Lesser Sac Cystic Lymphangioma: Gastric Outlet Obstruction

lesser Sac Cystic Lymphangioma Gastric Outlet checkCystic Lymhangioma of the lesser Sac in adult presenting with features of Gastric Outlet Obstruction A Case ReportS Suresh KumarSri Aurobindo Prasad DasVikram KateRunning title lesser pokeking cystic lymphangioma causing stomachal outlet obstruction describe WordsAbdominal cystic Lymphangioma Omental Bursa Outlet ObstructionArticle token Case ReportSection (speciality) military operation- Gastrointestinal SurgeryAbstract Non- organise (Case Report)ABSTRACTBackgroundCystic lymphangioma is a paediatric benign tumour, occurs normally in head and be intimate region. Adult Intra ab lymphangiomas are uncommon and barely few cases of lesser sac cystic lymphangioma are penninged in the literature.Case unveilingWe present a case of lesser sac cystic lymphangioma in a 26 category old gentlewoman who presented with features of gastric outlet obstruction. Clinical examination of the abdomen revealed 10 x 10 cm firm, non tender, mo bile intraabdominal lump in the epigastrium.An hurrying gastrointestinal endoscopy showed possible foreign compression at the boy of the stomach. Ultrasound of abdomen demonstrated a multicystic lesion criterion 10.2 X 8 cm, with internal echoes in peerless locule. tell enhanced computed tomography of the abdomen showed a giving multiloculated cystic lesion with hyper-dense content in the lesser sac extending up to the remaining lobe of the liver and indenting the stomach, lesser sac, and upper border of pancreas.On running(a) exploration, a 10X8 cm multi cystic lesion with clear fluid was found in the lesser sac precise close to the lesser curvature of stomach. The fall branches of go forth field gastric which were found cross through the cyst were ligated and the cyst was excised in Toto. Histopathological examination of the excised lesion showed features of cystic lymphangioma demo dilated lymphatic vessels with fibro-fatty tissue ingrained in the endothelial lining. certaintythough intraabdominal cystic lymphangiomas are very rare, it should be considered in all atypical cases of gastric outlet obstruction. A fair(a) knowledge about these benign lesions will aid in establishing the diagnosing and surgical management.Key WordsAbdominal cystic Lymphangioma Omental Bursa Outlet ObstructionBackgroundLymphagiomas are benign lesions generally occur as a result of lymphatic system malformation and infrequently reported subsequently(prenominal) trauma. 90% of the cases are seen within the first two years of aliveness and symptomatic presentation in adults is very rare. 1 Cystic lymphagiomas commonly collects neck and axilla but can occur anywhere in the body. Though Intraabdominal lymphangioma accounts for Case presentationA 26-year old lady presented to surgical out patient surgical incision with complaints of early satiety, vomiting few hours after food intake and faint-hearted fullness of upper abdomen. She also had features of dyspepsia for the past one year. She had genuine pain and had a feeling of a mobile lump in the upper abdomen for the past one month. There was no pancreatitis chronological succession before. General physical examination was unremarkable. Clinical examination of the abdomen revealed 10 x 10 cm lump in the epigastrium which was firm in consistency. The lump was non tender, freely mobile and intra-abdominal.InvestigationsThe haemogram and biochemical profiles were within normal limits. An upper gastrointestinal endoscopy was done which showed normal mucosa of stomach with possible external compression at the boy of the stomach. Ultrasound of abdomen was suggestive of a multicystic lesion measuring 10 X 8 cm, with internal echoes in one locule, present superior to pancreas adjacent to the left lobe of the liver. Rest of abdomen was unremarkable. air enhanced computed tomography of the abdomen showed a large multiloculated cystic lesion measuring 10.2 X 8 cm with hyper dense content in nigh locul i in the lesser sac extending up to the left lobe of the liver and indenting the stomach, lesser sac, and upper border of pancreas with a few branches of left gastric vessels coursing through it. (Figure 1) Correlating the clinical, USG and CECT abdomen findings a diagnosis of possible lymphangioma was made and the patient was planned for exploratory laparotomy as the symptoms were persisting.Surgical managementOn surgical exploration, a 10X8 cm multi cystic lesion with clear fluid was found in the lesser sac very close to the lesser curvature of stomach. (Figure 2) The descending branches of left gastric which were found coursing through the cyst were ligated and the cyst was excised in Toto. (Figure 3) A drain was placed in lesser sac and abdomen was closed in layers.Outcome and follow- upPostoperative telephone circuit was uneventful. The drain was removed on the 3nd postoperative day and the patient was fulfill on seventh post operative day. Histopathological examination of th e excised lesion showed features of cystic lymphangioma showing 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 examination and USG was done which showed no evidence of recurrence. The lady is presently on regular follow up for past 2 years with no evidence recurrence bank date.DiscussionIntra-abdominal cystic lymphangiomas are uncommon benign tumours that can involve the mesentery, omentum, colon, spleen, pelvis, groin, and retroperitoneum 5, 6. We had a case of cystic lymphangioma in the lesser sac which is very rare. Cystic lymphangiomas are considered to originate from malformed or malpositioned lymphatic tissue. Factors much(prenominal) as abdominal trauma, inflammatory process, lymphatic obstruction due to radi otherapy therapy or surgery may lead to secondary formation of such(prenominal) tumors. Our patient did not have any of the mentioned inciting factors the cause was probably inherent which had manifested late in life.Commonly known to present in childhood, lymphagiomas sometimes remain asymptomatic until late adulthood, and are discovered during evaluation of dark and chronic nonspecific symptoms like anorexia, nausea, vomiting, fatigue, and weight loss, which are secondary to good deal effect 4. This was seen in our patient who had early satiety and vomiting after food intake probably due to luck effect and had a vague feeling of mass in the abdomen. Other ways of presentation such as acute abdomen, mimicking acute appendicitis has also been reported 3.Contrast CT done in our patient revealed multicystic lesion measuring 10.2 X 8 cm, present superior to pancreas, in the lesser sac adjacent to the left lobe of the liver. Cystic lymphangioma usually presents as a large multilocular cystic mass with enhanced walls with multiple thin septa containing uncomplicated fluid on abdominal ult rasonography and contrast enhanced computerized tomography which is very often symptomatic 7.The differential diagnosis includes cystic lesions of, enteric urogenital or mesothelial origin. pancreatic pseudocysts from trauma, dermoid cysts or teratomas and cystic degeneration of solid tumours are also to be considered before making this rare diagnosis.Management of intra-abdominal cystic tumours depends on the clinical symptoms, size of the cyst, and the degree of clinical suspicion for malignancy. Imaging usually provides useable information for the planning of treatment. Complete removal of the tumour offers an excellent outlook and laparoscopic removal of lymphangioma also shown feasible in few reports. We therefore intractable 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 primary resection was incomplete.9 If the ply lymphatics are not completely ligated, chylous ascites may also occur.ConclusionThough intra-abdominal cystic lymphangiomas are very rare, it should be considered in cases of gastric or biliary obstruction where the cause could not be accept clearly. Reasonable knowledge about these benign lesions will aid in establishing the diagnosis during such instances. Complete surgical excision offers the best mishap for cure and should be attempted in all the cases to avoid recurrence. concurWritten informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is gettable for review by the Editor of this journal.Competing interests disclosuresThe authors have no potential or real conflict of interestsThe authors have no financial support or ties to discloseThe authors have no financial or non financial competing interests to advanceAuthors contributionsSuresh Kumar S, Das S A and Kate V diagnosed and managed the case. Suresh Kumar S, Das S A did the literature search. Su resh Kumar S and Das S A collected the images. Suresh Kumar S and Kate V drafted the manuscript. All authors read and approved the final manuscript.ReferencesHanagiri T, Baba M, Shimabukuro T, Hashimoto M, Takemoto H, Inoue A, Sugitani A, Shirakusa T. Lymphangioma in the mild intestine Report of a case and review of the Japanese literature. Surgery Today 1992 22 363-367Roisman I, Manny J, Fields S, Shiloni E. Intra-abdominal lymphangioma. Br J Surg 1989 76 485-489 gum benzoin HL Tan, Teegan Lim. 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