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Special Feature
March 2010

Image of the Month—Diagnosis

Arch Surg. 2010;145(3):308. doi:10.1001/archsurg.2010.13-b
Answer: Abdominal Lymphangioma

Abdominal lymphangioma of the mesentery is an uncommon, benign neoplasm that primarily originates in the lymphatic system and presents as an abdominal mass. It is a rare lesion in the pediatric population; in 2 major pediatric surgical centers, only 19 and 22 cases were reported in a 25- and 34-year period, respectively.1,2 It is difficult to differentiate this tumor from a lymphatic cyst, which is due to a congenital defect in lymphatic development and is similar to lymphatic tumors that are found elsewhere (eg, cystic hygroma). Lymphangiomas, like cystic mesenteric tumors, may be unilocular or multilocular and have an endothelial lining with clear fluid contents. Most patients remain asymptomatic until the lesion exerts mass effect owing to its size (pressure sensation or postprandial fullness). Diagnosis is made by ultrasound or computed tomography, and in a few occurrences, prenatal ultrasonography.3 The differential diagnosis includes enterocele, dermoid, chylous, or serous retention cyst, traumatic cyst, and rarely, lymphangiosarcoma.

Management may pose a challenging therapeutic dilemma, as the rare patient may present with intestinal compromise, complicating the preoperative diagnosis. Intestinal torsion, volvulus, perforation with acute abdomen, and hemoperitoneum have been reported in association with abdominal lymphangioma.46 Surgical removal by enucleation or excision is the only treatment, with resection of adjacent intestine if compromised. Incomplete resection can lead to recurrence and potentially malignant degeneration.7

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The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

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Article Information

Correspondence: R. Serene Perkins, MD, Clinical Assistant Professor, Director, International Surgery Program, Oregon Health & Science University, Department of Surgery, 3181 SW Sam Jackson Park Rd, L223, Portland, OR, 97239-3098 (sperkins429@gmail.com).

Accepted for Publication: April 27, 2009.

Author Contributions:Study concept and design: Perkins, and Lal. Acquisition of data: Perkins, Reddy. Analysis and interpretation of data: Perkins. Drafting of the manuscript: Perkins and Reddy. Critical revision of the manuscript for important intellectual content: Perkins and Lal. Statistical analysis: Reddy. Administrative, technical, and material support: Lal. Study supervision: Perkins.

Financial Disclosure: None reported.

References
1.
Alqahtani  ANguyen  LTFlageole  HShaw  KLaberge  JM 25 years' experience with lymphangiomas in children. J Pediatr Surg 1999;34 (7) 1164- 1168
PubMedArticle
2.
Hebra  ABrown  MF McGeehin  KMRoss  AJ  III Mesenteric, omental, and retroperitoneal cysts in children: a clinical study of 22 cases. South Med J 1993;86 (2) 173- 176
PubMedArticle
3.
Santo  SMarques  JPVeca  PMelo  Ada Graça  LM Prenatal ultrasonographic diagnosis of abdominal cystic lymphangioma: a case report. J Matern Fetal Neonatal Med 2008;21 (8) 565- 566
PubMedArticle
4.
de Vries  JJVogten  JMde Bruin  PCBoerma  Dvan de Pavoordt  HDHagendoorn  J Mesenterical lymphangiomatosis causing volvulus and intestinal obstruction. Lymphat Res Biol 2007;5 (4) 269- 273
PubMedArticle
5.
Prabhakaran  KPatankar  JZLoh  DLAhamed Faiz Ali  MA Cystic lymphangioma of the mesentery causing intestinal obstruction. Singapore Med J 2007;48 (10) e265- e267
PubMed
6.
Safdar  ABakhsh  MAhmed  IKibria  R An unusual cause of haemoperitoneum in a child. J Pak Med Assoc 2008;58 (8) 458- 460
PubMed
7.
Schwartz  SI ed  Principles of Surgery. 7th ed. New York, NY: McGraw Hill; 1999
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