The surgical experience for retroperitoneal, mesenteric and omental cyst in children

Operative Management of Intra-abdominal Lymphatic Malformations in Children: A Single Tertiary Center Experience

BACKGROUND

Intra-abdominal lymphatic malformations (LMs) are relatively rare congenital anomalies and can be divided into intra- and retroperitoneal subgroups. This study aims to evaluate the outcomes after surgical resection of intraperitoneal LMs in children.

METHODS

The records of all patients ≤16 years of age with intraperitoneal LMs managed at our tertiary center between 2007-2022 were reviewed. Patients with retroperitoneal LMs were excluded. Our preferred approach is surgical exploration for large (>5 cm), symptomatic lesions if they are potentially resectable on imaging.

RESULTS

A total of 12 patients (10 males) were diagnosed with intraperitoneal LMs located in the small bowel mesentery or omentum at a median age of 6.6 (range, 0.6-14.4) years. Ten (83%) patients presented with acute symptoms, including abdominal pain (n = 8; 67%) and vomiting (n = 3; 25%). Two (17%) intraperitoneal LMs were found on imaging performed for other reasons. Surgical exploration was performed in 11/12 (92%) cases. Intestinal volvulus around a mesenteric macrocyst had occurred in 4 (36%) patients. Complete macroscopic resection was achieved in 10/11 (91%) patients. Most lesions were localized to a short intestinal segment. One mixed type LM with an extensive mesenteric involvement was biopsied as the lesion was deemed to be unresectable in preoperative imaging and the diagnosis was initially unclear. There was one recurrence (8%) during postoperative follow-up on imaging (median 3.6 (range, 1.5-6.9) years) but the patient has remained asymptomatic and not undergone interventions. 6/8 (75%) of screened intraperitoneal LMs were positive for a somatic PIK3CA mutation.

CONCLUSIONS

Most large, pedunculated macrocystic LMs in the small bowel mesentery or omental location were amenable to macroscopic resection. Intraperitoneal LMs tend to present with acute symptoms including a risk for intestinal volvulus based on anatomical location. Our results suggest low recurrence rates or need for further interventions over follow-up.

LEVEL OF EVIDENCE

III.

Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee

BACKGROUND

Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment.

METHODS

Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question.

RESULTS

The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered.

CONCLUSION

Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

LEVEL OF EVIDENCE: 4

Pediatric Intraabdominal Cysts-A Case Series from a Single Tertiary Center Experience

OBJECTIVE

We aimed to analyze the clinical presentation, imaging, histopathology, and surgical management of pediatric intraabdominal cysts, which are relatively common but diverse lesions that pose diagnostic challenges.

MATERIALS AND METHODS

We conducted a retrospective analysis of pediatric intraabdominal cysts from 2010 to 2021 in a single tertiary center. We collected data on demographics, symptoms, radiological findings, surgical approaches, and histopathological diagnoses and compared them with the current literature.

RESULTS

A total of 36 cases were included. There were 30 females and 6 males, aged 1 to 16 years. Abdominal pain was the most common symptom, followed by tenderness and distention. Diarrhea and vomiting were also reported in some cases. The cysts varied in size, location, and origin and were diagnosed as lymphangioma, mucinous cystadenoma, paratubal cyst, lowgrade mucinous neoplasm, mature cystic teratoma, duplication cyst, mesothelial cyst, pseudocyst, serous cystadenoma, and simple hepatic cyst. The surgical management depended on the type and location of the cysts and involved excision, oophorectomy, appendectomy, or resection.

CONCLUSION

Pediatric intraabdominal cysts are heterogeneous lesions that require timely diagnosis and surgical resection. They may present with various symptoms and complications, depending on their size and location. Radiological and histopathological evaluation is essential for accurate diagnosis and optimal treatment.

Toddler with giant omental cyst, profound anemia, and shock: case report and review of the literature

Giant greater omental cysts with associated massive hemorrhage are rare. We encountered a 16-month-old boy with a four-day history of acute abdominal pain, distension, and paleness. Physical examination revealed a blood pressure of 74/27 mmHg. No well-defined masses were observed on abdominal palpation. The hemoglobin level on admission was 24 g/L. After initial resuscitation and blood transfusion, a computed tomography (CT) scan was performed, revealing a giant cystic mass with an intracystic hemorrhage. The diagnosis was confirmed via exploratory laparotomy, and the cyst, with the attached partial omentum was removed. Pathological findings revealed a simple cyst originating from the greater omentum. The patient recovered uneventfully and remained well during the two-year follow-up period. We reviewed the literature published over the last 27 years on cases of omental cysts to evaluate demographic characteristics, clinical presentations, complications, diagnostic tool options, and surgical approaches.

Mesenteric Cyst: A Case Report of a Healthy, Five-Year-Old Patient

Mesenteric and omental cysts can be seen at any age, with one in three cases seen in patients under 15 years old. These cysts represent one in 20,000 pediatric admissions. Here we share the case of a five-year-old female patient at a health center in a developing country, with the purpose of contributing to documentation in the region.

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.

Infected omental cyst complicated with subacute intestinal obstruction and ileal erosion in a 2-year-old boy: a case report

An omental cyst is a rare intraabdominal pathology that can cause acute abdomen and intestinal obstruction among children. A 2-year-old boy presented with fever, bilious vomiting, abdomen distension and loose stool of acute onset. The chest and abdominal radiographs showed right pleural effusion and prominent small bowels with thickening walls respectively. Ultrasonography revealed a gastrointestinal duplication cyst. An exploratory laparotomy was done and found a 5x5 cm infected omental cyst, severely adhered to and eroded into the ileum causing a small perforation. Omental cyst excision and ileal primary repair were done. The final diagnosis was a benign omental cyst. Omental cyst is usually asymptomatic; however, symptomatic omental cyst should be cautious for bleeding, intestinal obstruction, infection, torsion and rupture.

Laparoscopic-assisted excision of a huge polycystic omental lymphangioma in a 3 year old patient presenting with acute abdomen: case report and review

Lymphangioma is a rare benign neoplasm affecting mainly children. In this report we present a complicated case of polycystic omental lymphangioma in a 3 year old female presenting with acute abdomen. The patient underwent a laparoscopic-assisted excision of the lesion and had an excellent postoperative course. We discuss the effectiveness and advantages of this laparoscopic surgical approach in children and elaborate on the current literature.

Management of Mesenteric Cysts in Pediatric Population: Five-year Experience in Tertiary Care Center

Introduction To study the clinical features, diagnosis and treatment of mesenteric cysts in pediatric age group (< 15 years).

Materials and Methods This was a retrospective analysis which inculded 35 children diagnosed and treated for mesenteric cysts in the pediatric surgery department from January 2014 to January 2019. Patient’s data were retrieved from case sheets and analyzed. Patients with atleast one year follow-up were included in the study.

Results Thirty-five patients were included in the study. Twenty-one (60%) were males and fourteen (40%) were females. Mean age of presentation and surgery was 24 months. Twenty-six (74.2%) patients were managed by bowel resection, while 9 (25.7%) were managed by simple cystectomy. The average size of the cyst was 15 cm (ranging from 5 to 25 cm). Content of cysts was mostly chylous (82.9% cases). No recurrence was found throughout the follow-up period (1–2 years).

Conclusion Mesenteric cyst should be considered as a differential diagnosis in pediatric patients with acute or subacute intestinal obstruction and with or without a palpable lump in the abdomen. Mesenteric cysts can be managed surgically with favorable outcomes.

​Primary retroperitoneal pseudocyst: beware of the hoax solid enhancing adrenal mass

​We report the case of a 55-year-old male patient with an incidental finding on CT of a 'large adrenal mass'. The mass, which was intimately related to the left adrenal, was enhancing but not metabolically active. CT showed a 40×32 mm mass adjacent to the left adrenal and medial border of the spleen, 32 Hounsfield units (HU) precontrast and 116 HU postcontrast, consistent with a solid enhancing mass. The patient had no previous history of acute pancreatitis or any history of trauma. The patient proceeded to a laparoscopic left adrenalectomy; intraoperatively, a well-circumscribed lesion was identified intimately related to the splenic artery and able to be peeled away easily from the left adrenal. The lesion was unable to be dissected from the splenic artery and consequently the splenic artery was divided in order to completely resect this lesion. Histopathology identified the lesion as a 'non-pancreatic fibrous pseudocyst', with a thick calcified wall, the absence of epithelial lining and widespread inflammatory change.

Cystic intra-abdominal masses in children

Benign intra-abdominal cystic masses in infancy are fairly uncommon and their etiopathogenesis, histology and clinical presentation differ significantly. Our aim is to report our experience in their treatment in order to discuss the best diagnostic and treatment modality. The medical records of 5 children (2M, 3F) with cystic intraabdominal masses referred to our hospital between November 2012 and September 2016, were retrospectively reviewed. All patients underwent open surgery and subsequent histopathologic analysis. Different clinical presentations, localizations of the masses, diagnostic tools, surgical approaches, histological examinations and outcomes were reviewed. Patients mean age was 5.4 years (range: 8 months-9 years). Two patients presented recurrent abdominal pain and abdominal distension; 1 patient had a palpable mass discovered incidentally and 2 complained acute abdominal pain. Routine laboratory tests, tumor markers and abdominal ultrasound were immediately done in all patients. Three patients underwent MRI and 1 abdominal CT. At laparotomy 2 hepatic cysts, 2 mesenteric cyst and 1 retroperitoneal cyst were discovered. Histology reports described: 1 hepatobiliary cystadenoma, 1 benign hepatic hamartoma and 3 cystic lymphangiomas (1 retroperitoneal and 2 mesenteric). There were no major postoperative complications, deaths, or recurrences in our series (follow-up 3-24 months). Despite the rarity of these lesions, benign cystic abdominal masses in children are not so uncommon and should be considered as causes of acute abdominal pain. The differential diagnosis is not always possible preoperatively. In our series, radical excision of the lesions was possible in all cases, allowing reliable histological results and avoiding recurrences.

Imaging of the pediatric peritoneum, mesentery and omentum

The normal peritoneal structures, including the mesenteries and the omenta, are only a few cell layers thick and are visible on imaging based upon the tissues (e.g., fat) and structures (e.g., blood vessels and lymph nodes) contained within them. These structures become more visible and change in appearance when involved by pathological processes. In this pictorial essay, we discuss the normal anatomy of the various abdominopelvic peritoneal structures and illustrate numerous developmental and acquired diagnoses that involve these structures in the pediatric and young adult population.

A 7-Year-Old Girl with Early Developed Pseudocyst After Acute Pancreatitis: A Case Report and Literature Review

We report a 7-year-old Taiwanese girl with acute pancreatitis (AP) complicated with pseudocyst (PC). The girl was found to have a PC by ultrasonograpgy (USG) and magnetic resonance imaging 14 days after the onset of AP. The girl was discharged 21 days after management with an asymptomatic PC. The diagnostic criteria of AP included abdominal pain, serum amylase or lipase level, and imaging findings. Transabdominal USG after appropriate preparation with adequate fasting, intake of some liquids during the scanning, and right decubitus position enhance the demonstration of pancreas and peripancreatic structures. PC could be seen in up to 38% of pediatric AP patients. It can form within 2 weeks after the onset of symptoms, although most are late complications. Pancreatic PCs have to be differentiated from other intra-abdominal cysts on USG according to their image character and anatomic location. A well-prepared USG examination in combination with liquid intake and right decubitus position is of value in the diagnosis and follow-up of PC.

Abbreviations: ANC, acute necrotic collection; AP, acute pancreatitis; APFC, acute peripancreatic fluid collection; CECT, contrast-enhanced computed tomography; CRP, C-reactive protein; CT, computed tomography; MRI, magnetic resonance imaging; PAP, pediatric acute pancreatitis; PC, pseudocyst; USG, ultrasonography.

Case Report of Four Different Primary Mesenteric Neoplasms and Review of Literature

INTRODUCTION

It is rare for primary tumors to arise from the mesentery. Lymphangiomas appear as congenital malformations of the lymphatic system or benign neoplasms as a large, thin-walled, often multilocular cyst. Mesenteric infiltration is common and during surgical treatment, adjustment of structures such as the bowel and resection of the spleen may be required. Cystic mesotheliomas are rare, benign tumors that originate from the peritoneal mesothelium and are more common in women. Mesenteric cysts are mostly benign and rare intra-abdominal tumors, and can be seen as occupying a large cyst. Malignant fibrous histiocytoma is a rare pleomorphic sarcoma that is more commonly encountered in men. After the extremities, the second most common areas to be affected are the retroperitoneum and peritoneal cavity.

CASE PRESENTATION

We encountered four cases of different primary mesenteric neoplasms that were operated at the Gazi Yasargil teaching and research hospital, department of general surgery, Diyarbakir, Turkey, between 2013 and 2014. We reviewed these primary mesenteric neoplasms and compared them with previous literature.

CONCLUSIONS

Primary mesenteric tumors are rare and mostly benign tumors. Complete surgical excision is necessary for all tumors and follow-up is necessary after surgery for malignant fibrous histiocytoma due to recurrence.

Examine the patient not the hernia: identification of an asymptomatic giant primary retroperitoneal pseudocyst. A case report and literature review

We present the case of a 70-year-old man with a giant right-sided retroperitoneal pseudocyst, confirmed histologically after resection to be benign with appearances dissimilar to pancreatic and adrenal tissue. The cyst was noted incidentally on table at the time of laparoscopic surgery. Retroperitoneal pseudocysts most commonly arise from the pancreas and adrenal glands occurring as a result of an inflammatory process. Primary retroperitoneal pseudocysts are a rare entity. This case highlights the importance of examining the patient thoroughly and not focusing on the obvious. The mass was not palpated on initial review prior to listing for surgery, and the patient was asymptomatic from the mass.

Laparoscopic Excision of Large Intra-Abdominal Cysts in Children: Needle Hitch Technique

Laparoscopic surgery has both diagnostic and therapeutic advantages in the management of intra-abdominal cysts in children. Large cysts in small children pose technical challenges during laparoscopic surgery, requiring multiple incisions and advanced laparoscopic skills. This paper describes a novel laparoscopic technique using minimal manipulation for both aspiration and excision of the cyst. This simple, safe, and effective approach was used to achieve traction and facilitate excision of a large intra-abdominal cyst in a neonate and a young child.

Miscellaneous conditions of the peritoneal cavity--peritoneal tumors, pseudomyxoma, mesothelioma, fibroblastic reaction, cocoon, cystic lymphatic malformations, blue-bleb, and chylous ascites

The peritoneum is subject to both primary neoplasia and secondary malignancy from direct, trans-coelomic, or hematogenous spread from any cancer. The knowledge base in the pediatric age group is very limited due to the rarity of peritoneal conditions in children, and much of the information is extrapolated from adult literature. There have been few reports in the pediatric population on the diagnosis and management of peritoneal conditions including peritoneal malignancy. In this article, we aim to highlight some of these conditions and the treatments available with a special emphasis on the evolving role of cytoreduction surgery and hyperthermic intraperitoneal chemotherapy in the treatment of certain peritoneal malignancies in children.