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ROBERT J. KURTZ, M.D.
TOMAS M. HEIMANN, M.D. JAMES HOLT, M.A.*
A. ROBERT BECK, M.D.
Mesenteric and retroperitoneal cysts are rare intra-abdominal tumors. Ten new patients are presented as well as 152 other cases reported in the English literature. These 162 cases were then analyzed for significant trends. Patients under 10 years of age were significantly different from the older group with respect to a shorter duration of symptoms, a higher number of patients requiring an emergency operation, a lower number of recurrences and the location of the cyst. Patients with retroperitoneal cysts were more likely to have incomplete excision of the cyst and therefore had a higher incidence of recurrence. They also required marsupialization more often. Retroperitoneal cysts should be considered a different entity from mesenteric cysts even though they present clinically in a similar fashion. The outcome of surgical treatment is less satisfactory in patients with retroperitoneal cysts.
From the Department of Surgery and the Department of Biomathematics, * Mount Sinai School of Medicine, City University of New York, New York, New York
to the present. This approach allows the analysis of a large number of cases for trends or other factors that might help the clinician in the diagnosis and treatment of these conditions as well as leading to a better understanding of the problems related to the management of these rare diseases.
'ESENTERIC CYSTS are rare intra-abdominal masses. This entity was first described in 1507 by the Florentine anatomist Benevieni' while performing an autopsy on an 8-year-old boy. It was not until 1842 that Rokitansky2 recorded the first description of a chylous cyst and in 1852 Gairdner3 described the first omental cyst. Finally, in 1880 Tillaux4 performed the first successful operation on a cystic mesenteric tumor. This was followed by Pean,5 who in 1883 described the first marsupialization of a mesenteric tumor. Because mesenteric and retroperitoneal cysts are seen so infrequently there is very little information available on them.6 Most published studies consist of only a few cases. This has led to some false impressions and conclusions regarding these tumors of the abdomen. The rarity of these conditions has also contributed to the fact that the correct preoperative diagnosis is infrequently made.7 For these reasons, the authors have undertaken the review of their own institution's records but have also reviewed all the cases published in the English literature from 1950
Reprint requests: Robert J. Kurtz, M.D., Department of Surgery, Mount Sinai School of Medicine, One Gustave Levy Plaza, New York, NY 10029. Submitted for publication: August 19, 1985.
Incidence The medical records of all patients admitted to the Mount Sinai Hospital from 1950 to 1984 were reviewed. Ten patients with mesenteric or retroperitoneal cysts were identified in this 35-year period. During this time, there were approximately 1,064,000 admissions to the Mount Sinai Hospital, of which approximately 10% were pediatric admissions. The estimated incidence of 10 cases per 1,064,000 (1/106,400) admissions at our institution is similar to the previously reported incidences, which range from eight cases per 820,000 (1/102,500) admissions at the Mayo Clinic8 to three cases per 750,000 (1/250,000) admissions9 at the University of Mississippi Medical Center. The incidence in this study in the pediatric age group (less than 10 years old) is five cases per 101,000 (1/20,200) admissions. This figure is also in agreement with reports from Los Angeles Children's Hospital of three cases per 12,425 (1/4,142) admissions5 and Children's Hospital of Akron with two cases per 68,750 (1/34,375) admissions. '0
Clinical Material Ten patients with mesenteric or retroperitoneal cysts treated at our institution from 1950 until 1984 are reported. The diagnosis was proven in all cases at laparotomy. Five patients were male and five were female. They
6 months with a range of from 12 hours to 12 months. in the large bowel mesentery in 37 (24%). Operative treatment consisted of complete excision of the cyst in six cases (see Fig. * January 1986 FMG. They ranged in size in the eight patients in whom this information is known from four to 36 cm in diameter. which was partially excised at the first operation (see Fig. . while the average age of the patients with mesenteric cysts was 15 years. with a mean of nearly 6. There was one case each requiring resection of the transverse and the sigmoid colon. Abdominal pain was present in 58% of the cases and abdominal distention in 50%. This patient had a retroperitoneal cyst. One of these patients required an emergency operation for acute onset of abdominal pain. The average duration of symptoms before hospitalization was 2. and nine had abdominal pain.5%). Forty-eight per cent of the patients were females. The duration of symptoms ranged from 3 hours to 6 years. 2. A simultaneous intestinal resection was performed in 56 of the 134 patients in whom this information is known. Three of these four patients had retroperitoneal cysts. Of the 60 cases for whom this information is known. Computerized tomograph showing a large retroperitoneal cyst at the level of the kidneys. 1). Five ofthe patients were 10 years old or younger. The cyst was located in the small bowel mesentery in 91 patients (60%). Appearance of a large mesenteric cyst that was completely excised. The correct preoperative diagnosis was made in only three cases.0 to 39. In 11 patients the location was not given more specifically than in the mesentery. The estimated volume of the cysts ranged in these patients from 11 to 5600 cc. One hundred sixty-two patients were found.5 C. Only one patient developed a recurrence of the cyst and required a second operation. 1. The data obtained were analyzed using the computer services of the City University of New York. She is doing well 7 years after marsupialization of the cyst. including the 10 patients being presented. FIG. In three cases a right hemicolectomy was necessary with an ileotransverse anastomosis.Ito KURTZ AND OTHERS Ann. The cyst has been marsupialized and contains air and fluid. and two of these were patients with retroper- Analysis of Published Cases All cases of mesenteric and retroperitoneal cysts reported in the English literature from 1950 until the present were reviewed. Only cases described with sufficiently detailed information were included in this study.3 C with a mean of 37. 45% were operated on as emergencies. ranged in age from 6 months to 68 years with a mean of 22. despite the persistent drainage of fluid. itoneal cysts. Three patients required resection of a portion ofthe small intestine and in all ofthese cases the reconstruction was performed by an end-to-end anastomosis. and in 11 cases the location was not described. In 37 cases a resection of the small intestine was performed. 2). The average age of the patients with the retroperitoneal cysts was 33 years. Student's t-test was used to determine statistical significance for the numerical data and a chi square or Fisher's exact test analysis was employed to compare data grouped into categories. with a range from 1 day to 83 years. Their temperature on admission ranged from 37. and in the retroperitoneum in 23 (14. The mean age was 25 years. None of the cysts was malignant. Eight patients presented with abdominal distention. and in the remaining four the cyst was only partially excised.6 months. The correct preoperative diagnosis was made in 30 of the 122 patients (25%) in whom this information is known. Surg.
and in four (7%) it was retroperitoneal. but usually the diagnosis is made by the exclusion of other diagnoses.001 <0. while there were nine recurrences out of 84 patients (11%) in the older group (p < 0. respectively (p = NS). Ten cysts recurred. There were three deaths (2%).6 months). There was only one recurrence in 55 patients (2%) in the younger group. Discussion There are no pathonomonic signs or symptoms for retroperitoneal or mesenteric cysts. while only nine of the 30 patients (30%) in the older group (p < 0. the incidences of abdominal pain were 49 and 60%.01). the clinical diagnosis of a cyst should be considered."I'3 The clinical history and findings on the physical examination may suggest the possibility of a cyst.2 cm. The cyst was completely excised in 128 patients and partially excised in 15. This difference in distribution was statistically significant (p < 0.01). In 14 patients the cyst was marsupialized. requiring a second operation. Five of these recurrences occurred in the 23 patients (22%) whose cysts were retroperitoneal in location (p < 0. in nine (15%) in the large bowel mesentery.001 <0. TABLE 1.001 <0. There seems to be no obvious reason for this difference. the cyst was located in the small bowel mesentery. . Sixty-three per cent of the patients in the younger group were males. Five patients were found to have malignant cysts.05).001 <0.8 months. when the patient also presents with a long duration of symptoms (6. The statistically significant differences are listed in Table 1. the cyst was located in the small bowel mesentery.06). for the older group. Similarly. A bowel resection was done in 29 of the 51 patients (57%) in the younger group and in 27 of the 83 patients (33%) in the older group (p < 0.01).9 and 39.2. with a mean of 13. while the mesenteric cysts were 2080 and 13. 203 * No. There were 23 patients with retroperitoneal cysts and 139 with mesenteric cysts. The 162 patients were divided into two groups.01).0 cm and 1732 cc. The cyst was marsupialized in 5% ofthe patients in the younger age group and in 15% of the older patients (p = NS). Similarly. Two of the five malignant cysts were in the retroperitoneal group.05 6 (133) 5 (119) 116 (121) 4 (116) <0.00 1 <0. and in 18 (19%) it was retroperitoneal.5 cm. Although these findings are nonspecific. the correct diagnosis should be made in nearly every case. while only 38% were male in the older group (p < 0.00 1 12 (22) marsupialized Number of bowel resections 10 (22) 0 (20) 56 (114) * Total number of patients in whom this observation is known. respectively (p = NS). The correct preoperative diagnosis was made in 11 of48 patients (23%) in the younger group and in 19 of 74 (26%) in the older group (p = NS). The mean ages were 3.'3 Abdominal pain and abdominal distention were each present in more than 50% of the cases. in 47 (51%) of the 92 patients for whom this information is known. respectively (p < 0. Patients below the age of 10 years numbered 64 and those in the older group numbered 98. There were approximately equal numbers of males and females in the study when all the cases were considered. respectively.3 and 2300. respectively. Statistically Significant Differences between the Patients with Retroperitoneal and Mesenteric Cysts Total number of patients Average age (years) Number of emergency operations Number of second operations Number of recurrences Number cysts completely excised Number of cysts 23 40 (23)* 0(5) 9 (23) 5 (21) 139 23 (139) 27 (54) <0. The 162 patients were also divided in two groups based on the location of the cyst. Abdominal distention was present in 61% of the younger group and 47% of the older group (p = NS). The surgical treatment of choice for retroperitoneal. The cysts ranged in diameter from 2 to 36 cm. The correct preoperative diagnosis was made in only 25% of the reported cases. The duration of symptoms was 2. In 45 ofthe 58 patients (78%) who were under the age of 10 for whom this information is known. In the younger group 18 ofthe 29 patients (62%) for whom this information was known were treated as surgical emergencies. The volume and diameter of the retroperitoneal cysts were 2331 cc and 13. The locations of the cysts in the younger group were different from those in the adults. I ABDOMINAL CYSTS III Retroperitoneal Mesentery p The average estimated volume of the cyst was 2114 cc with a range of from 4 to 24840 cc. The cyst was completely excised in 95% ofthe patients in the younger group and 86% in the older group (p = NS). All five of the patients with the malignant cysts were in the older age group (p = 0. while the results for the older group were 13.1 years. Abdominal pain was present in approximately 62% of patients in each group.Vol.01) were so treated. The correct diagnosis was made before operation in about 22% of each group. there was a statistically significant increase in the number of male patients in the younger group. in 28 (30%) in the large bowel mesentery. There were three surgical mortalities in the older group of patients (p = NS). With a high index of suspicion and the use of ultrasonic imaging and computed tomography.001).2 months and 9. The cysts in the younger group had a mean diameter and volume of 13. Abdominal pain was present in 43% of the patients with retroperitoneal cysts and in 51 % of the patients with mesenteric cysts. When the patients were divided into the two groups based on age.
This resulted in a higher resectability rate and a significantly lower recurrence. Judd ES. The diagnosis of mesenteric cysts. . This treatment is less than ideal and results in a continuously draining fistula. the borders of these retroperitoneal cysts are not as well defined. 119:640645. Mesenteric cysts. 2. Review of the literature and report of a case. bd 2 Handbuch der Speciellen Pathologischen Anatomie. Whenever possible. Rehbock DJ.6 If this cannot be accomplished. 41:53-57. There was no difference in the duration of symptoms or presentation of these patients. Cooper FG. however. 7. Chylous cysts of the abdomen. Ann Surg 1936. 7:555. Gairdner WT. Tillaux PJ. and. Partial excision or simple drainage of the cyst usually results in a recurrence. Capresso PR. Arch Gen 1892. Transactions of the Pathological Society of London 1851. 10. Docherty MD. Phillips AK. 14. Mesenteric cysts. Barr WB. 119:838-842. Slocum MA. The incidence of malignant cysts was 3%. 30:1081-96. Vaughn AM. Mesenteric cysts: A review. Vanek VW. Wein: Braumuller and Seidel. there were fewer retroperitoneal cysts in the younger group. Yamashita T. 8. 9. Proc Staff Meet Mayo Clinic 1932. duration of symptoms. recurrences. Am J Gastroenterol 1964. 13. no emergency operations done in the group of statistically older patients with the retroperitoneal cysts. Judd ES. Parsons EO. then the next best alternative would be excision of the cyst with. if necessary. Am J Surg 1958. Handbuch der Pathologischen anatomie. Surg. Also. Beahrs OH. a complete excision should be performed. A remarkable cyst in the omentum. Cyste du mesentere un homme: ablation par la gastromie: quersion. mesenteric and omental cysts. These technical difficulties are the probable explanation for the statistical difference between these two groups with respect to the number of second operations. 97:363-67. von Rokitansky CF. 103:595-604. 3. Hardin WJ. All cancers were found in adults. 108:242246. 23:13-19. Surgery 1948. Steinreich OS. 170:291. rate of marsupialization. or volume of the cyst. Mesenteric and retroperitoneal lymphangioma. The last acceptable choice would be marsupialization of the cyst. diameter. In conclusion. 12. There is a statistically significant correlation between the recurrence of the cyst and location.January 1986 and mesenteric cysts is complete enucleation. Retroperitoneal. Ann Surg 1932. Analysis of the younger patients in this series shows that they have a shorter duration of symptoms and are more likely to present as surgical emergencies. Razkowski HJ. the resection of a portion of the adherent bowel. It is not possible to tell from the reported data whether malignant cysts originate from previously benign cysts or arose de novo. Hardy JD. Crisp NW. Warfield JO. Five of the 10 recurrences occurred in the patients with retroperitoneal cysts. size and location of the malignant cysts was identical to the benign cysts. There is no correlation between age. There were. They are significantly different with respect to complications and recurrences. Arch Surg 1974. Ann Surg 1955. therefore. Arch Surg 1984. 41:463-73.112 KURTZ AND OTHERS Ann. Des kystes du mesentery. These cysts are more likely to require marsupialization. Braquehage J. Mesenteric cysts. a recurrence is much more likely. retroperitoneal cysts and mesenteric cysts should be regarded as separate clinical entities. Furthermore. Retroperitoneal cysts are often incompletely excised and require multiple operations. 11. 1842. 5. Chylous mesenteric cyst. 4. Am J Surg 1938. 96:329- 339. and recurrence. Lees WM. and the number of bowel resections performed. 142:889-894. Revue de Therapeutiques Medico-Chirurgicale Paris 1880: 47:479. Am J Surg 1970. .'5". Retroperitoneal cysts are technically more difficult to excise completely because of their proximity to major blood vessels and other organs. A study of mesenteric cysts. Henry JW. 16. 6. True proliferating cystic lymphangomioma of the mesentery. References 1. 15. Surg Clin North Am 1950. There was only one death reported in patients with retroperitoneal cysts. Although the average size and volume of the cysts are identical for both groups of patients. 3:185 1.
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