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Mesenteric and Omental Cysts in Children Treatment & Management

  • Author: Amulya K Saxena, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
 
Updated: Apr 22, 2016
 

Approach Considerations

No medical therapy is available. In children with mesenteric or omental cysts, the most common indication for surgical intervention is the presence of an abdominal mass with or without signs of intestinal obstruction.

With the widespread use of prenatal ultrasonography, mesenteric and omental cysts are being diagnosed in utero.[6] 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.

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Surgical Therapy

The goal of surgical therapy for mesenteric and omental cysts is complete excision of the mass. Omental cysts can be removed without endangering the adjacent bowel.[10, 24, 25] The preferred treatment of mesenteric cysts is enucleation,[18, 8, 25, 5] though 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.[18, 10, 9, 24, 26] 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.[6] Approximately 10% of patients require this form of therapy.[18] If marsupialization is performed, the cyst lining should be sclerosed with 10% glucose solution,[22] 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.[18]

Laparoscopic management of mesenteric cysts is also being reported.[41, 42, 43] If necessary, depending on the expertise in laparoscopic surgery in children, laparoscopy could be used to localize the cysts, and resection could be performed through a small laparotomy or via an extended umbilical incision. Furthermore, reports suggest successful drainage and marsupialization of mesenterial cysts, which avoids enterotomy.[44] Management of mesenteric cysts by ultrasound-guided drainage has also reported to be successful.[45]

Procedural details

The patient should undergo standard preoperative preparation for a major laparotomy. This includes inserting a nasogastric tube, initiating intravenous (IV) 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.

Mesenteric cysts can be shelled out from between the leaves of the mesentery with fine electrocauterization, with care taken 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.[24, 25]

After operative treatment, the patient is maintained on NPO (nil per os) status with IV fluids and nasogastric suction until bowel function returns. Prophylactic antibiotics can be discontinued after one or two postoperative doses. If the patient is not able to eat by postoperative day 3, parenteral nutrition should be provided.

Complications from surgery, either early or late, are uncommon.[7]

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Long-Term Monitoring

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, long-term results for simple excision are favorable.[46]

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Contributor Information and Disclosures
Author

Amulya K Saxena, MD, PhD Consultant Pediatric Surgeon, Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Healthcare NHS Fdn Trust, Imperial College London, UK

Amulya K Saxena, MD, PhD is a member of the following medical societies: International Pediatric Endosurgery Group, British Association of Paediatric Surgeons, European Paediatric Surgeons' Association, German Society of Surgery, German Association of Pediatric Surgeons, Tissue Engineering and Regenerative Medicine International Society, Austrian Society for Pediatric and Adolescent Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP Professor of Surgery, Cooper Medical School of Rowan University; Chief, Division of Pediatric Surgery, Cooper University Hospital

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, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Southwestern Surgical Congress, Eastern Association for the Surgery of Trauma, Children's Oncology Group, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Additional Contributors

Kurt D Newman, MD 

Kurt D Newman, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Society of Surgical Oncology

Disclosure: Nothing to disclose.

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Large mesenteric cyst arising from the small-bowel mesentery.
Huge omental cyst within the greater omentum.
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, arising from the jejunal mesentery.
Huge mesenteric cyst arising from the transverse colon mesentery. Resection was required to remove this cyst.
Multiple jejunal mesenteric cysts surrounding a loop of jejunum. Intestinal resection was required to remove these cysts.
Ultrasound image demonstrating a thin-walled mesenteric cyst with an internal septum.
 
 
 
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