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Winberg H, Gerwins P, Hagelsteen K. Massive Chylous Ascites in a 9-Year-Old Girl with Malrotation-A Case Report. European J Pediatr Surg Rep 2024; 12:e1-e3. [PMID: 38214008 PMCID: PMC10781518 DOI: 10.1055/a-2221-9682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 10/21/2023] [Indexed: 01/13/2024] Open
Abstract
Malrotation leading to massive chylous ascites is rare. A 9-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss, or pain, but was bothered in social situations. Medical investigations, including ultrasound and computed tomography scans, revealed massive ascites. Laparocentesis yielded milk-colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures, and polymerase chain reaction for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast-enhanced magnetic resonance lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body magnetic resonance imaging revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd's procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 L of fluid. She was discharged the day after surgery and has been in good health for 1 year. We present a video illustrating the Ladd's procedure steps in this patient.
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Affiliation(s)
- Hans Winberg
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skånes Universitetssjukhus Lund, Lund, Sweden
| | - Pär Gerwins
- Department of Surgical Sciences, Radiology, Uppsala University, Uppsala, Sweden
| | - Kristine Hagelsteen
- Pediatrics, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Pediatric Surgery, Skånes Universitetssjukhus Lund, Lund, Sweden
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2
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Donovan DJ, Siskind T, Thanjan MT, Holzer RJ, Dayton JD, Carroll SJ. Chylous pericardial effusion with cardiac tamponade in a child treated with imatinib. Cardiol Young 2023; 33:1217-1219. [PMID: 36503590 DOI: 10.1017/s104795112200381x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Chylous pericardial effusions are extremely rare outside of thoracic and cardiac surgery patients. We report the case of an 8-year-old girl with history of recurrent benign giant cell granulomas who developed a large chylous pericardial effusion with cardiac tamponade soon after beginning therapy with imatinib. In this article, we discuss the presentation, diagnosis, and management and review the published literature of this rarely reported side effect of this medication.
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Affiliation(s)
- Denis J Donovan
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Tamar Siskind
- Division of Pediatric Cardiology, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Maria T Thanjan
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Queens, Weill Cornell Medical Center, Queens, NY, USA
| | - Ralf J Holzer
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Komansky Children's Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Jeffrey D Dayton
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Komansky Children's Hospital, Weill Cornell Medicine, New York, NY, USA
| | - Sheila J Carroll
- Division of Pediatric Cardiology, Department of Pediatrics, NewYork-Presbyterian Komansky Children's Hospital, Weill Cornell Medicine, New York, NY, USA
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3
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Schexnayder MM, Rutherford S, Rademacher N, Ryan KA, Dehghanpir SD. What is your diagnosis? Pleural fluid from a dog. Vet Clin Pathol 2022; 51:598-600. [PMID: 35288966 DOI: 10.1111/vcp.13078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 09/05/2021] [Accepted: 09/21/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Matthew M Schexnayder
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Stephanie Rutherford
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Nathalie Rademacher
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Kirk A Ryan
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
| | - Shannon D Dehghanpir
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Louisiana State University, Baton Rouge, LA, USA
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4
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Gordon K, Moore M, Van Zanten M, Pearce J, Itkin M, Madden B, Ratnam L, Mortimer PS, Nagaraja R, Mansour S. Case Report: Progressive central conducting lymphatic abnormalities in the RASopathies. Two case reports, including successful treatment by MEK inhibition. Front Genet 2022; 13:1001105. [PMID: 36238151 PMCID: PMC9550924 DOI: 10.3389/fgene.2022.1001105] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/07/2022] [Indexed: 11/13/2022] Open
Abstract
The RASopathies are a group of genetic conditions resulting from mutations within the RAS/mitogen-activated protein kinase (RAS-MAPK) pathway. Lymphatic abnormalities are commonly associated with these conditions, however central conducting lymphatic abnormalities (CCLA) have only recently been described. CCLAs may be progressive and can result in devastating systemic sequelae, such as recurrent chylothoraces, chylopericardium and chylous ascites which can cause significant morbidity and even mortality. Improvements in imaging modalities of the central lymphatics have enhanced our understanding of these complex abnormalities. Management is challenging and have mainly consisted of diuretics and invasive mechanical drainages. We describe two adult males with Noonan syndrome with a severe and progressive CCLA. In one patient we report the therapeutic role of targeted molecular therapy with the MEK inhibitor 'Trametinib', which has resulted in dramatic, and sustained, clinical improvement. The successful use of MEK inhibition highlights the importance of understanding the molecular cause of lymphatic abnormalities and utilising targeted therapies to improve quality of life and potentially life expectancy.
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Affiliation(s)
- Kristiana Gordon
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Matthew Moore
- Cardiovascular Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Malou Van Zanten
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom
| | - Julian Pearce
- Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Maxim Itkin
- Division of Interventional Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Brendan Madden
- Cardiovascular Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Lakshmi Ratnam
- Department of Interventional Radiology, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter S Mortimer
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,Lymphovascular Clinic, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Rani Nagaraja
- Gastroenterology Department, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Sahar Mansour
- Lymphovascular Research Unit, Molecular and Clinical Sciences Research Institute, University of London, London, United Kingdom.,SW Thames Regional Genetics Service, St. George's University Hospitals NHS Foundation Trust, London, United Kingdom
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Salatto A, Indrio F, Campanella V, Curci M, Maggipinto C, Cocomazzi R, Canale F, Nobili M, Bartoli F. A Rare Case of Mesenteric Chylous Cyst in Infant: Case Report and Review of Literature. Front Surg 2021; 8:666488. [PMID: 34195222 PMCID: PMC8236529 DOI: 10.3389/fsurg.2021.666488] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/19/2021] [Indexed: 11/13/2022] Open
Abstract
The occurrence of a mesenteric cyst (MC) is common in adults while in children and in infants is rare. In adults mesenteric cysts are often asymptomatic and discovered incidentally; however, in children they commonly present with symptoms of abdominal pain or distension with fever and leucocytosis. We report on a rare case, in our experience, of Mesenteric Chylous cyst (MCC) in an infant with signs and symptoms of intestinal obstruction. Discussion of literature is also reported.
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Affiliation(s)
- Alessia Salatto
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Flavia Indrio
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Vittoria Campanella
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Marina Curci
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Cosetta Maggipinto
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Raffaella Cocomazzi
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Francesco Canale
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Maria Nobili
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
| | - Fabio Bartoli
- Department of Medical and Surgical Science, University of Foggia, Foggia, Italy
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Vailas M, Benetatos N, Maroulis I, Kaplanis C, Drakos N, Mulita F, Sotiropoulou M, Germanos S. A gelatinous veil inside the abdomen of a pancreatic cancer patient. What lies beneath it? Clin Case Rep 2021; 9:e04353. [PMID: 34136253 PMCID: PMC8190690 DOI: 10.1002/ccr3.4353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 04/28/2021] [Indexed: 02/05/2023] Open
Abstract
Chylous ascites following pancreatic surgery results from surgical damage to the cisterna chyli or tributaries, with an incidence in pancreatic surgery of 1.8%-11%. Usually, conservative treatment is effective.
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Affiliation(s)
- Michail Vailas
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | - Nikolaos Benetatos
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | - Ioannis Maroulis
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | - Charalampos Kaplanis
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | - Nikolaos Drakos
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | - Francesk Mulita
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
| | | | - Stylianos Germanos
- Department of SurgeryUniversity of PatrasUniversity Hospital of PatrasPatraGreece
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Hur S, Jun H, Jeong YS. Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization. Gland Surg 2021; 10:1260-1267. [PMID: 33842273 DOI: 10.21037/gs-2019-ursoc-10] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol® lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol® lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol® is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
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Affiliation(s)
- Saebeom Hur
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Hoyong Jun
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
| | - Yoon Soo Jeong
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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8
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Abstract
Chylothorax is a rare condition characterized by lymph accumulation in the pleural space. When it occurs independent of trauma, it is even more rare and difficult to treat as identification of lymphatic leak is unpredictable. In addition, treatment of this condition with conventional lymphangiography and thoracic duct embolization may not result in positive outcomes. As such, the role of contrast-enhanced dynamic magnetic resonance lymphangiography to guide treatment is key to maximizing success with the advantage of localizing the site of lymphatic leak. Herein, we summarize etiologies of nontraumatic chylothorax, offer an updated treatment algorithm to stratify affected patients and determine appropriate treatment options, and review procedural techniques critical to efficient and effective treatment.
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Affiliation(s)
- Luis D Goity
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maxim Itkin
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Nadolski
- Division of Interventional Radiology, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Mandavdhare HS, Sharma V, Singh H, Dutta U. Underlying etiology determines the outcome in atraumatic chylous ascites. Intractable Rare Dis Res 2018; 7:177-181. [PMID: 30181937 PMCID: PMC6119674 DOI: 10.5582/irdr.2018.01028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Chylous ascites is an uncommon entity and infectious etiology is the most common cause in developing countries. However, recently, whether there is any change in trend of etiologies in developing countries is not known. In this study, a retrospective analysis of the data of cases of atraumatic chylous ascites was conducted. Twelve patients of atraumatic chylous ascites with a mean age of 35 years were studied and 6 of them were males. The mean duration of symptoms was 9.6 months and the clinical presentation was abdominal distension (12 cases), pain abdomen (10 cases), loss of appetite and weight (9 cases), peripheral lymphadenopathy (4 cases) and fever (3 cases). Etiologies were tuberculosis (3 cases), malignancy (2 cases), radiotherapy related (2 cases), pancreatitis related (2 cases), lymphatic malformation (2 cases) and multifactorial (1 case). Eight improved with conservative measures, 2 were lost to follow up and 2 died. Our outcomes found infectious etiology still as the most common cause of atraumatic chylous ascites. Benign treatable causes could be managed successfully with conservative measures while malignant etiology had a poor prognosis. Underlying etiology determines the outcome in atraumatic chylous ascites.
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Affiliation(s)
- Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
- Address correspondence to:Dr. Harshal S Mandavdhare, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh160012, India. E-mail:
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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10
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Mallick B, Mandavdhare HS, Aggarwal S, Singh H, Dutta U, Sharma V. Mycobacterial chylous ascites: report of three cases and systematic review. Ther Adv Infect Dis 2018; 5:69-75. [PMID: 30013774 DOI: 10.1177/2049936118772754] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Accepted: 04/04/2018] [Indexed: 01/23/2023] Open
Abstract
Background Chylous ascites is an uncommon presentation of mycobacterial infection. Methods We report three cases of tubercular chylous ascites, and in addition, we performed a systematic review of the published literature for the clinical presentation, treatment, and outcomes of mycobacterial chylous ascites. We followed the PRISMA guidelines for the systematic review. Results A total of 33 cases (including three of ours) were included. The mean age of the reported cases was 32.54 ± 17.56 years, and a male predominance (76%) was noted. The predominant clinical features were abdominal distension, abdominal pain, fever and loss of appetite and weight. Mycobacterium tuberculosis (MTB) and Mycobacterium avium-intracellulare (MAC) infection were responsible for 16 and 15 cases, respectively. All patients with MAC related chylous ascites had HIV infection. The mechanisms were related to lymph nodal enlargement, constrictive pericarditis and remote scrofuloderma. Overall, there was 29% mortality. Use of anti-mycobacterial therapy with use of total parenteral nutrition, octreotide and medium chain triglyceride-based diet resulted in improvement in the rest of the cases. The cause of death in our case was anti-tubercular therapy-induced hepatitis; three deaths were due to disseminated mycobacterial infection, one due to cardiopulmonary failure and unknown in four patients. Conclusion Chylous ascites due to mycobacterial infection is uncommon and associated with poor outcome. However, early diagnosis and nutritional management along with antimycobacterial therapy can improve outcome.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Harjeet Singh
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Lee DL, Madhuvrata P, Reed MW, Balasubramanian SP. Chylous mesenteric cyst: A diagnostic dilemma. Asian J Surg 2016; 39:182-6. [PMID: 23769746 DOI: 10.1016/j.asjsur.2013.04.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 10/23/2012] [Accepted: 04/15/2013] [Indexed: 11/21/2022] Open
Abstract
A mesenteric cyst is defined as a cyst that is located in the mesentery of the gastrointestinal tract and may extend from the base of the mesentery into the retroperitoneum. A case report of a patient with mesenteric cyst is presented. In addition, a systematic review was performed of English language literature on chylous mesenteric cysts in adult humans. Of the 18 articles included in the review, there were 19 cases of chylous mesenteric cysts reported. Male to female ratio was 1.4:1 with a median age of 46 years. A preoperative diagnosis of mesenteric cyst was made in four patients based on computed tomography. All patients underwent surgery and there were no reports of recurrence on follow up. Chylous mesenteric cyst is a rare entity that needs to be recognized whenever a preliminary diagnosis of intra-abdominal cystic mass is made.
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