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 antenatal ultrasonography (US), mesenteric and omental cysts are being diagnosed in utero. [45, 6] No role for treating these cysts in utero is recognized. If cysts are discovered antenatally, intervention during early infancy is indicated to prevent potential complications such as obstruction and intestinal volvulus. [46]
Surgical Therapy
The goal of surgical therapy for mesenteric and omental cysts is complete excision of the mass. [47] Omental cysts can be removed without endangering the adjacent bowel. [11, 6, 25]
Surgical options
The preferred treatment of mesenteric cysts is enucleation, [19, 9, 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. [19, 11, 10, 6, 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. [19] If marsupialization is performed, the cyst lining should be sclerosed with 10% glucose solution, [23] 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. [19]
Laparoscopic management of mesenteric cysts is also being reported. [48, 49, 50, 51, 52] 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. [53] Management of mesenteric cysts by means of US-guided drainage has also reported to be successful. [54]
Preparation for surgery
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.
Operative details
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. [6, 25]
Postoperative Care
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.
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. [55]
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Large mesenteric cyst arising from the small-bowel mesentery.
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Huge omental cyst within the greater omentum.
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Small omental cyst arising on a pedicle from the greater omentum in the region of the transverse colon.
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Multiple mesenteric cysts, some filled with chyle, arising from the jejunal mesentery.
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Huge mesenteric cyst arising from the transverse colon mesentery. Resection was required to remove this cyst.
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Multiple jejunal mesenteric cysts surrounding a loop of jejunum. Intestinal resection was required to remove these cysts.
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Ultrasound image demonstrating a thin-walled mesenteric cyst with an internal septum.
