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Pseudocyst in the transverse mesocolon producing obstruction of the duodenum at the ligament of treitz
PSEUDOCYST IN THE TRANSVERSE MESOCOLON PRODUCING OBSTRUCTION OF THE DUODENUM AT THE LIGAMENT OF TREITZ * WILLIAM
M.
MCMILLAN,
M.D.
AND
Chicago, Illinois
W
MASON,
M.D.
At the time of admission the rectal temperature was IOO.Z’F., the pulse I 12, respirations 22 and the blood pressure I 03 : 50. The tongue was dry. The abdomen was diffusely tender and hat and there was a questionable mass in the right upper quadrant. The boweI sounds were
year old Negro man was County HospitaI on FebTABLE
~
H.
Russelcille, Alabama
E present a case of high intestinal obstruction with an unusual etiology as well as a rare type of pseudocyst of
the pancreas. This thirty-three admitted to Cook
R.
I
Riarch
February
Blood Chemistry 20th
Non-protein nitrogen. Creatinine. Total protein.. Chloride.. Sodium. _. Potassium.. CO, combining power.. GI “cost...................... Calcium.....................~..... Blood amylase (units). . .., Urine amylase (umts).
26th
26th
64 82 138 1118 I.7 2 6.61 4.3 7.3..... . . . ..~._... 102 102 76 67 i61 ’ 93 90 143 .I.. _. .#136 134 ‘4’ 18.7; 19.5 14.4’ 11.3, 13.3 21.8 15.2 58 60 48 46 70 1 82 I 58
27
100
..,..
__...
2lst
23rd
’ ( :~__~ __I~.
76 I.7 6.8
.I104 .I138 41.7 34
/
. . ...’ . . . ..~.__.....__
.._.. 32 64 I
64 ‘.
24th
j
_...O._...,...., ,116 ljZ/.....
~ 16
,.... ! .
1128
,....
I ...
‘G ‘07 93 93 136 138 139 ‘33 14.8 17.2’ 14.4 15.. 66 48 66 52
. _..,,
11.3 ..,.. . .._........
‘07 ‘37 18.3 40
,,.,
. . . ..~..._ I_._.
:
ruary 19, 193 I, giving a history of sudden onset of painless vomiting three days before admission. About three hours after the onset of vomiting the patient noted a dull, constant, non-radiating pain around his umbiIicus which progressed in severity and became more generalized. He vomited severa times daiIy from the time of onset unti1 his admission to the hospital. Past history was essentiaIIy negative except for an episode of vague epigastric pain some eight months previousIy. This pain Iasted for severa days. The patient consuIted a doctor who toId him he had a peptic uIcer aIthough no x-rays were made. There was no history of trauma, aIcohoIism, previous surgery or drug ingestion.
hyperactive. There was a 2+ albuminuria, a white bIood count of 17,600 and a hemogIobin of 80 gm. per cent. X-rays of chest and abdomen at that time revealed no pathologic disorder. The Kahn test was negative. The patient was given intravenous fluids, penicillin and a Levin tube was passed and suction instituted. The gastric secretion contained bile and had ten units of free acid. Amylase studies the morning after admission reveaIed the serum amyIase to be thirty-two units and the urinary diastase sixty-four units. On February 2&h, nine days after admission, a barium mea1 using umbrathor reveaIed a markedly diIated stomach with marked stasis of umbrathor in the stomach. There was a faint outline of umbrathor in the duodenal Ioop.
* From the Division of Surgery of Northwestern University MedicaI SchooI and Department County Hospital, Chicago, III.
494
American
of Surgery of Cook
Journal
of Surger_t.
McMiIIan,
Mason-Pseudocyst
in Transverse
Oliguria deveIoped on the third hospital day which persisted for two days during which time abdominal tenderness and fever subsided. Gastric suction returned up to 3,000 ,cc. of fluid per twenty-four-hour period. The fluid and eIectroIyte repIacement was diffrcuIt
MesocoIon
497
of its extensive ramifications and the patient’s very poor condition; however, the cyst was drained and an anterior gastroenterostomy performed. This procedure was carried out to safeguard the patient in the event of a recurexamination of the waI1 rence. Microscopic
FIG. I.
requiring an average of 6,000 cc. daily consisting of 2,000 cc. 3 per cent gIucose in physioIogic saIine, 2,000 cc. 5 per cent gIucose in water, 300 cc. in 3 per cent saline, 1,000 cc. amigen and 300 cc. whoIe bIood with 12 gm. of potassium chIoride and water soIubIe vitamins. BIood chemistries for this period are recorded in Table I. On March 7, 195 I, an expIoratory Iaparotomy was performed and a Iarge, soft mass was found Iying retroperitoneally and extending between the Ieaves of the right transverse mesocoIon and protruding through the Iigament of Treitz obstructing the duodenum at this point.* After aspiration with a No. 32 needIe which returned partiaIIy coaguIated oId bIood it was deemed safe to open the cyst which possessed a thick waI1. ExpIoration and inspection of the inside of the cyst reveaIed no connection with any other structure. The uppermost limit of the cyst was found to be about I inch beIow the Iower border of the pancreas. The cyst was not removed because * Type No. 3 with additiona feature. October,
1952
reveaIed a non-specific cyst without epitheIia1 Iining. The patient’s postoperative course was satisfactory and he toIerated a Iiquid diet on the second postoperative day and by the tenth postoperative day was on a soft diet. By March 26, 195 I, his bIood chemistries were norma and he was having daiIy bowe1 movements. He was discharged asymptomatic on ApriI 2, 195 I, forty days after admission. A three-month foIIow-up showed no evidence of recurrence of the cyst. We present this unusua1 type of high small bowe1 obstruction caused by a hemorrhagic pseudocyst. No etioIogy couId be found to expIain the cyst other than the miIdIy elevated bIood and urinary amyIase at the time of admission which suggested a pancreatitis. Adams and Nishijamal in discussing the Iocation of pseudocysts of the pancreas Iisted as the three most common locations: (I) Cysts presenting between the stomach and transverse coIon and behind the gastrocolic Iigament; (2) cyst protruding into Iesser sac and presenting
498
McMiIIan,
Mason-Pseudocyst
between the stomach and liver; (3) cyst lying between the layers of the mesocolon either behind the transverse coIon or below it. Pathways to these Iocations are shown in Diagram A, (IA) In our case the cyst foIIowed another route as shown in Diagram A, (rB). It was beIieved that the cyst most likely represented a pseudocyst of the pancreas, aIthough at the time of operation the cyst lay in juxtaposition but did not communicate with the pancreas. By definition a pseudocyst of the pancreas is one which forms folIowing trauma to the pancreas or degenerating changes in the pancreas with resuIting accumulation of
in Transverse
MesocoIon
fluid outside the substance of the gland itseIf. Such a cyst has no epitheIia1 lining. This case did fit this criteria. Diagram B illustrates how the cyst herniated its way through the Iigament of Treitz along the side of the dista1 end of the duodenum, coIIapsed the duodenum and produced a high intestina1 obstruction. REFERENCES I. ADAMS, R. and NISHIJAMA, R. Surgical treatment of pancreatic cysts. Surg., Gynec. Ed Obst., 83: 181, 1946. 2. CARTER, R. F. and SLATTERY, L. R. Factors influencing management of pancreatic cysts. S. Clin. Nortb America, 27: 41 I, 1947.
THE studies of E. L. Wynder and others on 830 cases of Iung cancer indicate that in those who are predisposed lung cancer can deveIop, especiaIIy if the patient has smoked many cigarettes daiIy for twenty or more years. HistoIogicaIIy, squamous cell or anapIastic Iung cancer is only rarety seen in those who do not smoke and it is rare in women (since few women have been “chain smokers” for the past twenty or more years). Wynder also says that the increasing incidence of Iung cancer seems to paraIIe1 the increasing use of tobacco and that, aImost invariabIy, epithelium becomes maIignant only after many years of chronic irritation, and inhaIing cigarette smoke can produce such an irritation, especially in susceptibIe individuals. (Richard A. Leonardo, M.D.)
American
Journal
oj Surgery
M.
MCMILLAN,
M.D.
AND
Chicago, Illinois
W
MASON,
M.D.
At the time of admission the rectal temperature was IOO.Z’F., the pulse I 12, respirations 22 and the blood pressure I 03 : 50. The tongue was dry. The abdomen was diffusely tender and hat and there was a questionable mass in the right upper quadrant. The boweI sounds were
year old Negro man was County HospitaI on FebTABLE
~
H.
Russelcille, Alabama
E present a case of high intestinal obstruction with an unusual etiology as well as a rare type of pseudocyst of
the pancreas. This thirty-three admitted to Cook
R.
I
Riarch
February
Blood Chemistry 20th
Non-protein nitrogen. Creatinine. Total protein.. Chloride.. Sodium. _. Potassium.. CO, combining power.. GI “cost...................... Calcium.....................~..... Blood amylase (units). . .., Urine amylase (umts).
26th
26th
64 82 138 1118 I.7 2 6.61 4.3 7.3..... . . . ..~._... 102 102 76 67 i61 ’ 93 90 143 .I.. _. .#136 134 ‘4’ 18.7; 19.5 14.4’ 11.3, 13.3 21.8 15.2 58 60 48 46 70 1 82 I 58
27
100
..,..
__...
2lst
23rd
’ ( :~__~ __I~.
76 I.7 6.8
.I104 .I138 41.7 34
/
. . ...’ . . . ..~.__.....__
.._.. 32 64 I
64 ‘.
24th
j
_...O._...,...., ,116 ljZ/.....
~ 16
,.... ! .
1128
,....
I ...
‘G ‘07 93 93 136 138 139 ‘33 14.8 17.2’ 14.4 15.. 66 48 66 52
. _..,,
11.3 ..,.. . .._........
‘07 ‘37 18.3 40
,,.,
. . . ..~..._ I_._.
:
ruary 19, 193 I, giving a history of sudden onset of painless vomiting three days before admission. About three hours after the onset of vomiting the patient noted a dull, constant, non-radiating pain around his umbiIicus which progressed in severity and became more generalized. He vomited severa times daiIy from the time of onset unti1 his admission to the hospital. Past history was essentiaIIy negative except for an episode of vague epigastric pain some eight months previousIy. This pain Iasted for severa days. The patient consuIted a doctor who toId him he had a peptic uIcer aIthough no x-rays were made. There was no history of trauma, aIcohoIism, previous surgery or drug ingestion.
hyperactive. There was a 2+ albuminuria, a white bIood count of 17,600 and a hemogIobin of 80 gm. per cent. X-rays of chest and abdomen at that time revealed no pathologic disorder. The Kahn test was negative. The patient was given intravenous fluids, penicillin and a Levin tube was passed and suction instituted. The gastric secretion contained bile and had ten units of free acid. Amylase studies the morning after admission reveaIed the serum amyIase to be thirty-two units and the urinary diastase sixty-four units. On February 2&h, nine days after admission, a barium mea1 using umbrathor reveaIed a markedly diIated stomach with marked stasis of umbrathor in the stomach. There was a faint outline of umbrathor in the duodenal Ioop.
* From the Division of Surgery of Northwestern University MedicaI SchooI and Department County Hospital, Chicago, III.
494
American
of Surgery of Cook
Journal
of Surger_t.
McMiIIan,
Mason-Pseudocyst
in Transverse
Oliguria deveIoped on the third hospital day which persisted for two days during which time abdominal tenderness and fever subsided. Gastric suction returned up to 3,000 ,cc. of fluid per twenty-four-hour period. The fluid and eIectroIyte repIacement was diffrcuIt
MesocoIon
497
of its extensive ramifications and the patient’s very poor condition; however, the cyst was drained and an anterior gastroenterostomy performed. This procedure was carried out to safeguard the patient in the event of a recurexamination of the waI1 rence. Microscopic
FIG. I.
requiring an average of 6,000 cc. daily consisting of 2,000 cc. 3 per cent gIucose in physioIogic saIine, 2,000 cc. 5 per cent gIucose in water, 300 cc. in 3 per cent saline, 1,000 cc. amigen and 300 cc. whoIe bIood with 12 gm. of potassium chIoride and water soIubIe vitamins. BIood chemistries for this period are recorded in Table I. On March 7, 195 I, an expIoratory Iaparotomy was performed and a Iarge, soft mass was found Iying retroperitoneally and extending between the Ieaves of the right transverse mesocoIon and protruding through the Iigament of Treitz obstructing the duodenum at this point.* After aspiration with a No. 32 needIe which returned partiaIIy coaguIated oId bIood it was deemed safe to open the cyst which possessed a thick waI1. ExpIoration and inspection of the inside of the cyst reveaIed no connection with any other structure. The uppermost limit of the cyst was found to be about I inch beIow the Iower border of the pancreas. The cyst was not removed because * Type No. 3 with additiona feature. October,
1952
reveaIed a non-specific cyst without epitheIia1 Iining. The patient’s postoperative course was satisfactory and he toIerated a Iiquid diet on the second postoperative day and by the tenth postoperative day was on a soft diet. By March 26, 195 I, his bIood chemistries were norma and he was having daiIy bowe1 movements. He was discharged asymptomatic on ApriI 2, 195 I, forty days after admission. A three-month foIIow-up showed no evidence of recurrence of the cyst. We present this unusua1 type of high small bowe1 obstruction caused by a hemorrhagic pseudocyst. No etioIogy couId be found to expIain the cyst other than the miIdIy elevated bIood and urinary amyIase at the time of admission which suggested a pancreatitis. Adams and Nishijamal in discussing the Iocation of pseudocysts of the pancreas Iisted as the three most common locations: (I) Cysts presenting between the stomach and transverse coIon and behind the gastrocolic Iigament; (2) cyst protruding into Iesser sac and presenting
498
McMiIIan,
Mason-Pseudocyst
between the stomach and liver; (3) cyst lying between the layers of the mesocolon either behind the transverse coIon or below it. Pathways to these Iocations are shown in Diagram A, (IA) In our case the cyst foIIowed another route as shown in Diagram A, (rB). It was beIieved that the cyst most likely represented a pseudocyst of the pancreas, aIthough at the time of operation the cyst lay in juxtaposition but did not communicate with the pancreas. By definition a pseudocyst of the pancreas is one which forms folIowing trauma to the pancreas or degenerating changes in the pancreas with resuIting accumulation of
in Transverse
MesocoIon
fluid outside the substance of the gland itseIf. Such a cyst has no epitheIia1 lining. This case did fit this criteria. Diagram B illustrates how the cyst herniated its way through the Iigament of Treitz along the side of the dista1 end of the duodenum, coIIapsed the duodenum and produced a high intestina1 obstruction. REFERENCES I. ADAMS, R. and NISHIJAMA, R. Surgical treatment of pancreatic cysts. Surg., Gynec. Ed Obst., 83: 181, 1946. 2. CARTER, R. F. and SLATTERY, L. R. Factors influencing management of pancreatic cysts. S. Clin. Nortb America, 27: 41 I, 1947.
THE studies of E. L. Wynder and others on 830 cases of Iung cancer indicate that in those who are predisposed lung cancer can deveIop, especiaIIy if the patient has smoked many cigarettes daiIy for twenty or more years. HistoIogicaIIy, squamous cell or anapIastic Iung cancer is only rarety seen in those who do not smoke and it is rare in women (since few women have been “chain smokers” for the past twenty or more years). Wynder also says that the increasing incidence of Iung cancer seems to paraIIe1 the increasing use of tobacco and that, aImost invariabIy, epithelium becomes maIignant only after many years of chronic irritation, and inhaIing cigarette smoke can produce such an irritation, especially in susceptibIe individuals. (Richard A. Leonardo, M.D.)
American
Journal
oj Surgery