Lesser Sac Cystic Lymphangioma: Gastric Store Obstruction

Cystic Lymhangioma of the Lesser Sac in adult presenting with features of Gastric Outlet Obstruction - A Case Report

  • S Suresh Kumar
  • Sri Aurobindo Prasad Das
  • Vikram Kate

Running subject: Lesser sac cystic lymphangioma leading to gastric outlet obstruction

Key Words:

Abdominal cystic Lymphangioma; Omental Bursa; Shop Obstruction

Article type: Circumstance Report

Section (speciality): Surgery- Gastrointestinal Surgery

Abstract: Non- Structured (Case Report)

ABSTRACT:

Background:

Cystic lymphangioma is a paediatric harmless tumour, occurs commonly in brain and neck of the guitar region. Adult Intraabdominal lymphangiomas are uncommon and only few instances of less sac cystic lymphangioma are reported in the literature.

Case display:

We present a case of less sac cystic lymphangioma in a 26 time old woman who presented with features of gastric outlet obstruction. Clinical examination of the abdomen disclosed 10 x 10 cm company, non sensitive, mobile intraabdominal lump in the epigastrium.

An top gastrointestinal endoscopy demonstrated possible exterior compression at the boy of the abdominal. Ultrasound of belly exhibited a multicystic lesion measuring 10. 2 X 8 cm, with inside echoes in a single locule. Contrast enhanced computed tomography of the tummy showed a big multiloculated cystic lesion with hyper-dense content in the minimal sac increasing up to the left lobe of the liver and indenting the stomach, minimal sac, and top border of pancreas.

On surgical exploration, a 10X8 cm multi cystic lesion with clear substance was found in the lesser sac very near the smaller curvature of abdomen. The descending branches of kept gastric which were found coursing through the cyst were ligated and the cyst was excised in Toto. Histopathological study of the excised lesion confirmed top features of cystic lymphangioma showing dilated lymphatic vessels with fibro-fatty tissues ingrained in the endothelial coating.

Conclusion:

Though intraabdominal cystic lymphangiomas are incredibly rare, it should be considered in every atypical circumstances of gastric outlet obstruction. A reasonable knowledge about these harmless lesions will assist in establishing the analysis and medical management.

Key Words:

Abdominal cystic Lymphangioma; Omental Bursa; Shop Obstruction

Background

Lymphagiomas are harmless lesions generally appear because of this of lymphatic system malformation and infrequently reported after injury. 90% of the conditions have emerged within the first 2 yrs of life and symptomatic display in parents is very unusual. [1] Cystic lymphagiomas commonly includes throat and axilla but can occur anywhere in your body. Though Intraabdominal lymphangioma accounts for <1% it is of particular importance as a result of atypical demonstration, difficulty in differentiating from other causes and relatively little knowledge about this uncommon entity among the list of treating doctors. Reported sites of intraabdominal lymphangioma include small bowel mesentery, wide ligament, hepaticoduodenal ligament, and retroperitoneum. [2]. Very few cases of minimal sac lymphangiomas have been reported with various symptomatology [3, 4]. We survey an unusual circumstance of cystic lymphangioma of the lesser sac presented with GOO.

Case presentation

A 26-year old lady shown to medical outpatient section with problems of early satiety, vomiting few time after food intake and hazy fullness of top abdominal. She also experienced features of dyspepsia for days gone by twelve months. She had developed pain and had a feeling of any mobile lump in top of the abdomen for the past one month. There was no pancreatitis episode before. Standard physical examination was unremarkable. Clinical study of the abdomen unveiled 10 x 10 cm lump in the epigastrium which was firm in reliability. The lump was non tender, widely mobile and intra-abdominal.

Investigations

The haemogram and biochemical profiles were within normal limitations. An upper gastrointestinal endoscopy was done which showed normal mucosa of abdominal with possible exterior compression at the guy of the abdominal. Ultrasound of belly was suggestive of an multicystic lesion measuring 10 X 8 cm, with inside echoes in one locule, present superior to pancreas next to the remaining lobe of the liver organ. Rest of abdomen was unremarkable.

Contrast increased computed tomography of the tummy showed a big multiloculated cystic lesion calculating 10. 2 X 8 cm with hyper thick content in some loculi in the minimal sac extending up to the left lobe of the liver organ and indenting the tummy, lesser sac, and top border of pancreas with a few branches of still left gastric vessels coursing through it. (Figure: 1) Correlating the medical, USG and CECT tummy findings a identification of possible lymphangioma was made and the individual was organized for exploratory laparotomy as the symptoms were persisting.

Surgical management

On surgical exploration, a 10X8 cm multi cystic lesion with clear fluid was within the smaller sac very near the less curvature of abdominal. (Figure: 2) The descending branches of still left gastric which were found coursing through the cyst were ligated and the cyst was excised in Toto. (Figure: 3) A drain was located in smaller sac and belly was finished in tiers.

Outcome and follow- up

Postoperative course was uneventful. The drain was removed on the 3nd postoperative day and the patient was discharged on seventh post operative day. Histopathological study of the excised lesion exhibited features of cystic lymphangioma exhibiting dilated lymphatic vessels with fibro-fatty tissue ingrained in the endothelial lining. (Figure: 4)

Patient was followed up at one month, six months, one year and two year after surgery. On each visit, clinical assessment and USG was done which revealed no evidence of recurrence. The lady is presently on regular follow-up for past 2 years with no data recurrence till date.

Discussion

Intra-abdominal cystic lymphangiomas are unusual harmless tumours that can require the mesentery, omentum, intestines, spleen, pelvis, groin, and retroperitoneum [5, 6]. We'd a case of cystic lymphangioma in the reduced sac which is very uncommon. Cystic lymphangiomas are considered to result from malformed or malpositioned lymphatic structure. Factors such as stomach injury, inflammatory process, lymphatic blockage due to rays therapy or surgery may lead to secondary creation of such tumors. Our patient didn't have any of the pointed out inciting factors; the cause was probably congenital which got manifested overdue in life.

Commonly recognized to present in child years, lymphagiomas sometimes continue to be asymptomatic until late adulthood, and are discovered during analysis of obscure and persistent nonspecific symptoms like anorexia, nausea, throwing up, tiredness, and weight damage, which are extra to mass effect [4]. This is seen in our patient who possessed early on satiety and vomiting after diet probably scheduled to mass impact and acquired a vague sense of mass in the tummy. Other ways of demonstration such as acute abdomen, mimicking serious appendicitis has also been reported [3].

Contrast CT done in our patient revealed multicystic lesion calculating 10. 2 X 8 cm, present more advanced than pancreas, in the smaller sac adjacent to the remaining lobe of the liver. Cystic lymphangioma usually reveals as a large multilocular cystic mass with enhanced surfaces with multiple slim septa containing easy fluid on belly ultrasonography and distinction improved computerized tomography which is very often diagnostic [7].

The differential medical diagnosis includes cystic lesions of, enteric urogenital or mesothelial source. Pancreatic pseudocysts from stress, dermoid cysts or teratomas and cystic degeneration of sound tumours are also to be looked at before making this rare examination.

Management of intra-abdominal cystic tumours will depend on the clinical symptoms, size of the cyst, and the degree of medical suspicion for malignancy. Imaging usually provides useful information for the planning of treatment. Complete removal of the tumour offers a fantastic prognosis and laparoscopic removal of lymphangioma also shown feasible in few records. We therefore made a decision to perform a laparotomy and complete excision of the cyst was done. On the other hand, recurrence has been reported in 10% of patients in whom principal resection was imperfect. [9] When the feeding lymphatics aren't completely ligated, chylous ascites may also occur.

Conclusion:

Though intra-abdominal cystic lymphangiomas are incredibly rare, it ought to be considered in conditions of gastric or biliary obstruction where the cause could not be recognized clearly. Reasonable knowledge about these benign lesions will assist in establishing the analysis during such occasions. Complete medical excision offers the best opportunity for cure and really should be attempted in all the circumstances to avoid recurrence.

Consent

Written prepared consent was from the individual for publication of the Case statement and any accompanying images. A backup of the written consent is designed for review by the Editor of this journal.

Competing pursuits disclosures

The authors haven't any potential or real turmoil of interests

The authors haven't any financial support or ties to disclose

The authors haven't any financial or non financial competing passions to declare

Authors' contributions

Suresh Kumar S, Das S A and Kate V diagnosed and been able the case. Suresh Kumar S, Das S A do the literature search. Suresh Kumar S and Das S A collected the images. Suresh Kumar S and Kate V drafted the manuscript. All creators read and approved the ultimate manuscript.

References

  1. Hanagiri T, Baba M, Shimabukuro T, Hashimoto M, Takemoto H, Inoue A, Sugitani A, Shirakusa T. Lymphangioma in the tiny intestine: Report of any case and review of the Japanese books. Surgery Today 1992; 22: 363-367
  2. Roisman I, Manny J, Domains S, Shiloni E. Intra-abdominal lymphangioma. Br J Surg 1989; 76: 485-489
  3. Benjamin HL Tan, Teegan Lim. Cystic lymphangioma of the lesser sac presenting as severe appendicitis: A case report. Situations J. 2008; 1: 147.
  4. Massoud Baghai-Wadji, Azadeh JalalKamali, ToorajReza Mirshekari. Cystic lymphangioma of the smaller sac. Can J Surg. 2006; 49: 292.
  5. Fernandez Hurtado I, Bregant J, Mulet Ferragut JF, et al. abs cystic lymphangioma. Cir Pediatr. 1998 ; 11: 171-3
  6. Chuang-Wei Chen, Sheng-Der Hsu, Chien-Hua Lin, Ming-Fang Cheng, Jyh-Cherng Yu Cystic lymphangioma of the jejunal mesentery in an adult: A case article. World J Gastroenterol 2005; 11: 5084-5086
  7. Angela D. Levy, Vito Cantisani, Markku Miettinen. Abdominal Lymphangiomas: Imaging Features with Pathologic Correlation. AJR 2004; 182: 1485-1491

8. Kenney B, Smith B, Bensoussan AL. Laparoscopic excision of an cystic lymphangioma. J Laparoendosc Surg. 1996; 6: S99-101.

9. Steyaert H, Guitard J, Moscovici J, Juricic M, Vaysse P, Juskiewenski S: Abdominal cystic lymphangioma in children: benign lesions that can have a proliferative course. J Pediatr Surg 1996, 31:677-680.

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