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Mesenteric and Omental Cysts

Amulya K Saxena, MD, Attending Pediatric Surgeon, Department of Pediatric Surgery, Medical University of Graz, Austria

Updated: Jan 16, 2008

Introduction

History of the Procedure

In 1907, the Italian anatomist Benevieni first reported a mesenteric cyst following an autopsy on an 8-year-old girl.1 In 1842, von Rokitansky described a chylous mesenteric cyst.2 Gairdner published the first report of an omental cyst in 1852.3 Tillaux performed the first successful surgery for a cystic mass in the mesentery in 1880.4

Frequency

Mesenteric and omental cysts are rare; the incidence is about 1 per 140,000 general hospital admissions and about 1 per 20,000 pediatric hospital admissions.5,6,7 In a study from Egleston Children's Hospital at Emory University from 1965-1994, 14 patients were treated for mesenteric or omental cysts, which represents a prevalence of about 1 case per 11,250 admissions.8 Approximately one third of cases occur in children younger than 15 years.9,10,11 The mean age of children affected is 4.9 years.9,11,12,13,14,15,16 Mesenteric cysts are 4.5 times more common than omental cysts.17

Etiology

As proposed by Gross, mesenteric and omental cysts are thought to represent benign proliferations of ectopic lymphatics that lack communication with the normal lymphatic system.9,18,19 Cysts are thought to arise from lymphatic spaces associated with the embryonic retroperitoneal lymph sac, making them analogous to cystic hygromas, which arise in the neck in association with the jugular lymph sac.20 Another proposed etiology is lymphatic obstruction;21 however, experimental occlusion of lymphatic channels in animals does not produce mesenteric or omental cysts because of the rich collaterals in the lymphatic system, which sheds doubt on this particular theory.6,18,20 Other etiologic theories include (1) failure of the embryonic lymph channels to join the venous system, (2) failure of the leaves of the mesentery to fuse, (3) trauma, (4) neoplasia, and (5) degeneration of lymph nodes.8

Mesenteric cysts can occur anywhere in the mesentery of the gastrointestinal tract from the duodenum to the rectum, and they may extend from the base of the mesentery into the retroperitoneum.8,6 In a series of 162 patients, 60% of mesenteric cysts occurred in the small-bowel mesentery, 24% in the large-bowel mesentery, and 14.5% in the retroperitoneum. They most commonly occur in the ileal mesentery of the small bowel or the sigmoid mesentery of the colon.5 Omental cysts are confined to the lesser or greater omentum.22

Pathophysiology

Mesenteric and omental cysts can be simple or multiple, unilocular or multilocular, and they may contain hemorrhagic, serous, chylous, or infected fluid.8 The fluid is serous in ileal and colonic cysts and is chylous in jejunal cysts.7,11 They can range in size from a few millimeters to 40 cm in diameter. In a series from Egleston Children's Hospital in Atlanta, the mean size was 14.9 X 11.5 X 4.7 cm.8

Presentation

Mesenteric and omental cysts can be discovered as an incidental finding during laparotomy for another condition or they can manifest as an acute life-threatening intra-abdominal catastrophe.22 Children generally present with abdominal distention and few associated symptoms other than vague abdominal pain with or without a palpable mass.21 The mass may be huge, simulating ascites.22 The most common mode of acute presentation in children is that of a small-bowel obstruction, which may be associated with intestinal volvulus or infarction.11,13,15

In the series from Egleston Children's Hospital in Atlanta, 21% of patients were asymptomatic, 71% presented with abdominal distention, 50% with abdominal pain, 50% with vomiting, and 43% with a palpable abdominal mass.8 Approximately 10% of patients with mesenteric and omental cysts present with an acute abdominal emergency.22 These masses can be detected using prenatal ultrasonography and appear as a sonolucent mass. The prenatal differential diagnosis includes dilated bowel (eg, intestinal atresia), dilated stomach (eg, pyloric atresia), gastrointestinal duplication, hydronephrosis, ovarian cyst, and cystic teratoma.

In a series of 82 children who underwent surgery for various causes of intestinal volvulus, mesenteric cysts were the underlying etiology in 3.65% of cases.23 A very unusual presentation of a mesenteric cyst is that of an irreducible inguinal hernia.1 The differential diagnosis includes intestinal duplication cyst; ovarian, choledochal, pancreatic, splenic, or renal cysts; hydronephrosis; cystic teratoma; hydatid cyst; and ascites.22

Indications

In children, the most common indication for surgical intervention is the presence of an abdominal mass with or without signs of intestinal obstruction. Various complications have been associated with mesenteric and omental cysts, including intestinal obstruction (most common), volvulus, hemorrhage into the cyst, infection, rupture, cystic torsion, and obstruction of the urinary and biliary tract.22 Malignant transformation of mesenteric cysts has occurred in adults,5 but malignant mesenteric and omental cysts have not been reported in children.22

Relevant Anatomy

Mesenteric cysts most commonly occur in the small-bowel mesentery on the mesenteric side of the bowel. Mesenteric cysts can often be shelled out from between the leaves of the mesentery while taking care to avoid damage to the mesenteric vessels,21 or they may require concomitant bowel resection in order to ensure that the blood supply to the bowel is not compromised.22 In a series from Egleston Children's Hospital in Atlanta, one third of patients required intestinal resection along with resection of the mesenteric cysts.8

Omental cysts can always be removed without resecting the adjacent transverse colon or the stomach.21,22

Workup

Laboratory Studies

  • No specific laboratory studies aid in the diagnosis of mesenteric and omental cysts.

Imaging Studies

  • Radiography
    • Plain abdominal radiography may reveal a gasless, homogeneous, water-dense mass that displaces bowel loops laterally or anteriorly in the presence of a mesenteric cyst or posteriorly in the presence of an omental cyst.8,21
    • Fine calcifications can sometimes be observed within the cyst wall.13,24,25
  • Ultrasonography
    • The imaging modality of choice is abdominal ultrasonography.11,15,16,25 Ultrasonography reveals fluid-filled cystic structures, commonly with thin internal septi and sometimes with internal echoes from debris, hemorrhage, or infection.9,16,25 However, these can be confused with large ovarian cysts in the fetus and newborn.
    • Enteric duplication cysts, on the other hand, are thick-walled structures that share a common muscular wall with the adjacent bowel. They also have a clearly visible mucosal lining on ultrasonography.22
  • CT scanning
    • Abdominal CT scanning adds minimal additional information, although it can reveal that the cyst is not arising from another organ such as the kidney, pancreas, or ovary.7
    • Radionuclide scanning of the biliary tract excludes choledochal cysts from diagnostic consideration.22

Other Tests

  • No other tests are necessary.

Diagnostic Procedures

  • No further diagnostic procedures are necessary.

Histologic Findings

Cystic lymphangiomas are sometimes differentiated from mesenteric and omental cysts.6,9,15 Cystic lymphangiomas have an endothelial cell lining, foam cells, and thin walls that contain lymphatic spaces, lymphoid tissue, and smooth muscle. Mesenteric cysts lack smooth muscle and lymphatic spaces, and the cells lining the cysts are cuboidal or columnar in nature.6 Lymphangiomas are more diffuse and occur in the mesentery or retroperitoneum, and patients may present earlier in life than those with mesenteric or omental cysts.6,15 In a series of 191 patients with lymphangioma, 4.7% of patients presented with lymphangioma in the mesentery.26

For the purposes of this discussion, a mesenteric cyst is defined as any cyst that is located in the mesentery and may or may not extend into the retroperitoneum; a mesenteric cyst also has a recognizable lining of endothelial or mesothelial cells. An omental cyst has the same histologic characteristics but is confined to the greater or lesser omentum.22

Treatment

Medical Therapy

No medical therapy is available.

Surgical Therapy

The goal of surgical therapy is complete excision of the mass. Omental cysts can be removed without endangering the adjacent bowel.9,13,14 The preferred treatment of mesenteric cysts is enucleation,5,7,14,21 although intestinal resection is frequently required to ensure that the remaining bowel is viable. Bowel resection may be required in 50-60% of children with mesenteric cysts, whereas resection is necessary in about one third of adults.5,9,11,13,15 Any resulting mesenteric defect must be closed to prevent an internal hernia.

If enucleation or resection is not possible because of the size of the cyst or because of its location deep within the root of the mesentery, the third option is partial excision with marsupialization of the remaining cyst into the abdominal cavity.22 Approximately 10% of patients require this form of therapy.5 If marsupialization is performed, the cyst lining should be sclerosed with 10% glucose solution,10 electrocautery, or tincture of iodine to minimize recurrence. Partial excision alone with or without drainage is not indicated because of the high recurrence rate associated with these procedures.5

Preoperative Details

The patient should undergo standard preoperative preparation for a major laparotomy. This includes inserting a nasogastric tube, initiating intravenous fluid therapy, and beginning prophylactic antibiotics preoperatively in the event that a bowel resection is required. If time allows, the patient should undergo mechanical bowel preparation for the same reason.

Intraoperative Details

Mesenteric cysts can be shelled out from between the leaves of the mesentery using fine electrocautery, taking care not to damage the blood vessels to the adjacent intestine. If this is not feasible, a standard bowel resection with a primary end-to-end anastomosis is performed. Intestinal diversion is not necessary unless gross peritonitis from a long-standing bowel perforation is present.

Omental cysts are excised by removing the involved portion of the mesentery up to the transverse colon if necessary. In the vast majority of cases, removing the adjacent colon or stomach is not necessary.13,14

Postoperative Details

The patient is maintained nothing by mouth (NPO) with intravenous fluids and nasogastric suction until bowel function returns. Prophylactic antibiotics can be discontinued after 1-2 postoperative doses. If the patient is not able to eat by the third postoperative day, parenteral nutrition should be provided.

Follow-up

Routine postoperative follow-up care 2-3 weeks after discharge from the hospital is indicated. The child's family should be warned about the potential for intestinal obstruction from adhesions. If the patient was treated with marsupialization, closer follow-up for possible recurrence should be instituted. Otherwise, no long-term follow-up for surgical problems is necessary.

Complications

Complications from surgery, either early or late, are uncommon.8 Complications associated with mesenteric and omental cysts are discussed above.

Outcome and Prognosis

Overall results in pediatric patients are favorable. The recurrence rate ranges from 0-13.6%,9,11,14,15,17 averaging about 6.1% in a series of 162 adults and children.5 Most recurrences occur in patients with retroperitoneal cysts or those who had only a partial excision.5,14,15,17 Essentially, no mortality is associated with mesenteric or omental cysts in children; only one pediatric death has been reported since 1950.27 In a series from Egleston Children's Hospital in Atlanta, no major postoperative complications, recurrences, or deaths occurred.8

Future and Controversies

With the widespread use of prenatal ultrasonography, mesenteric and omental cysts are being diagnosed in utero.22 No role for treating these cysts in utero is recognized. If cysts are discovered prenatally, intervention during early infancy is indicated to prevent potential complications such as obstruction and intestinal volvulus.

Multimedia

Large mesenteric cyst arising from the small-bowe...

Media file 1: Large mesenteric cyst arising from the small-bowel mesentery.

Huge omental cyst within the greater omentum.

Media file 2: Huge omental cyst within the greater omentum.

Small omental cyst arising on a pedicle from the ...

Media file 3: Small omental cyst arising on a pedicle from the greater omentum in the region of the transverse colon.

Multiple mesenteric cysts, some filled with chyle...

Media file 4: Multiple mesenteric cysts, some filled with chyle, arising from the jejunal mesentery.

Huge mesenteric cyst arising from the transverse ...

Media file 5: Huge mesenteric cyst arising from the transverse colon mesentery. Resection was required to remove this cyst.

Multiple jejunal mesenteric cysts surrounding a l...

Media file 6: Multiple jejunal mesenteric cysts surrounding a loop of jejunum. Intestinal resection was required to remove these cysts.

Ultrasound image demonstrating a thin-walled mese...

Media file 7: Ultrasound image demonstrating a thin-walled mesenteric cyst with an internal septum.

References

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  2. von Rokitansky CF. Handbuch der pathologischen anatomie, bd2 Handbuch der Speciellen Pathologischen Anatomie. Wein: Braumuller & Seidel; 1842.

  3. Gairdner WT. A remarkable cyst in the omentum. Trans Path Soc Lond. 1852;3:1851.

  4. Tillaux PJ. Cyste du mesentere un homme: ablation par la gastromie: quersion. Revue de Therapeutiques Medico-Chirurgieale Paris. 1880;47:479.

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Keywords

mesenteric cysts, omental cysts, cyst, abdominal cyst, intra-abdominal cyst, abdominal mass, chylous mesenteric cyst, cystic hygromas, abdominal distention, ascites, intestinal volvulus, dilated bowel, intestinal atresia, dilated stomach, pyloric atresia, gastrointestinal duplications, hydronephrosis, ovarian cyst, cystic teratoma, inguinal hernia, intestinal duplication cyst

Contributor Information and Disclosures

Author

Amulya K Saxena, MD, Attending Pediatric Surgeon, Department of Pediatric Surgery, Medical University of Graz, Austria
Amulya K Saxena, MD is a member of the following medical societies: European Pediatric Surgeons Association, German Society of Pediatric Surgery, German Society of Surgery, and International Pediatric Endosurgery Group
Disclosure: Nothing to disclose.

Medical Editor

Kurt D Newman, MD, Vice Chairman, Department of Pediatric Surgery, Children's National Medical Center; Professor, Departments of Surgery and Pediatrics, George Washington University School of Medicine
Kurt D Newman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Deborah F Billmire, MD, Associate Professor, Department of Surgery, Indiana University Medical Center
Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Pediatric Oncology Group, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP, Professor of Surgery and Pediatrics, Temple University School of Medicine; Chief, Section of Pediatric Surgery, Temple University Children's Medical Center
Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Children's Oncology Group, Eastern Association for the Surgery of Trauma, International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, and Southwestern Surgical Congress
Disclosure: Nothing to disclose.

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