Abdominal lymphangiomas in children: interest of the laparoscopic approach

Toddler with giant omental cyst, profound anemia, and shock: case report and review of the literature

Giant greater omental cysts with associated massive hemorrhage are rare. We encountered a 16-month-old boy with a four-day history of acute abdominal pain, distension, and paleness. Physical examination revealed a blood pressure of 74/27 mmHg. No well-defined masses were observed on abdominal palpation. The hemoglobin level on admission was 24 g/L. After initial resuscitation and blood transfusion, a computed tomography (CT) scan was performed, revealing a giant cystic mass with an intracystic hemorrhage. The diagnosis was confirmed via exploratory laparotomy, and the cyst, with the attached partial omentum was removed. Pathological findings revealed a simple cyst originating from the greater omentum. The patient recovered uneventfully and remained well during the two-year follow-up period. We reviewed the literature published over the last 27 years on cases of omental cysts to evaluate demographic characteristics, clinical presentations, complications, diagnostic tool options, and surgical approaches.

Clinical and radiological characteristics and considerations in the surgical management of a giant omental cyst: a case report

Background

Omental cysts are rare benign tumours. They occur due to malformation of the mesenteric lymphatic spaces which fail to communicate with the systemic lymphatic drainage. Diagnosis is challenging due to its rarity, indolent clinical progress, and non-specific clinical presentation in a normally well child. This case highlights the important clinical and radiological features of a giant omental cyst and a different perspective of management using combined ultrasound-guided percutaneous drainage with laparoscopic surgical excision.

Case presentation

We report a case of a giant omental cyst in a 3-year-old boy who presented with gradual abdominal distension over 3 months. He was initially treated for constipation. He had no abdominal pain or history of trauma. There was a non-shifting dullness and fluid thrill on abdominal examination. Persistent distention led to further imaging with ultrasound and computer tomography scan which revealed a giant cystic lesion occupying the whole abdominal cavity. A diagnosis of a giant omental cyst was made. The initial ultrasound-guided percutaneous drainage with gradual decompression of the cyst facilitated a safe and complete laparoscopic excision of the cyst. He recovered well after surgery.

Conclusion

Attention to important clinical and radiological features helps in the diagnosis of a giant omental cyst. Management with combined ultrasound-guided pigtail drainage and laparoscopic excision is safe and feasible.

Robotic-assisted laparoscopic management of mesenteric cysts in children

BACKGROUND

Mesenteric cysts (MCs) are rare intra-abdominal masses in children, and laparoscopic complete cyst resection is still difficult. This study reviewed our experience in diagnosing and managing MCs at our center, focusing on the clinical characteristics of MCs and the effectiveness of robotic-assisted laparoscopic surgery.

METHODS

We conducted a retrospective analysis of the records of all patients diagnosed with MCs and managed with robotic-assisted laparoscopic surgery at our center between February 2021 and August 2022. We analyzed demographic characteristics, clinical manifestations, preoperative imaging data, surgical methods, postoperative complications, and final outcomes.

RESULTS

Totally, 12 consecutive patients with a mean age of 5.81 ± 3.02 years were admitted. The most common symptom was abdominal pain (58.33%). Eight patients were associated with cyst complications, including five cases of infection, two cases of volvulus, and one case of hemorrhage. The mean size of cysts was 8.39 ± 5.91 cm. The cysts were located in ileal mesentery in eight cases, lesser curvature of the stomach in two cases, and colon mesentery in two cases. Solely cyst excision was performed in eight cases, and bowel en bloc resection of the cyst in four cases. Robotic-assisted laparoscopic surgery was performed successfully in all patients, without conversion. The mean operation time was 106.17 ± 33.74 min. Pathological results reported lymphangioma or lymphatic malformation in all patients. Two cases of chylous leakage were treated conservatively, and no complications of peritoneal infection, anastomotic leakage, and recurrence were observed.

CONCLUSIONS

Mesenteric cysts should be removed promptly once the diagnosis is confirmed to avoid cyst complications. For uncomplicated mesenteric cysts, laparoscopic cyst excision, or cyst excision with bowel resection can be effectively performed in children, especially under the robot system.

The Effectiveness of Abdominal Lymphangioma Laparoscopic Removal in Children: A Single Center Experience

Background: Lymphangiomas represent 5% of all benign pediatric tumors. Abdominal lymphangiomas (ALs) are extremely rare. Therapy includes surgery, sclerotherapy, or pharmacological treatment. Laparoscopic resection (LR) has been already described, but mainly as case reports. The aim of this study is to present our series of ALs LR. Materials and Methods: From 2007 to 2020, 10 cases of ALs were electively treated by LR. Patients' age ranged from 4 months to 14 years. Preoperative diagnosis was achieved by ultrasonography and magnetic resonance images. In all cases LR was performed with four trocars: a 10 mm transumbilical trocar for camera and extraction and three 3-5 mm operative trocars. Results: Lymphangiomas arise from mesocolon in 5 giant cases, ileal mesentery in 3 and right adrenal gland in 2. LR was achieved without intraoperative complications and need of conversion in all cases. Two giant cases needed a percutaneous puncture under laparoscopic view to gain working space. A minimal ileal resection by video-assisted procedure was carried out in 2. Median hospital length was 4 days; no recurrence of disease at serial ultrasound examinations was seen at median follow-up of 5.9 years. Discussion: Several approaches have been proposed for AL treatment. The main challenges are the huge dimensions, the difficulty to achieve a complete resection, and the risk of recurrence. In this series, elective LR of ALs resulted as feasible and effective, and we consider it the standard surgical therapy.

Chylous content might determine the optimal surgical approach for mesenteric lymphatic malformations in childhood

BACKGROUND

Mesenteric lymphatic malformations (LMs) represent rare congenital anomalies that can include chylous or nonchylous content. The pathologic mechanisms explaining this phenomenon are poorly understood and not yet described. Furthermore, the current management approach does not consider the contents of the mesenteric LMs. In the present study, we have defined the relationship between the lymphatic mesenteric cyst content and the histologic evidence of LMs within the bowel wall.

METHODS

We retrospectively investigated all patients with mesenteric LMs treated surgically at our department from 1999 to 2018.

RESULTS

A total of 11 patients (6 girls and 5 boys) were included in our analysis. Seven patients had presented with LMs located in the jejunal mesentery, three in the ileocecal region, and only one in the mesocolon transversum and omentum. Of the 11 children, 7 had had LMs with nonchylous content and 4 had presented with chylous content LMs. Intestinal resection was performed in all 4 patients with chylous content LMs and 4 patients with nonchylous content LMs. Histopathologic evaluation of the surgical specimens determined that only the LMs with chylous content displayed malformed lymphatic channels throughout the bowel wall. The resected small bowel of four patients with nonchylous content showed no LM extension throughout the intestinal wall.

CONCLUSIONS

LMs with chylous content seem to develop from malformed lymphatic channels within the bowel wall. In such cases, segmental intestinal resection is mandatory. In contrast, mesenteric LMs with nonchylous content can potentially be treated without bowel resection if the blood supply can be preserved. This finding is, to the best of our knowledge, reported in the present study for the first time.

Laparoscopic-assisted excision of a huge polycystic omental lymphangioma in a 3 year old patient presenting with acute abdomen: case report and review

Lymphangioma is a rare benign neoplasm affecting mainly children. In this report we present a complicated case of polycystic omental lymphangioma in a 3 year old female presenting with acute abdomen. The patient underwent a laparoscopic-assisted excision of the lesion and had an excellent postoperative course. We discuss the effectiveness and advantages of this laparoscopic surgical approach in children and elaborate on the current literature.

Large intra-abdominal cystic lymphangioma managed by laparoscopic partial excision and modified drain with no need for open resection

A 57-year-old woman was referred to the emergency department after a CT scan ordered by her general practitioner to investigate her abdominal pain showed a large cystic mass. The simple cystic appearance with its location in the small bowel mesentery prompted a provisional diagnosis of cystic lymphangioma. However, concerns regarding the size, location and local involvement of neurovascular structures presented a technical surgical challenge. Here we present a case of minimally invasive laparoscopic drainage using a modified Jackson-Pratt drain that avoided a laparotomy and open resection.

Complete Resolution of Retroperitoneal Lymphangioma with a Single Trial of OK-432 in an Infant

Retroperitoneal lymphangioma is extremely rare. Although these neoplasms are benign, they can grow progressively with subsequent compression and infiltration of the adjacent structures. Surgical excision is demanding when the lesion surrounds vital structures and it is generally fraught with a high recurrence and morbidity rate. We report the case of a huge retroperitoneal lymphangioma in a newborn treated successfully with intracystic injection of OK-432.

Laparoscopic Excision of Large Intra-Abdominal Cysts in Children: Needle Hitch Technique

Laparoscopic surgery has both diagnostic and therapeutic advantages in the management of intra-abdominal cysts in children. Large cysts in small children pose technical challenges during laparoscopic surgery, requiring multiple incisions and advanced laparoscopic skills. This paper describes a novel laparoscopic technique using minimal manipulation for both aspiration and excision of the cyst. This simple, safe, and effective approach was used to achieve traction and facilitate excision of a large intra-abdominal cyst in a neonate and a young child.

Sclerotherapy with bleomycin versus surgical excision for extracervical cystic lymphatic malformations in children

PURPOSE

Sclerotherapy (ST) with bleomycin is an effective treatment for cervical cystic lymphatic malformations (LM) in children. However, its efficacy for treating extracervical cystic LM in children has not been investigated adequately. This retrospective study compares the efficacy of ST with surgery for treating extracervical cystic LM in children.

METHODS

The subjects of this study were children treated for extracervical cystic LM at our hospital between 1970 and 2013. We evaluated retrospectively the hospital records of these children for age, gender, presenting symptoms, location of the lesion, radiological findings, treatments, complications, duration of hospitalization, and outcome.

RESULTS

We analyzed the records of 70 children (M:F = 1:9) with a mean age of 52.57 ± 54.87 months (range 1-204 months). The number of children treated by surgery alone, ST alone, and surgery plus ST was 53 (77 %), 13 (18 %), and 4 (5 %), respectively. Surgery comprised total excision (n = 41), near-total excision (n = 9), partial excision (n = 6), and incisional biopsy (n = 1). The complication and recurrence rates were lower, the complete response rate was higher, and the length of hospitalization was shorter in the ST group than in the surgery group (5 vs. 15 % and 8 vs. 17 %, respectively, p < 0.05; 91 vs. 77 %, respectively, p = 0.05; and 2.42 ± 1.67 vs. 13.57 ± 16.24 days, respectively, p = 0.03).

CONCLUSION

ST is as safe as surgery for extracervical macrocystic or mixed LMs in children, but is much more effective with higher success rates and lower recurrence rates. Thus, ST provides a cost-effective and appropriate mode of treatment for children with extracervical cystic LM.

Successful laparoscopic removal of mesenteric and omental cysts in toddlers: 3 cases with a literature review

Mesenteric and omental cysts are rare benign intraabdominal anomalies with uncertain etiologies. Surgical removal is the preferred treatment owing to complications related to cyst enlargement. A 1-year-old boy with an intrauterine diagnosis of a cystic mass adjacent to his stomach and liver, a 3-year-old girl, and a 3-year-old boy with an incidental diagnosis of intraabdominal cysts were scheduled for laparoscopic surgery. The mass of the 1-year-old boy was a multiloculated cyst originating from the lesser omentum, the incidental mass in the girl was a multiseptated cyst located in the jejunoileal mesentery, and the incidental mass of the 3-year-old boy was a uniloculated cyst originating from the ileal mesentery. All the cysts were excised either laparoscopically or in a laparoscopy-assisted manner. The laparoscopic or laparoscopy-assisted excision of the mesenteric and omental cysts seems to be a feasible, safe, and cost-effective surgical procedure with shorter operative times, even in toddlers.

Laparoscopic excision of a retroperitoneal lymphatic malformation in a newborn

Abdominal lymphatic malformations may be challenging to eradicate. Retroperitoneal lesions may more difficult to resect than mesenteric ones; however, the latter may predispose to intestinal volvulus, leading to calls for their prompt excision. Such lesions identified perinatally may pose particular challenges: in one case, respiratory failure caused by abdominal distension required emergency drainage followed by later laparoscopic excision; laparoscopy has also been used promptly to diagnose and resect neonatal mesenteric lymphatic malformations with their inherent volvulus risk. We illustrate that even if neonatal laparoscopy identifies a retroperitoneal rather than mesenteric lymphatic malformation, curative endosurgical excision remains feasible.

Gastrointestinal tract lymphangiomas: findings at CT and endoscopic imaging with histopathologic correlation

OBJECTIVE

To evaluate and describe CT and endoscopic imaging findings in patients with pathologically confirmed gastrointestinal tract lymphangiomas.

METHODS

Findings from imaging examinations in 6 patients with pathologically confirmed lymphangioma were retrospectively reviewed (computed tomographic images obtained in 6 patients and endoscopic images obtained in 4 patients were available for review). Two radiologists evaluated lesion location, size, shape, edge, number, attenuation, the thickness of capsule wall and the degree of enhancement through PACS or workstation.

RESULTS

Lymphangiomas in gastrointestinal tract showed similar features in CT imaging: Contrast-enhanced CT scan showed the oval submucosal masses with homogeneous low attenuation. The lymphangioma appeared as a well-defined, smoothly marginated and non-enhancing cystic mass with intact overlying intestinal mucosa. In one case, the lymphangiomas were multiple with volvulus. Remarkably, CT imaging showed 2 patients with intussusception due to the mass. Endoscopic photographs manifested multiple colplanate mucosal protrusions in the gastric wall or intestinal wall. One case showed submucosal pedunculated proliferative lesion with adenomatous surface.

CONCLUSIONS

Lymphangiomas exhibited typical appearances that reflected their cystic pathologic features. They showed similar features in CT imaging: well-demarcated, non-enhancing, homogeneous low attenuation cystic masses with intact overlying mucosa. Endoscopic photographs showed submucosal masses with distension of overlying mucosal vessels.