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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)01063-0
10.1016/j.ijscr.2024.110282
110282
Case Series
Giant mesenteric cysts: A rare case series with clinical insights
Shaker Kamar Qamar.shaker@damascusuniversity.edu.sy
a
Alomar Khaled Khaled.alomar@damascusuniversity.edu.sy
a⁎
Shaker Omar b
Brnbow Ziad c
Mahmod Jaber jaber.mahmod@damascusuniversity.edu.sy
a
Dalati Husam a
a Damascus University, University Pediatric Hospital, Damascus, Syria
b Damascus Hospital, Damascus, Syria
c University Pediatrics' Hospital, Tishreen Military Hospital in Damascus, Syria
⁎ Corresponding author. Khaled.alomar@damascusuniversity.edu.sy
12 9 2024
10 2024
12 9 2024
123 11028210 8 2024
5 9 2024
9 9 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and significance

Mesenteric cysts are rare, non-cancerous tumors found mainly in children. The symptoms can vary depending on the size and location of the cyst. While the exact cause is unknown, complete surgical removal is the main and most effective treatment for mesenteric cysts.

Case presentation

Three cases involving young boys were presented. They primarily complained of abdominal swelling without pain. Radiological tests revealed mesenteric cysts near the jejunum and transverse colon, and another near the sigmoid colon, which were both successfully removed.

Clinical discussion

Despite being uncommon, mesenteric cysts should be considered when diagnosing abdominal masses in children.

Conclusion

Surgical intervention is crucial for patients with mesenteric cysts. Complete surgical removal leads to a positive prognosis, even for large or complex cases. This stresses the importance of considering. Environmental factors are potential causes for the formation and development of these tumors.

Highlights

• Mesenteric cysts are rare, non-malignant tumors.

• Accurate diagnosis and surgical management are essential for successful treatment.

• Complete surgical excision is the gold standard treatment approach.

• Histological examination confirms the definitive diagnosis.

• Recurrence typically occurs early, making long-term follow-up for recurrence less beneficial.

Keywords

Case series
Large cyst
Pediatric surgery
Mesenteric
Abbreviations

CT computerized tomographic

DRE digital rectal examination
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pmc1 Introduction

Mesenteric cysts are uncommon abdominal tumors that primarily affect children. They occur at an estimated rate of 0.5-1 per 100,000 to 250,000 hospital admissions [1]. These cysts develop within the mesentery, a tissue fold that anchors and supports the small intestine in the abdomen. While they can occur anywhere along the mesentery, the ileum is the most frequent location [2].

Mesenteric cysts can vary greatly in size, ranging from small to quite large, as illustrated in our case study. These cysts can cause various symptoms, including abdominal pain, a palpable abdominal mass, constipation, and other non-specific abdominal complaints. They may also be discovered incidentally during imaging for other reasons.

Fortunately, complications from mesenteric cysts are rare. Abdominal ultrasound or computed tomography (CT) scans are highly effective in diagnosing these cysts, allowing for definitive treatment through complete surgical resection.

We report three rare cases of a mesenteric cyst and review the relevant literature to enhance understanding of its morphology and facilitate early diagnosis and treatment. The work has been reported in line with the process criteria [3].

2 Case reports

2.1 Case 1

We report the case of a 7-year-old boy who presented with progressive abdominal enlargement without associated abdominal pain, vomiting, or weight loss. He did not have jaundice or any changes in his urination habits. Upon arrival at the hospital, the child was in good general condition with normal vital signs.

Physical examination revealed a soft, distended abdomen throughout. A palpable mass was found in the left upper quadrant; During examination, the mass was easily mobile laterally and not attached to the abdominal wall. Laboratory tests were normal.

Abdominal ultrasound identified a large, fluid-filled cystic mass that nearly filled the abdomen and extended into the pelvis. A CT scan confirmed the ultrasound findings, demonstrating a large cyst occupying the abdomen without attachment to any solid structures (Fig. 1.A-B).Fig. 1 A: Axial tomography showing a large cystic formation filling a large part of the abdomen with septa within it.

B: Coronal section showing the extension of the cyst formation from the epigastrium to the pelvis.

C: An intraoperative image showing the mesenteric cyst on the mesentery of the transverse colon.

D: An intraoperative image showing the location of the mesenteric cyst in the mesentery of the transverse colon.

Fig. 1

An exploratory laparotomy was performed. This revealed a large, fluid-filled cyst on the mesentery of the transverse colon. The cyst was completely excised without rupture during surgery (Fig. 1.C-D).

2.2 Case 2

An approximately 8-year-old boy came to the hospital with a progressively enlarging abdomen, occasional yellow vomit, frequent epigastric pain, and a 3-month history of constipation. He did not report any changes in urine color. When he arrived, he was in good condition with normal vital signs.

Physical examination showed a soft, swollen abdomen without palpable masses, hepatomegaly, or splenomegaly.

No tenderness during clinical examination of the abdomen.

Laboratory tests were normal.

Abdominal ultrasound revealed fluid filling the entire abdomen, from the epigastrium to the pelvis, with no enlargement of the liver or spleen. A needle aspiration of the fluid bloody fluid, with negative cytology and normal albumin levels.

An abdominal CT scan showed a large, two-component cystic mass compressing the small intestine and not connected to any solid organs. Parts of the mass were located behind the spleen (Fig. 2.A-B). An exploratory laparotomy was performed, revealing a large cyst on the jejunal mesentery, isolated from other abdominal structures. The cyst consisted of two components, which were completely excised after ligation of their blood supply (Fig. 2.C).Fig. 2 A: Axial CT shows a cystic mass in the epigastrium and left hypochondrium, clearly compressing the small intestine.

B: Coronal CT demonstrates two cystic formations: one in the left hypochondrium and another on the right side of the abdomen.

C: Image after removing the cyst intact, revealing two cystic components.

Fig. 2

2.3 Case 3

We are presenting the case of a 12-year-old boy who has been experiencing chronic constipation and daytime urinary incontinence for 5 months. He did not report any vomiting or abdominal pain. On examination at the hospital, he appeared to be in good general condition and his laboratory test results were normal.

During the abdominal examination, a soft and nonanimating mass was felt below the umbilicus A digital rectal examination (DRE) showed a normal anal sphincter and no palpable masses within the rectum.

An abdominal ultrasound revealed a cystic formation in the pelvis that was compressing the bladder and rectum. A laparotomy was performed through an incision below the umbilicus, and during surgery, a cystic formation in the pelvis at the level of the sigmoid colon mesentery was found and completely removed (Fig. 3.A).Fig. 3 A: Mesentery of the sigmoid colon. The green arrow points to the umbilicus and the blue arrow points to the mesentery of the sigmoid colon. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Fig. 3

Histological analysis of all three cases, including this one, confirmed the diagnosis of a mesenteric cyst (Fig. 4.A-C).Fig. 4 A: The cyst wall is lined primarily by granulation tissue and, in some areas, by flattened or cuboidal cells.

B: The cyst wall is backed by macrophages containing hemosiderin and clusters of chronic inflammatory cells (H&E).

C: Area of infarction showing ischemic necrosis, fibrin deposits, and siderophages.

Fig. 4

3 Discussion

Mesenteric cysts are rare, non-cancerous growths that mainly develop in the abdomen of children [1]. Some studies suggest a higher occurrence in Caucasians over 10 years old, but these cysts can affect individuals of any age or race. They originate within the mesentery, a tissue fold that supports and anchors the small intestine. These cysts can develop anywhere along the mesentery, from the duodenum to the rectum. However, they most commonly occur near the ileum, followed by the transverse colon and the space behind the abdominal lining [3].

Mesenteric cysts can vary in size and location within the abdomen. They can be single or have multiple compartments and contain fluid that is either serous or hemorrhagic [4]. In some cases, the cyst may be multilocular and contain hemorrhagic fluid.

The exact cause of mesenteric cysts remains unknown, with several competing theories proposed, including ectopic tissue, occult trauma, lymph node degeneration, and abnormalities in the lymphatic system [5,6]. However, the most widely accepted theory suggests that mesenteric cysts arise from the benign growth of misplaced lymphatic vessels within the mesentery, which become isolated pockets within the main lymphatic system [7].

Mesenteric cysts can present with various clinical symptoms. The most common symptom is abdominal pain, sometimes accompanied by nausea, vomiting, or constipation. Up to 60 % of patients may have a palpable abdominal mass that they can feel [8].

Potential complications associated with mesenteric cysts include intestinal volvulus, obstruction, and rupture with fluid leakage.

Diagnosing mesenteric cysts can be challenging due to their similarity to other conditions, such as intestinal duplication cysts, ascites, abdominal lymphangiomas, and cysts of the gallbladder or kidney [9,10].

Ultrasound is a valuable diagnostic tool for evaluating cystic lesions in the abdomen. It helps distinguish between solid and fluid-filled masses and provides information about the cyst's characteristics.

Computed tomography (CT) scans can also create detailed images of the cyst, revealing its precise location and relationship to surrounding organs. Additionally, CT scans can confirm the cystic nature of the lesion and help rule out other possibilities.

Surgical excision is the preferred treatment for mesenteric cysts, especially for large or symptomatic ones. In some cases, observation may be an option for small, asymptomatic cysts, particularly when surgery poses a high risk. Draining the fluid with a needle might be another alternative for cysts containing clear fluid.

Complete surgical excision is the gold standard treatment and aims to prevent not only the high recurrence rate of these cysts but also the inflammation that can occur with partial removal or aspiration [11]. Since recurrence typically happens early [12], long-term follow-up specifically for this purpose may not be very beneficial.

In all the cases presented, the individuals came from rural areas. In these areas, refining of petroleum derivatives is carried out using primitive methods, leading to air and soil pollution. It can be believed that environmental factors significantly affect the development of these tumors, and it can be predicted that these tumors may develop after birth, following the occurrence of some acquired mutations.

4 Conclusion

Mesenteric cysts are significant tumors and a key consideration when diagnosing cystic lesions in the abdomen. In the cases we have observed, environmental factors may play a crucial role in the development of these tumors, highlighting the need to explore preventative measures and ways to avoid infection.

Consent of patient

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Method

The work has been reported in line with the process checklist criteria.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Ethical approval

Ethical approval for this study (Ethical Committee N° NAC 207) was provided by the Ethical Committee NAC of Pediatric University Hospitals, Damascus, SYRIA on 1 July 2024.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Kamar Shaker and khaled Alomar: Conceptualization, resources, who wrote, original drafted, edited, visualized, validated, literature reviewed the manuscript.

Omar Shaker: Supervision, visualization, validation, resources, and review of the manuscript.

Ziad brnbow: Visualization, validation, and review of the manuscript.

Jaber Mahmod: Pediatric Specialist - Professor of Pediatrics at Damascus University- Children's University Hospital.

Husam Dalati: Professor of pediatric surgery, head of pediatrics surgery department in university pediatrics hospital, who performed and supervised the operation.

Guarantor

Khaled Alomar.

Research registration

N/A.

Conflict of interest statement

The authors declare that they have no competing interests.

Availability of data and materials

The datasets generated during and/or analyzed during the current study are not publicly available because the data were obtained from the hospital computer-based in-house system. Data are available from the corresponding author upon reasonable request.
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