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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 75-84

Mesenteric cysts revisited: An ever-intriguing issue


1 Department of Surgery, Armed Forces Hospital, Southern Region, Saudi Arabia
2 Department of Pathology, Armed Forces Hospital, Southern Region, Saudi Arabia
3 Department of Radiology, Armed Forces Hospital, Southern Region, Saudi Arabia; Department of Radiology, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Web Publication10-Sep-2018

Correspondence Address:
Dr. M Ezzedien Rabie
Department of Surgery, Armed Forces Hospital Southern Region, Khamis Mushait
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ssj.ssj_78_17

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  Abstract 

Background: Mesenteric cysts continue to intrigue the surgeons and radiologist alike.
Patients and Methods: Our records were reviewed to identify mesenteric cysts, diagnosed in the period from February 2014 to September 2016.
Results: We identified one male and four females, with a median age of 44 years. Abdominal pain was the presenting feature in all patients. ultrasound was done in four cases, where the cyst was missed in one case, and no clue to its nature was given in the remaining three, while computed tomography suspected the diagnosis in four patients and failed in one. Laparoscopic excision was attempted in only one patient, but eventually, all patients underwent open surgical excision. In four patients, the cyst was removed intact, while in the fifth, a minor wall break occurred, resulting in limited spillage of cyst contents. Histopathological examination showed simple mesothelial cyst in three cases, a pseudocyst in the fourth case and a cystic lymphangioma in the fifth. All patients tolerated surgery well, and up to the time of writing this paper, no recurrence was reported.
Conclusion: Mesenteric cysts, with its numerous types, continue to intrigue the concerned physicians. Regardless of the approach, excision of the intact cyst should be the aim, most conveniently by open surgery. Although laparoscopy could be employed, this should be entertained with caution, to avoid cyst rupture or leaving part of the wall behind, thus predisposing to recurrence.

Keywords: Cystic-laparoscopy, mesenteric cyst, lymphangioma


How to cite this article:
Rabie M E, Hummadi A, Al Skaini MS, Shah SA, Shamshad H, Jamil S, Hassan WE, Shah MT. Mesenteric cysts revisited: An ever-intriguing issue. Saudi Surg J 2018;6:75-84

How to cite this URL:
Rabie M E, Hummadi A, Al Skaini MS, Shah SA, Shamshad H, Jamil S, Hassan WE, Shah MT. Mesenteric cysts revisited: An ever-intriguing issue. Saudi Surg J [serial online] 2018 [cited 2018 Sep 22];6:75-84. Available from: http://www.saudisurgj.org/text.asp?2018/6/3/75/240915


  Introduction Top


Mesenteric cyst is a collective morphologic term, that encompasses different pathologies. It was first described at autopsy by Benevenni in 1507,[1] but the credit for its first successful removal goes to Tilaux and Millard in 1880,[2] who also introduced the clinical sign carrying his name, Tilaux sign. When positive, this sign denotes the mobility of the cyst in a transverse plane, perpendicular to the root of the mesentery, but not in a longitudinal one.

Due to its rarity and the different pathological features, it exhibits our full understanding of the condition may be lacking.


  Patients and Methods Top


Our reports were reviewed to identify patients diagnosed with mesenteric cysts, in the period from February 2014 to September 2016. Their demographic data, mode of presentation, radiologic findings and operative procedures, as well as the final histopathologic diagnosis, were extracted.


  Results Top


We identified five patients, one male and four females, with a median age of 44 years. The most common presenting symptom was abdominal pain, which was present in all patients and associated with features of subacute bowel obstruction in one. Patients' demographics and mode of presentations are summarized in [Table 1]. The ability of ultrasound/computed tomography (US/CT) scan to suggest the diagnosis of mesenteric cyst is shown in [Table 2]. The median diameter of the cysts was 9.5 cm and the location and dimensions of the individual cysts are presented in [Table 3]. In the first patient, laparoscopic excision was attempted, but converted to open procedure to avoid rupture of the extremely thin-walled cyst, while the other four patients underwent open surgical excision from the outset. In four patients, the cyst was removed intact, while some spillage due to minor rupture of the cyst wall occurred in the fourth. In four patients, bowel resection was unnecessary, while it was performed along with cyst excision in only one. Histopathological examination showed simple mesothelial cyst in three cases, a pseudocyst in the fourth case and a cystic lymphangioma in the fifth. The surgical procedure and its complications as well as the histopathologic diagnosis are shown in [Table 4]. All patients tolerated surgery well, and up to the time of writing this paper, no recurrence was reported.
Table 1: Patients' demographics and mode of presentation

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Table 2: Suggestion of the diagnosis of mesenteric on ultrasound/computed tomography scan

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Table 3: Cyst location and dimensions on computed tomography scan

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Table 4: Procedure done, its complications, and histopathology of the cyst

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Case summaries

First case

A 52-year-old female, known hypertensive on treatment, referred to our service with US evidence of abdominal cyst. She gave a history of a long-standing upper abdominal pain associated with vomiting, which worsened 2 weeks before presentation. There was no history of previous operations or other comorbidities.

On examination, she looked well with stable vital signs. Her chest and heart examinations were normal and abdominal examination showed vague mild tenderness.

Laboratory investigations showed normal blood picture as well as the liver and renal values.

CT showed a large, well-defined, thin-walled cyst, 72 mm × 68 mm × 50 mm, in the stomach bed, with clear surrounding fat planes and no solid components or postcontrast enhancement. Posteriorly, the cyst compressed the body of the pancreas and anteriorly it indented the gastric antrum and pylorus [Figure 1]. These signs were suggestive of a mesenteric cyst, but other possibilities should be considered.
Figure 1: (a and b) Computed tomography scan showing a cystic structure in the lesser sac, lying posterior to the stomach and abutting the pancreas (C)

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A provisional diagnosis of mesenteric cyst was made and the patient was prepared for laparoscopic exploration. At laparoscopy, the gastrocolic omentum was divided, to reveal a thin-walled translucent cyst in the lesser sac, arising from the transverse mesocolon [Figure 2]. As laparoscopic dissection as well as retrieval of the thin-walled cyst without rupture appeared difficult, conversion to open surgery was performed. With careful dissection, the cyst was enucleated intact [Figure 3] and the resultant rent in the transverse mesocolon was closed. This was followed by closure of the abdomen with suction drain insertion. The cyst was then aspirated at a side table to obtain a clear straw-colored fluid.
Figure 2: A translucent cyst arising within the leaves of the transverse mesocolon (C)

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Figure 3: A thin-walled translucent cyst about 9 cm × 8 cm in diameter

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Postoperatively, the patient convalesced well and was discharged for follow-up, where she appeared in the clinic 10 days later in good shape.

The histopathology report was consistent with benign mesothelial cyst [Figure 4].
Figure 4: Photomicrograph showing a collagenous wall lined by a single layer of epithelium with no atypia or necrosis diagnostic for benign mesothelial cyst. (a: H and E ×10, b: H and E ×40, c: CKAE1/3, ×10)

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Second case

A 29-year-old female, presented with abdominal pain of 4 months' duration, with occasional nausea and vomiting. There were no other associated symptoms and her history was unremarkable.

On examination, there was a tinge of pallor, but she looked generally well with stable vital signs. Her chest and heart examinations were normal and abdominal examination showed vague mild tenderness.

Here blood works showed low hemoglobin (9.1 g/dl, reference range 12–16 g/dl) and leukocytic count of 10,000/mm3 (reference range 4000–10.000/mm3). Her urea, creatinine, and electrolytes, as well as her liver functions, were within normal limits.

CT scan showed a well-defined, homogeneous, thin-walled, nonenhancing 125 mm × 105 mm × 95 mm cyst in the right lumbar and iliac regions, displacing the surrounding bowel, features suggestive of a mesenteric cyst [Figure 5].
Figure 5: Computed tomography abdomen showing a large 12.5 cm × 10.5 cm × 9.5 cm cystic structure (C) lying lateral to the colon and displacing it medially. (a: Axial view, b: Coronal view)

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Exploratory laparotomy through a midline incision was performed, where the intact cyst was dissected free from the right mesocolon and excised without bowel resection [Figure 6] and [Figure 7].
Figure 6: The thin-walled cyst after dissecting the covering layers

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Figure 7: A thin translucent cyst, about 14 cm in its greatest dimension

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Histopathology report showed thin, fibrocollagenous cyst wall, lined by single layer of cuboidal epithelium, consistent with benign mesenteric mesothelial cyst, with no evidence of malignancy [Figure 8].
Figure 8: Photomicrograph showing a thin fibrocollagenous wall lined by a single layer of keratin-positive epithelium with no atypia or mitosis, diagnostic of benign mesothelial cyst. (a: H and E ×10, b: H and E ×40, c: CKAE1/3, ×10)

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The postoperative period was uneventful and she was discharged for follow-up. Twelve days later, she appeared in the clinic in good health.

Third case

A 44-year-old, previously healthy female, presented with colicky abdominal pain, frequent vomiting, constipation, and mild distension for 1 week.

On examination, she looked relatively well; her vital signs were normal and systemic examination was unremarkable.

Abdominal examination revealed a soft abdomen with upper abdominal fullness and active bowel sounds.

Laboratory investigations revealed hemoglobin of 12.4 g/dl (reference range 12–16 g/dl), leukocytic count 10.900/mm3 (reference range 4000–10.000/mm3), serum albumin 20 g/l (reference range 34–54 g/l), serum creatinine 108 μmol/l (reference range 30–99 μmol/l), and serum amylase 170 u/l (reference range 40–140 u/l).

CT scan showed a well-defined, thick-walled, marginally calcified, nonenhancing, 6.5 cm × 6.3 cm cyst at the umbilical region, with proximal small bowel dilatation and distal collapse [Figure 9].
Figure 9: A 6 cm × 6.5 cm cystic structure with wall calcification (white arrow) occupying the lower abdomen, with proximal bowel dilatation (red arrow) and distal collapse (yellow arrow). (Axial view A, Coronal view B)

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The patient was prepared for laparotomy and the abdomen was opened through a midline incision. On exploration, there was a globular bosselated lesion attached to an ileal loop, about 60 cm from the ileocaecal junction. Adhesions were also found between the lesion and other bowel loops as well as the abdominal wall, with bowel dilatation proximally. Careful dissection freed the lesion from the neighboring bowel loops and abdominal wall, but it remained inseparable from the ileal loop [Figure 10].
Figure 10: The exteriorized cyst with the attached small bowel loop

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The lesion, along with the attached loop, was excised and the bowel was reanastomosed, followed by closing the abdomen with suction drain.

The postoperative period was uneventful and the patient was discharged in good condition for follow-up in the clinic.

Histopathological examination revealed a benign cyst, with no epithelial lining, consistent with mesenteric pseudocyst [Figure 11].
Figure 11: Photomicrograph showing fibrous wall with calcification and no epithelial lining, diagnostic of pseudocyst. (H and E, ×4)

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Fourth case

A 41-year-old, previously healthy female, presented with intermittent abdominal pain, aggravated by fatty meals, of 6-month duration.

On examination, she looked relatively well, with stable vital signs and her chest and heart examinations were unremarkable.

Abdominal examination revealed a vague upper abdominal mass with no organomegaly or ascites.

Laboratory investigations, including complete blood count, liver, and renal functions, were within normal.

CT scan revealed a large, well-defined, lobulated, unilocular cyst, 12.5 cm × 12.5 cm × 8 cm, in the left hypochondrium and epigastrium, posterior to the stomach and abutting the pancreatic body and tail. There was no calcification or internal septations and the contents were close to water in density with no contrast enhancement [Figure 12]. Although the features were suggestive of a mesenteric cyst, its intimate relation to the pancreas raised the possibility of its pancreatic origin. However, this was excluded by magnetic resonance imaging (MRI).
Figure 12: An 8 cm × 12.5 cm × 12.5 cm cystic mass occupying the upper abdomen, lying below the stomach, in front of the pancreas and liver (white arrow)

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To provide more clues to the nature of the cyst, percutaneous CT-guided aspiration was performed and fluid cytology showed scattered lymphocytes in a degenerate background.

The patient was prepared for exploratory laparotomy, and through a midline incision, the lesser sac was opened, to reveal a lobulated cystic mass, abutting, but separate from, the superior border of the pancreas. The cyst was excised in toto without jeopardizing the vasculature of nearby structures [Figure 13]. Cystic aspirate was sent for biochemical as well as cytological examination and the whole specimen was sent for histological analysis.
Figure 13: A bosselated cystic structure, about 14 cm × 16 cm in diameter, with brownish fluid content

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The postoperative period was uneventful and the patient was discharged in good condition.

Histopathological examination revealed a multiloculated cyst with abundant lymphocytes, consistent with cystic lymphangioma [Figure 14].
Figure 14: Photomicrograph showing a multiloculated cyst, lined by flattened endothelial cells with proteinaceous material. Lymphoid infiltrate is noted inside the wall, diagnostic of cystic lymphangioma (H and E, ×10)

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Fifteen months after discharge, the patient appeared in the clinic with an incisional hernia in the lower part of the incision, with no evidence of cyst recurrence.

Fifth case

A 63-year-old previously healthy male was referred to our service with suspected pancreatic pseudocyst.

His complaint was abdominal pain with epigastric fullness for 3 years, which became severer over the past 3 months.

On examination, he looked well with stable vital signs. His chest and heart examinations were normal and abdominal examination showed vague mild tenderness.

Laboratory investigations showed hemoglobin of 12.2 gm/dl (reference range 14–18 g/dl). Apart from that, other laboratory investigations including liver and renal values were normal.

CT scan showed a large, unilocular, cystic lesion, 13 cm × 11 cm × 8 cm, in the left lumbar region [Figure 15] with a tiny focus of capsular calcification. Due to its mass effect, there was mild dilatation of the left ureter and pelvicalyceal system and the radiological features were suggestive of a mesenteric cyst.
Figure 15: A large unilocular cystic lesion, 13 cm × 11 cm × 8 cm, in the left side of the abdomen (C), with no internal septations or mural nodules (a: Axial view, b: Sagittal view)

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The patient was prepared for exploratory laparotomy, and at the commencement of the procedure, a left ureteric catheter was inserted. The lesser sac was then opened to visualize the cyst which was carefully dissected from the adjacent structure and extracted in toto. During the procedure, minimal spillage of the cyst contents, due to a minor tear of the thin wall occurred. This was followed by closure of the abdomen with suction drain insertion.

Postoperatively, the patient convalesced well and was discharged for follow-up, where he appeared in the clinic 10 days later in good shape.

The histopathologic diagnosis was consistent with a simple mesothelial cyst [Figure 16], [Figure 17], [Figure 18].
Figure 16: High-power micrograph: Mesothelial-lined compressed pink cyst wall (H and E, ×40)

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Figure 17: Immunohistochemistry antibody (Cytokeratin AE1/AE3). ×40 high-power micrograph: Brown staining mesothelium with bluish compressed cyst wall

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Figure 18: Immunohistochemistry antibody (Calretinin). ×40 high-power micrograph: Brown staining mesothelium and bluish compressed cyst wall

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  Discussion Top


Mesenteric cysts can affect people of different ages. In 1986, Kurtz et al. performed a review involving 162 published reports, probably the largest in the literature. They found an incidence of 1/106,400 hospital admissions in patients older than 10 years, with a higher incidence of 1/20,200 in younger patients. These figures are still quoted till now.[3]

The rarity of this condition is demonstrated by the scarcity of cases encountered each year in large hospitals. In a span of 10 years, O'Brien et al. reported only 6 cases,[4] and over 14 years, Tan et al. reported only 16 cases,[5] while in a 3 years' period, Asoglu et al. reported only three cases.[6] In our institution, a tertiary referral hospital, we encountered five cases over a period of 2½ years. This paucity of cases with its varied pathology renders wide experience with this condition hardly possible.

Several classification systems of mesenteric cysts exist. Probably, the most comprehensive and widely used, is that proposed by de Perrot et al. Based on the histological features of the cyst, six different types are present: “(1) cysts of lymphatic origin (simple lymphatic cyst and lymphangioma); (2) cysts of mesothelial origin (simple mesothelial cyst, benign cystic mesothelioma, and malignant cystic mesothelioma); (3) cysts of enteric origin (enteric cyst and enteric duplication cyst); (4) cysts of urogenital origin; (5) mature cystic teratoma (dermoid cysts), and (6) pseudocysts (infectious and traumatic cysts).”[7] Despite being the most comprehensive, it does not encompass all pathologies encountered, and from time to time, rare forms are reported. For example, mucinous mesenteric cyst of the sigmoid mesocolon [8] and mesenteric cysts caused by endometriosis [9] were reported. The categories we encountered here were three benign mesothelial cysts, one pseudocyst and one cystic lymphangioma.

Radiologically, a mesenteric cyst exhibits certain characters. On CT, it appears as a circumscribed cystic mass with no postcontrast enhancement. Depending on the contents, which may be clear fluid, chyle or, rarely, hemorrhagic, the cyst density may vary and fine calcifications along the cyst wall are sometimes seen. The soft density of the cyst renders it easily indentable by the surrounding structures, such as the mesenteric vessels.[10] On MRI, it appears as a multilocular mass, usually hypointense on T1WI with T2 hyperintense fluid contents, with no postcontrast enhancement.[11] However, the radiologic diagnosis is far from certain in many cases due to the existence of mimickers,[12],[13],[14] including among others, loculated ascites, gastrointestinal duplication cysts, pancreatic pseudocyst, cystic pancreatic tumor, and peritoneal inclusion cyst.[15] In this context, although US usually discovers the cyst, further evaluation by CT scan is always necessary. In our patients, US, which was performed in four patients, was notoriously inaccurate, as it missed the cyst in one case and failed to give a clue to its probable nature in the remaining three. However, CT scan suspected the diagnosis in four out of five cases, without confirmation, which was only possible after surgical excision. In this regard and due to the uncertainty of the diagnosis, CT-guided aspiration was carried out in the fourth patient. In addition, the fifth patient was referred to us as a pancreatic pseudocyst. This reflects the confusion which arises when such lesion is encountered.

Although commonly benign, malignant forms have been rarely reported. In their report on 16 cases, Tan et al. found a malignant focus on histological examination of three cysts and a focus of gastrointestinal stromal tumor in a fourth.[5] In addition, serous cystadenocarcinoma of the mesentery [16] and malignant transformation of benign mesenteric cyst were seen.[17] In this context, mucinous cystadenocarcinoma of ovarian origin, attached to the transverse mesocolon and disguising as a mesenteric cyst, has also been reported.[18] In an extremely unusual report, pseudomyxoma peritonei followed the rupture of a hitherto benign mesenteric cyst after its malignant transformation.[19] For this reason, excision of the intact cyst without rupture should be the primary goal. In addition, following excision of the cyst, the thorough histological examination is mandatory to specify its type and more importantly, to exclude the rarely encountered malignant forms. In this series, all cysts were subjected to histological examination and found to be benign.

In accordance with the term pseudocyst elsewhere, a mesenteric cyst is termed pseudocyst when it lacks an epithelial lining,[20],[21] Under this title, two subtypes are included: the inflammatory and the posttraumatic types, which may follow an abdominal inflammatory or traumatic process, respectively.[22] Injury to the lymphatics or encapsulation of a hematoma with subsequent cyst formation, have been suggested as the probable mechanisms for the posttraumatic cases,[22] whereas breakdown of the mesenteric lymph nodes with subsequent entrapment of the inflammatory fluid or lymph within the leaves of the mesentery, may be the explanation for the postinflammatory mesenteric cysts.[23] The third case in our report was a pseudocyst, as no epithelial lining was found on histological examination. As there was no history of previous abdominal trauma, the presence of adhesions to the surroundings bowel loops underlines its probable inflammatory nature.

Three simple mesothelial cysts were found in our series. Cysts of mesothelial origin include simple mesothelial cyst, benign cystic mesothelioma, and malignant cystic mesothelioma.[7] This differentiation depends on the morphologic and histopathologic examination of the excised specimen, which again underscores the importance of total cyst excision and its subsequent histologic examination.

Cysts of lymphatic origin include simple lymphatic cysts and cystic lymphangiomas.[7] Although generally discouraged, we performed aspiration of a mesenteric cyst under CT guidance. Cytological analysis of the aspirate revealed lymphocytes, thus highlighting its lymphatic nature. However, and despite that, there was no radiological evidence of malignancy, we advise against this diagnostic maneuver, as excisional surgery would be the ultimate goal.

The size of the cyst may vary from 4 cm to 36 cm.[3],[5] With this variation in size, the presentation may also vary. When small, a mesenteric cyst may remain asymptomatic, to be discovered incidentally on routine clinical [24] or radiological examination.[25] In symptomatic cases, abdominal pain, nausea, vomiting, and abdominal mass are the most common features,[5],[23] as seen in our patients. Although the majority follow a rather chronic course, some patients may present acutely [23],[26],[27] due to the onset of complications. These complications include infection [26],[28],[29],[30] rupture,[29],[31] hemorrhage [30],[32],[33] torsion,[34] volvulus and bowel obstruction.[23],[35] It is the onset of complications that unveils the presence of the cyst in many cases.[26],[28] In our series, one patient presented with subacute bowel obstruction. In this regard, incidentally discovered cysts should be excised electively whenever possible, to avoid future complications.[23],[33],[35]

Historically, three methods have been employed in the management of mesenteric cysts: aspiration, marsupialization, and surgical excision. Currently, aspiration and marsupialization have almost been abandoned, leaving open surgical excision as the standard of care. During surgery, excision of the cyst without bowel resection is possible in many cases.[22] However, bowel resection may be necessary.[28] In this series, we succeeded to enucleate the cyst without bowel resection in four cases, while bowel resection was necessary in only one.

In the era of minimally invasive surgery, the laparoscopic approach has been nominated to be the new standard of care for managing such cysts.[5],[6],[21],[36],[37],[38] However, there are certain concerns. As mesenteric cysts have a definite, albeit small, incidence of malignancy, and in the presence of potentially or frankly malignant mimickers, the enthusiasm for the laparoscopic approach [6],[37] should be cautiously entertained. Proponents for the laparoscopic approach count on the radiologic features of the cyst,[6],[36] or the cytologic analysis of the cyst aspirate [38] to exclude malignancy, with both being inaccurate in this regard. In addition, aspiration may disseminate cancer cells [18] if the cyst was malignant. Moreover, although it may be possible to avoid cyst rupture during dissection,[37] inadvertent rupture [38] is more likely to happen, predisposing to recurrence if part of the wall is left behind.[17] Even with successful dissection of the intact cyst, retrieval mandates aspiration of its contents [21],[36],[37],[39] with the possible risk of fluid spillage. However, advocates of the laparoscopic approach perform aspiration after placement of the specimen in a retrieval bag.[39] In our series, laparoscopic excision was attempted in the first patient, but conversion to open surgery was timely done, when the extreme thinness of the wall became apparent after dissecting the overlying layers.

Another way of management has been relatively recently reported when Ma et al. performed drainage of a 26-cm mesenteric cyst under US guidance. However, the authors gave no comment on the follow-up result, and additionally, counted only on the radiologic features of the cyst and cytologic analysis of its content to exclude malignancy.[40] In a related scenario, ethyl alcohol was injected into the cavity of a posttraumatic mesenteric cyst after aspiration, to decrease the incidence of recurrence.[41] However, we believe that these methods should be exceptionally employed.


  Conclusion Top


Owing to its rarity, mesenteric cysts continue to intrigue the radiologist, pathologist, and surgeon alike, due to the challenges encountered in their diagnosis and management. Excision of the intact cyst should be the primary goal of treatment. Currently, open surgery is the most convenient approach to achieve this end, although laparoscopic surgery is being increasingly employed. However, caution should be exercised to avoid cyst wall rupture, which may lead to recurrence if part is left behind, or dissemination of malignancy, if the cyst was of the rare malignant variant or a malignant mimicker.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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