A Rare Case of Gastroenteric Cyst Across the Chest and Abdomen Through the Left Diaphragm
Minglei Song1, Lingling Zhang2, Yang Li3 and Fumin Cao1*
1Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
2Department of Pathology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
3Department of Computed Tomography, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
*Corresponding author: Fumin Cao, Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, Shijiazhuang, Hebei, China, Tel: 13933132002; E-mail: email@example.com
Citation: Song M, Zhang L, Li Y, Cao F (2019) A Rare Case of Gastroenteric Cyst Across the Chest and Abdomen Through the Left Diaphragm. J Clinical Case Rep Case Stud 2019: 1-3
Received: 15 March, 2019; Accepted: 01 July, 2019; Published: 30 July, 2019
The gastroenteric cyst is a rare developmental malformation, especially in the adult population. Majority of the cysts are located in the posterior mediastinum with right side more common than the left side. Usually, the lesions are identified in infancy and without symptoms. In this report, we present a rare case with two remarkable features. First, the cyst was across the chest and abdomen through the left diaphragm. Second, the patient was 46 years of age at the time of detection with upper abdominal pain. The clinical manifestations, diagnosis, and management are described and compared to findings in the literature.
Keywords: Gastroenteric cyst; Across the chest and abdomen; Calcification
Gastroenteric cyst is a rare developmental cyst. There have been reported cases of the disease as early as 70 years ago with only 27 published reports in the literature thus far. The majority of the cases are asymptomatic and identified in infancy. Histologically, gastroenteric cysts are derived from gastrointestinal epithelial cells [1-3] and rarely contain other tissues, such as pancreatic tissue or respiratory epithelial cells [2,4]. The cysts are usually located in the posterior mediastinum, with right side more common than the left side . To our knowledge, this is the first case of the gastroenteric cyst across the chest and abdomen through the diaphragm reported in the English literature.
A 46-year-old man presented to our hospital with the history of experiencing severe upper abdominal pain for six days. The patient did not complain of metastatic pain, abdominal distension, diarrhea, nausea and vomiting, and fever.
He had no other pertinent medical history.
On physical examination, he was afebrile and had normal respiratory, cardiovascular and abdominal examinations. Chest and abdominal enhancement computerized tomography (CT) imaging showed there was a cystic mass, with size 8.2 × 5.3 × 4.4 cm, across the chest and abdomen through the left diaphragm. The upper pole was at the level of the inferior vena cava into the right atrium; the lower pole reached the upper edge of the celiac trunk. There was a suspected pedicle connecting the lower pole and the descending aorta. About 1/3 of the cyst body was in the chest, while 2/3 in the abdomen (Figure 1). The cyst was close to the descending aorta and diaphragm. The left diaphragm appeared non-continuous. There were several circular calcified lesions in the cyst. Enhanced CT scan showed visible enhancement in the cyst wall.
Figure 1: The cyst across the chest and abdomen through the left diaphragm. The upper pole was at the level of the inferior vena cava into the right atrium, and the lower pole reached the upper edge of the celiac trunk. There are calcification lesions in the cyst (arrow). A). The cyst acress the chest and abdomen through the left diaphragm. the upper lobe was at the level of the inferior venacava into the tight atrium, and the lower pole reached the upper edge of the celiac trunk. There are calcification lesions in the cyst (arrow). B). The cyst across the chest and abdomen through the left diaphragm. the left diaphragm appeared non-continuous.
No abnormal findings were found in pertinent preoperative laboratory evaluation.
For a deﬁnitive diagnosis, the patient underwent an exploratory laparotomy via the abdominal midline incision. After the gastrocolic ligament and posterior parietal peritoneum were cut, a visible mass was located between the descending aorta and the left adrenal gland. The mass was adhered to the diaphragm and the aorta. After these adhesions were dissected, an oval cystic mass with the entire capsule was extirpated entirely, followed by repair of the diaphragm. The cyst, measuring 8.2 × 5.3 × 4.4 cm, with wall thickness of 0.3-0.6 cm, was filled with viscous jelly-like substance and hemorrhagic fluid.
On histologic examination, it was revealed that the cyst lumen was lined with gastrointestinal mucosa (Figure 2). The wall of the cyst had calcifications. Dysplastic or malignant lesions were not found. Based on these ﬁndings, the lesion was deﬁnitively diagnosed as a gastroenteric cyst. The patient recovered well and was discharged from the hospital.
Figure 2: Histopathology of the gastroenteric cyst. Gastric mucosal
Gastroenteric cysts are benign lesions caused by congenital dysplasia, mostly located in the posterior mediastinum of thoracic cavity [1-3]. In our patient, the observation in operation was consistent with the findings from the preoperative CT scan that the gastroenteric cyst crossed the chest and abdomen through the left diaphragm. To our knowledge, this is the first case reported in the English literature in the world.
Although preoperative imaging can provide morphological description and location, the deﬁnitive diagnosis of gastroenteric cysts depends on postoperative pathological examination. In our case, besides the common pathological feature¾ gastrointestinal type mucosa—calcification was found in the wall and within the cyst, a rare lesion in gastroenteric cysts.
Majority of the gastroenteric cyst cases are asymptomatic and usually identified in infancy. The presence or absence of clinical symptoms is related to the location and size of the cyst and the degree of compression on surrounding organs. Compression of the cyst on esophagus causes dysphagia, while compression on nerves causes pain. Reisli et al. reported a patient with funnel chest complicated with massive mediastinal gastrointestinal cyst, which compressed the thoracic duct . This is an adult patient with 46 years of age at the time of detection. He experienced upper abdominal pain, which may be due to adhesion to the diaphragm.
Due to the possibility of malignant transformation of the lesion , surgical excision of gastrointestinal cysts is the best approach. Once completely removed, it seldom relapses. Surgery for gastroenteric cysts located in the thorax is easy to be performed usually. In our case, the cyst crossed the chest and abdomen through the left diaphragm with 2/3 located in the abdomen. Therefore, we selected the middle incision of the upper abdomen for the surgical approach. The cyst was adjacent to the vital organs, including the thoracic aorta, the left adrenal gland, and the left diaphragm. Furthermore, the cyst was tightly adhered to the adjacent organs, with a pedicle cord between the lower pole and the descending aorta, consistent with the finding from the CT scan. Thus, the surgery was challenging. In this case, the gastroenteric cyst was excised entirely, and the diaphragm was repaired carefully. The postoperative recovery was well, and the patient was discharged successfully. We followed up the patient regularly. No early and long-term complications were observed.
In summary, we reported the ﬁrst case, to our knowledge, of a patient presenting with a congenital gastroenteric cyst across the chest and abdomen through the left diaphragm. Complete excision was successfully performed in this case despite the complex anatomical structure.