan, is the preferred modality for initial evaluation of many potential causes of pediatric abdominal pain.