Large Gastric Mesenteric Cyst: Case Report and

Literature Review
MOHAMMED HASSAN, M.D./+ NICK DOBRILOVIC, M.D.,* JOEL KORELITZ, M.D.*

the '^Departmoit of Surgery, The Jewish Hospital, Cincinnnti, Ohio; fDepartment of Surgery, Good
Samaritmi Hospital, Cincinnati, Ohio

The case is a 33-year-old white female presenting with a 3-day history of abdominal pain. On
initial examination, she was found to have significant right lower quadrant tenderness. Workup
included computed tomography, which demonstrated a large cystic mass appearing to be of
ovarian origin. The patient required an exploratory laparotomy, at which time she was found lo
have a large cyst involving the lesser curvature of her stomach. The cyst was successfully resected,
and the patient had a rapid postoperative recovery with complete resolution of symptoms. Histopathologic evaluation of the specimen identified a mesenteric cyst. Mesenteric cysts are uncommon; gastric involvement is exceedingly rare. A review of the literature is presented.

CYSTS ARE RARE LESIONS and Were deM

scribed by the Florentine anatomist Antonio
Benivieni during the latter years of the I5tb century.
They may occur anywhere between the duodenum and
rectutn with a frequency of approximately 1 in
105.000 hospitalized patients. C^lassically. though,
they have been de.scribed to involve the stnall bowel
tnesentery. Half of all mesenteric cysts involve the
small bowel. 40 per cent the mesocolon. and 10 per
cent other sites.' They can present with chronic abdominal pain, acute abdomen, or even without pain.
Diagnostic strategies include the use of abdominal
computed totnography (CT) and ultrasonography
(US). Management involves surgical resection of the
cyst and possibly adjaeent bowel.
Case Report
A 33-year-old white female presenled with right lower
quadrant abdominal pain of 3-day duration. She had a past
medical history significant for appendectomy and gastroesophagea! reflux disease. Abdominal exam demonstrated
exquisite tenderness in the right lower quadrant as well as
some distension. Pelvic exam revealed a palpable mass on
the right side.
Laboratory studies revealed multiple Gram-positive organisms in the patient's urine and a slightly elevated CA-

Presented al ihc Antuial ScicntitU' Meeting and Postgraduate

Course Program. Southeastern Surgical Congress. New Orleans.
LA. February 11-15. 2(K)5.
Address correspondence and reprint requests to Mohammed
Ha.ssan, M.D., L7O Amy Engcl. Hattt)n Research II-J. Good Samaritan Hospital, 375 Dixmylh Ave.. Cincinnati, OH 45220.

125 (41 lU/mL). Her p-HCG was negative and other studies
unremarkahle.
Ultrasonography of the abdomen and pelvis demonstrated
a large, .septated. complex, eystie mass measuring 18 em x
14 em visualized within the mid to lower abdomen and
extending well into the pelvis. An abdcmiinal CT sean
(Fig. 1) confirmed US findings demonstrating additional
anatomic detail of septations within the cystic structure and
suggesting the right ovary as the source.
At the time of laparotomy through a low midline incision.
a large blue/blaek-colored eystie structure was identified.
As the suspeeled source, the right ovary was examined first
but found to be normal in appearance. Because the right
ovary was not involved as had been initially suspected, the
midline incision was extended superiorly. This allowed for
exposure of the entire eystie structure measuring approximately 25 cm X 10 cm X 10 cm in si/e. The cyst appeared
entirely filled with tluid and was attached to the inferior
portion of the lesser curvature of the stomach, just proximal
to the pylorus. A 2-cm pedicle was the only structure connecting the cyst to the stomach (Figs. 2 and 3). The pedicle
was splayed out and carefully examined and revealed no
maior blood vessels within the pedicle. The pedicle was
clamped, ligated, and the cyst excised. Postoperatively. the
patient had an uneventful recovery and was discharged 3
days alter surgery.

Discussion

Mesenteric cysts are uncommon, and gastric involvement is exceedingly rare. Some have reported
that mesenteric cysts occur twice as frequently in
women as in men.- whereas others suggest equal incidence.-'"^ The majority of cysts occur in the stiiall
bowel mesentery, and 40 per cent involve the mesocolon. tnost commonly sigmoid.' Bearhs et al. classify

571

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[-HI,

THE AMERICAN SURGEON

Abdominal CT scan

the mesenieric L-ysts into four eliologic groups: embryologic. developmental, traumatic, and degenerative.''''
Mesenteric cy.sts can appear in .single or multiple
numbers. Fluid volume within a mesenteric cyst varies
widely, ranging from a few millihters to 8 L.'-^'^
According to Moynihan. fluid can be serous, chylous.
or bloody.*^ Cysts with seroas contents are characteristic of mesocolon cysts, while chylous cysts tend to
be characteristic of small bowel mesentery. !n the case
presented, involving gastric mesentery, fluid was serous.
Examination of a cyst's inner surface has proved
especially useful for purposes of pathologic classification.'" Histologic classifications include simple
mesenteric cyst, lymphangioma. pseudocyst (nonpancreatic). enteric duplication cyst, enteric cyst, and mesothelial cyst.''
In the case presented, sectioning of the specimen
revealed several encapsulated cystic structures filled
with yellow-tan material with a smooth lining to the

FIG. 2. Cy.st with pedicle.

July 2005

Vol. 71

FIG, 3. Cyst removal.

inner cy.st wall. By histopathologic evaluation, findings were highly suggestive of a simple mesenteric
cyst based on cyst wall composition: loosely structured and moderately inflamed fibrous tissue containing small foci of organizing hemorrhage. No neoplastic process was appreciated. Immunohistochemical
staining for factor VIII and vimentin were negative
(Fig. 4) which are markers for cystic lymphangiomas
and mesothelial cysts, respectively.
Clinically, mesenteric cysts can present with
chronic abdominal pain, acute abdomen, or no symptoms at all. Acute abdomen occurs in one third of the
adult population as opposed to two thirds in the pediatric population.'- Presenting symptoms include pain
(8l7r). palpable mass (58%). nausea and vomiting
(45%). constipalion (27%). and diarrhea (6%).'-^ The
abdominal pain most likely results from traction and
stretching on the root of the mesentery and peritoneum. Acute symptoms are secondary to complications of obstruction, rupture, hemorrhage, or infection.'-7-

Fin, 4,

Hematoxylin and eosin, x2(X).

No. 7

LARGE GASTRIC MESENTERIC CYST

Palpation of an abdominal mass is the most common finding on physical examination. Hypertympanism can often be detected over the area of the cyst. As
the cyst enlarges, chance for misdiagnosis increases as
physical findings begin to resemble those of ascites,
including detection of a positive fluid wave.'"^
Diagnostic tests include small bowel series, intravenous pyelogram radiography (IVP). and barium
enema that rule out cysts of gastrointestinal or genitourinary origin. Abdominal CT. ultrasound, and
magnetic resonance imaging (MRI) are noninvasive
studies able to accurately identify cystic structures.
Ultrasound appears to yield the most information for
the least expense."^^ '^^ '*' Although often performed,
angiography is usually of little additional value. Differential diagnoses include ovarian cyst, pancreatic
pseudocyst within the gastrocolic mesentery, peduncLilated uterine fibroid, and omental cyst.'-''
There are several treatment methods for mesenteric
cysts, Enucleation is the treatment of choice for mesenteric cysts yielding low recurrence. A larger scale
resection of the cyst and adjacent bowel should be
considered if the cyst is close to bowel. Another form
of treatment is marsupialization. which can result in a
chronic drainage sinus. Although the risk of infection
is increased, internal drainage is an option for cysts of
more difficult exposure such as sigmoid mesocolon
cysts. Simple aspiration has been assessed, but the
infection and recurrence rates have been prohibitive.
Finally, the cyst could be partially excised, with cauterization or phenolization of the residual portions of
cyst tissue, which remain near the root of the mesentery.'"'-'"
Mortalities of the late 1940s and 1950s have ranged
from 4 per cent to 60 per cent. With improved technology, the present mortality rate ranges from 0 per
cent to 8 per cent with enucleation and 3 per cent to 15
per cent with excision and resection of adjacent
bowel.- Burnett reported a mortality rate of 4 per cent
with marsupialization, 60 per cent with drainage, 33
per cent with aspiration. 16 per cent with resection,
and 7 per cent with enucleation.'''
The case presented describes a large gastric mesenteric cyst. This is an exceedingly rare finding. The

Hassan et al.

573

patient was successfully treated by complete excision.

She experienced a rapid recovery with complete resolution of symptoms.
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