Mesenteric Research Articles

Atraumatic Hepatic Laceration with Hemoperitoneum.

Introduction: A rare case of atraumatic liver laceration associated with hemoperitoneum is presented in a patient with amyloidosis who came to the hospital for abdominal pain. Case Presentation: The imaging findings reveal significant hepatomegaly with finely heterogeneous hepatic density and subcapsular hypo-dense streaks in segments VI and VII, likely representing lesions. Post-contrast enhancement shows a punctiform contrast medium extravasation within the subhepatic fluid collection, visible from the arterial phase and intensifying in subsequent study phases. Discussion: These imaging findings suggest an atraumatic hepatic laceration, a diagnosis confirmed by the presence of hemoperitoneum distributed bilaterally under the diaphragm, in the paracolic gutters, along the mesentery root, and predominantly in the peri-hepatic region. Conclusion: The detailed imaging analysis provided critical insights into the diagnosis and management of this rare clinical presentation.

Stage IV gastric cancer with microsatellite instability–high achieving long-term survival by gastrectomy after nivolumab as third-line therapy: a case report and literature review

BackgroundThe prognosis for stage IV gastric cancer remains poor; however, the advent of immune checkpoint inhibitors (ICIs) such as nivolumab has increased the number of patients with long-term survival. Patients with microsatellite instability (MSI)–high gastric cancer have been recognized as a highly effective population for ICIs. Herein, we report a patient with MSI–high advanced gastric cancer treated with gastrectomy after the administration of nivolumab as third-line therapy.Case presentationA 73-year-old woman presented with a type 3 tumor in the lower part of the gastric body, which was diagnosed as gastric cancer through biopsy. Staging laparoscopy revealed that the tumor had invaded the pancreas and the posterior lobe of the transverse mesocolon, and disseminated nodules were found near the ligament of Treitz. After 4 courses of S-1 plus cisplatin therapy, laparoscopic gastrojejunal bypass was performed because of difficulty in oral intake. She received S-1 plus oxaliplatin therapy after a gastrojejunal bypass; however, her regional lymph nodes were enlarged. After six courses of paclitaxel plus ramucirumab as second-line chemotherapy, computed tomography (CT) showed exacerbation of peritoneal dissemination; thus, nivolumab was selected as the third-line therapy. The tumor was characterized by MSI–high. At 24 courses, CT and gastroscopy revealed a complete clinical response of the tumor; however, re-growth of the primary tumor was observed at 36 courses. The patient underwent distal gastrectomy with D1 + lymph node dissection, and received S-1 monotherapy as adjuvant therapy for 1 year. No recurrence was noted at 39 months after the surgery.ConclusionsWe report a patient with highly advanced gastric cancer with peritoneal dissemination, which worsened during second-line therapy and was successfully treated with gastrectomy after nivolumab administration as a third-line therapy. MSI–high gastric cancer is a target that should be actively considered for the administration of ICIs, such as nivolumab, and multidisciplinary treatment combined with chemotherapy and gastrectomy, including conversion surgery, can lead to patients’ long-term survival.

Retroperitoneal Approach to D3-Lymph Node Dissection With Left Colic Artery Preservation in the Treatment of Sigmoid Cancer.

Laparoscopic approaches and robot-assisted operations are used for colorectal cancer surgery because of their minimal invasiveness.1 However, changes in intra-abdominal pressure during laparoscopy can lead to cardiovascular complications in compromised patients;2 obesity and intraabdominal adhesions may further interfere with laparoscopic procedures. The retroperitoneal approach may facilitate minimally invasive surgery, even in patients with comorbidities. The technique for high ligation of the inferior mesenteric artery has been described in left colonic surgeries.3 However, complete termination of the blood supply through this artery may lead to a higher frequency of anastomotic leakage.4. We present a novel retroperitoneal approach for D3-lymph node dissection with low ligation of the inferior mesenteric artery and preservation of the left colic artery. This method can reduce the duration of laparoscopic procedures for compromised patients and meet the standards for extended lymph node dissection with tumor-specific mesocolic excision.5,6. The procedure started with the installation of a paraumbilical optical trocar to introduce a 30-degree optical system. The SILS™ Port (Covidien, Medtronic) was inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. The horizontal aspect of the duodenum served as the cranial landmark during interfascial dissection, with the dissection proceeding in a cranial and medial direction. During the dissection, the left ureter was the primary landmark, passing medial to the gonadal vessels and Gerota's fascia.The aorta was exposed medially and the inferior mesenteric artery was identified. The inferior mesenteric artery was skeletonized from its origin until the branching of the left colic artery and the sigmoid artery. The left colic artery was skeletonized until the passage of the inferior mesenteric vein, and the apical lymphatic nodes with mesocolic tissue were mobilized and excised. The inferior mesenteric artery was cut below the left colic artery.The final step was performed laparoscopically. The parietal fascia along Toldt's line was cut laterally to complete the mesocolon excision. The parietal fascia was cut along the right side of the aorta to free the mesocolonic medial border. The sigmoid mesocolon was dissected at the proximal and distal resection margins.Following mobilization, the colon was cut 10 cm distal to the tumor margin using a linear stapler. The specimen was then extracted using an SILS incision. The sigmorectal anastomosis was made. Atypical hepatic resection was performed using two additional trocars. The incidence of pain syndrome in the early postoperative period was low. Blood loss reached 100 mL. The duration of the surgery was 300 min. The retroperitoneal step took 63 min. Metastases were observed in 7 of the 41 harvested lymph nodes. The patient was discharged on the 8th postoperative day. The retroperitoneal technique can be safely performed. Anatomical structures are readily accessible and easily visualized with this approach after special training, enabling extended lymph node dissection.

Artificial intelligence for surgical safety during laparoscopic gastrectomy for gastric cancer: Indication of anatomical landmarks related to postoperative pancreatic fistula using deep learning.

Postoperative pancreatic fistula (POPF) is a critical complication of laparoscopic gastrectomy (LG). However, there are no widely recognized anatomical landmarks to prevent POPF during LG. This study aimed to identify anatomical landmarks related to POPF occurrence during LG for gastric cancer and to develop an artificial intelligence (AI) navigation system for indicating these landmarks. Dimpling lines (DLs)-depressions formed between the pancreas and surrounding organs-were defined as anatomical landmarks related to POPF. The DLs for the mesogastrium, intestine, and transverse mesocolon were named DMP, DIP, and DTP, respectively. We included 50 LG cases to develop the AI system (45/50 were used for training and 5/50 for adjusting the hyperparameters of the employed system). Regarding the validation of the AI system, DLs were assessed by an external evaluation committee using a Likert scale, and the pancreas was assessed using the Dice coefficient, with 10 prospectively registered cases. Six expert surgeons confirmed the efficacy of DLs as anatomical landmarks related to POPF in LG. An AI system was developed using a semantic segmentation model that indicated DLs in real-time when this system was synchronized during surgery. Additionally, the distribution of scores for DMP was significantly higher than that of the other DLs (p < 0.001), indicating the relatively high accuracy of this landmark. In addition, the Dice coefficient of the pancreas was 0.70. The DLs may be used as anatomical landmarks related to POPF occurrence. The developed AI navigation system can help visualize the DLs in real-time during LG.

Closed-loop obstruction due to internal hernia: An atypical clinical presentation of acute abdomen - A case report

Abstract Internal hernia is the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. They can be congenital or acquired after abdominal surgery. We report a case of a 58-year-old woman who presented with complaints of abdominal pain and nonbilious vomiting for 2 days. She underwent an abdominal hysterectomy 15 years ago. After baseline blood investigations and imaging, a diagnosis of subacute intestinal obstruction was made. As she clinically worsened over 24 h, CT imaging was done, which suggested acute small bowel obstruction secondary to adhesions. Surgery revealed herniation with incarceration of distal ileal loops through a defect in the sigmoid mesocolon. Bowel resection was done, and the defect was closed. The clinical presentation of internal hernias, especially transmesosigmoid hernia, is nonspecific, and they rapidly progress to bowel ischemia. Early intervention and surgical correction are prudent for good clinical outcomes.

A RARE CASE OF TRANSMESOCOLIC HERNIATION OF SMALL BOWELTHROUGH A CONGENITAL DEFECT PRESENTING AS A CLOSED BOWEL OBSTRUCTION - A CASE REPORT AND LITERATURE REVIEW OF REPAIRS OF INTERNAL HERNIAS

Transmesocolic hernia is an uncommon type of Internal hernia with incidence ranging from approximately 5–10% of all Internal Hernias. To the best of our knowledge, this is the first reported case of a transmesocolic hernia in adults without any surgical history or trauma. Small bowel loops were found herniating into the supracolic compartment through a congenital defect in transverse mesocolon presenting clinically as Small Bowel obstruction. A 20-year-old man was admitted with clinical features of intestinal obstruction. An abdominal X-ray showed multiple small bowel loops with air fluid levels. Contrast-enhanced CT of the abdomen revealed small bowel obstruction not only on the right, but also on the left side of the collapsed descending colon. Emergency Exploratory Laprotomy was performedand bowel loops with discolouration seen enclosed in hernial sac in supracolic compartment which were milked out of defect and observed to have obtained vascularity almost immediately. The postoperative period was uneventful. Preoperative diagnosis of bowel obstruction caused by a transmesocolic hernia remains difficult despite the currently available imaging techniques. Prompt surgery can prevent serious complications such as Bowel gangrene, peritonitis and sepsis.

The efficacy and safety of laparoscopic radical gastrectomy after neoadjuvant chemotherapy combined with immunotherapy and targeted therapy

Objectives: To explore the efficacy and safety of laparoscopic radical gastrectomy after neoadjuvant chemotherapy combined with immunotherapy and targeted therapy in patients with gastric cancer. Methods: A retrospective analysis of clinical and pathological data of 20 patients with locally advanced gastric cancer (clinical TNM stage T3-4aN+M0) admitted to the Cancer Hospital, Chinese Academy of Medical Sciences from July 2021 to July 2023. All patients received 3 cycles of SOX (Oxaliplatin+S-1) regimen combined with immunotherapy (Trastuzumab) and targeted therapy (Apatinib) as neoadjuvant treatment followed by laparoscopic radical gastrectomy for gastric cancer. Surgical outcomes, postoperative pathological response, and postoperative recovery were observed. Quantitative data, except for age and operation time, were expressed using Median (range). Results: Among the 20 patients, there were 18 males and 2 females, aged 41 to 73 years [(60.6±9.7) years]. All 20 patients underwent laparoscopic surgical treatment after neoadjuvant therapy, with one patient undergoing laparoscopic conversion to open total gastrectomy with partial transverse colon resection due to tumor invasion into the transverse mesocolon. Eight patients underwent totally laparoscopic radical gastrectomy, all with Billroth Ⅱ+Braun anastomosis at the distal stomach. Eleven patients underwent laparoscopic-assisted radical gastrectomy, among which total gastrectomy with Roux-en-Y anastomosis was performed in ten cases, and proximal gastrectomy with esophagogastrostomy overlap anastomosis was performed in one case. The mean operation time for the 20 patients was (165.0±34.1) minutes; intraoperative blood loss was 80 (20-100) ml; and the number of lymph nodes retrieved was 68 (21-89). Postoperative pathological TNM staging revealed stage T0N0M0 in six cases, stage Ⅰ in two cases, stage Ⅱ in three cases, and stage Ⅲ in nine cases. Six patients (30.0%) achieved pathological complete response, and nine patients (45.0%) achieved significant pathological response. The median postoperative time to flatus was 4 (1-5) days; oral intake resumed after 3 (2-5) days; and the median length of hospital stay was 13 (6-19) days. One patient developed colonic anastomotic leakage with intra-abdominal infection, and one patient developed duodenal stump leakage with intra-abdominal infection, both classified as Clavien-Dindo grade 3A complications, and improved after treatment and discharged. One patient developed gastric paresis, and two patients developed pleural effusion, classified as Clavien-Dindo grade 2 complications, and improved after treatment and discharged. There were no deaths within 30 days after discharge. Conclusions: Laparoscopic radical gastrectomy for gastric cancer after neoadjuvant treatment with the SOX regimen combined with immunotherapy and targeted therapy is safe and feasible, with satisfactory short-term efficacy. However, there is an increase in overall surgical risk and difficulty, and it is recommended to be performed in experienced gastric cancer centers.

Mesenteric root pseudocyst: finding in an asymptomatic patient—a case report

BackgroundMesenteric cysts are one of the rarest abdominal tumor masses, representing a little-studied pathology. In turn, the variability and non-specificity of clinical manifestations make diagnosis difficult, as it can be reached by imaging findings due to another cause or by non-specific abdominal pain.Case presentationThis article describes the case report of an asymptomatic 28-year-old patient who presented a 6-cm abdominal cystic mass with mixed density, which was found incidentally by computed tomography. Exploratory laparoscopy was performed followed by conversion to conventional surgery to extract the tumor mass. The anatomical pathology diagnosis was pseudocyst of the mesentery root. Mesenteric cysts are one of the rarest abdominal tumor masses, representing a little-studied pathology. In turn, the variability and non-specificity of clinical manifestations make diagnosis difficult, as it can be reached by imaging findings due to another cause or by non-specific abdominal pain.ConclusionsMesenteric cysts are rare, and their nonspecific symptoms often lead to diagnosis based on imaging findings. Complete laparoscopic enucleation is the standard treatment.

Small bowel obstruction caused by transmesosigmoid internal hernia

Internal hernia is an uncommon occurrence contributing to intestinal obstruction, posing diagnostic challenges. Among the infrequent manifestations, one noteworthy type is associated with the sigmoid colon, categorized into three subtypes: inter-sigmoid, trans-mesosigmoid, and intra-mesosigmoid. We present a case of a 48-year-old female who presented with small bowel obstruction as an emergency. CT showed intestinal obstruction with translational point at mid jejunum without any mass identified. At laparotomy we identified an internal hernia in the sigmoid mesocolon with full thickness mesentery defect (transmesosigmoid), bowel was viable and reduced where the defected was closed. Early identification of internal hernia and early management prevent mortality and morbidity; sigmoid related hernia is rear type of internal hernia. Most internal hernia diagnosed during laparotomy searching for case of acute intestinal obstruction.

Inoperable Renal Malignant Glomus Tumor, the answers for all the "W's"?

Glomus tumor, arising from glomus bodies (specialized neurovascular structures involved in thermoregulation), commonly occurs in extremities and rarely in viscera. The spectrum of glomus tumors range from benign tumors to tumors with uncertain malignant potential to tumors of the malignant subtype. A vast majority of visceral glomus tumors are benign. Most common visceral tumors arise in the gastrointestinal tract. Glomus tumors of the kidney are a rare entity of which malignant glomus tumors are exceedingly rare. The index patients in the existing case reports were middle-aged males. We report our experience with malignant glomus tumor of the left kidney in a 60-year-old female, with computed tomography (CT) showing involvement of renal vein and inferior vena cava (IVC). Percutaneous biopsy was performed as imaging did not conform to the appearance of a conventional renal tumor and was reported as malignant glomus tumor after immunohistochemistry. After informed decision, the patient and family elected to proceed with surgery. However, intraoperatively, the left renal mass was found to infiltrate the pancreas, duodenum, aorta, and root of the colonic mesentery due to which surgery was aborted. Biopsy obtained intraoperatively again confirmed diagnosis of left renal malignant glomus tumor. She had an uneventful postoperative recovery. Options of treatment were reviewed by a multidisciplinary board. In light of no proven benefit for systemic therapy, she was referred for supportive care. She was under follow-up and she expired after 7 months due to progressive disease. Our literature review focuses on the clinicopathologic features and the current standard of management of malignant renal glomus tumors.

Small Bowel Volvulus on Incomplete Common Mesentery in Adults with Rare Late Presentation: Report of a Case

Small bowel volvulus complicating incomplete common mesentery corresponds to an arrest in the 180° rotation of the primitive intestinal loop. The root of the mesentery is very short and the entire small intestine is pedunculated on the superior mesenteric artery. This situation carries a very high risk of small bowel volvulus and entero-mesenteric infarction. Acute volvulus requires emergency surgery; imaging should not delay surgical management. The surgical procedure consists of untwisting the volvulus (anticlockwise) and assessing the viability of the intestine. The intestine is stored in the position of complete common mesentery: coetus in the left iliac fossa. We report the observation of a 24-year-old patient admitted for small bowel volvulus on incomplete common mesentery, operated on as an emergency with a favourable postoperative outcome.

The duodenal window approach to pancreatoduodenectomy.

The pancreatoduodenectomy (PD) technique is yet to be standardized. One of the most difficult passages in PD is the mobilization of the second, third, and fourth parts of the duodenum. This maneuver is classically performed from the supramesocolic space after the division of the gastrocolic ligament, but traction on the transverse mesocolon and the superior mesenteric pedicle can cause bleeding from the venous and arterial branches of the pancreatic head and uncinate process. We hereby describe a technique to access and mobilize the distal duodenum and proximal jejunum (D2 to J1) through the duodenal window and the Treitz's foramen, performing an almost complete Kocher's maneuver before opening the gastrocolic ligament and mobilizing the hepatic flexure. The anatomical basis and the surgical technique of the duodenal-window-first PD are discussed. The duodenal-window-first approach is a standardizable step of PD that allows an easy and safe mobilization of D2 to J1. This technique has been applied to 15 cases of PD, both open and robotic, with no specific morbidity. Therefore, we propose the adoption of the duodenal-window-first technique as a routine standardized step of PD.

A giant liposarcoma originating from peripancreatic fat tissue with identification using 3D-CT angiography: a case report

BackgroundLiposarcoma originating from peripancreatic fat tissue is extremely rare. This case report presents a surgical case of a giant liposarcoma originating from peripancreatic fat tissue with origin identification using 3-Dimensional Computed Tomography Angiography (3D-CTA).Case presentationA 59-year-old female was referred to our hospital with a giant abdominal tumor. Computed tomography revealed a 34 cm tumor composed of fatty tissue, exerting pressure on the posterior aspect of the pancreas. Suspecting liposarcoma, we planned for surgery. At first, the tumor appeared to be intra-abdominal tumor, based on the identification of the tumor’s feeding artery as a branch of the dorsal pancreatic artery using 3D-CTA, we concluded that the liposarcoma originated from the peripancreatic fat tissue and situated in the retroperitoneum. During surgery, we observed a well-capsulated, elastic, yellowish mass without infiltration into surrounding tissues. We carefully dissected the tumor from the greater omentum and transverse mesocolon while preserving the tumor capsule. We ligated the feeding artery at the border with the pancreatic parenchyma and successfully completed the excision of the tumor. The resected specimen weighted 2620 g and was pathologically diagnosed as a well-differentiated liposarcoma. There was no injury to the tumor’s capsule, and the surgical margins were negative.ConclusionsIn this report, we present an extremely rare case of a liposarcoma originating in the peripancreatic fat tissue. The use of 3D-CTA was instrumental in identifying the primary site of this giant tumor, enabling us to guide the surgery and achieve complete resection successfully.

The Role of Colon in Isolated Intestinal Transplantation: Description of 4 Cases.

Intra-abdominal desmoid tumors are a rare and complex clinical problem. These tumors are locally invasive, and surgical ablation represents the mainstay of treatment. When localized at the root of the mesentery, their resection may require extensive excision of the intestine resulting in intestinal failure and life-long total parenteral nutrition. Intestinal transplantation, either autotransplantation or allotransplantation, has been used as a viable option to treat this group of patients. Herein, we describe a series of 4 patients with unresectable intra-abdominal desmoid tumor who underwent cadaveric isolated intestinal and ascending colon transplantation.

Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer.

Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.

Variant origins of the middle colic artery from the coeliac trunk and its branches.

The middle colic artery usually arises from the superior mesenteric artery, but in rare cases it may arise from the coeliac trunk or its branches. The aim of this study was to investigate variant origins of the middle colic artery on computed tomography and anatomical dissection. Variant middle colic arteries were identified on computed tomography as part of an ongoing study investigating anatomical variations of vessels of the upper abdomen. Three-dimensional reconstructions were made to demonstrate the variant findings. Cadaveric dissections were performed as part of a routine dissection course. We report five cases of rare variant origins of the middle colic artery arising from the coeliac axis. Among these sites of origin were the coeliac trunk, the gastrosplenic trunk, the splenic artery, and the common hepatic artery. Four cases were identified on multi-detector computed tomography and one in a cadaver. In all cases, the vessels passed posterior to the body of the pancreas before entering the transverse mesocolon. Knowledge of middle colic artery variations is important to prevent inadvertent injury in digestive surgery, especially in the hepatopancreatic area. Variant origins of the middle colic artery are rare, and their knowledge is crucial to prevent unnecessary iatrogenic injury during abdominal surgery.

The laparoscopic surgery results of isolated enteric duplication in the transverse mesocolon: A case report

Enteric duplication cysts found throughout the alimentary tract are rare congenital mass lesions, which usually share a common wall with the gastrointestinal tract. However, many cases of isolated enteric duplication (IED) cysts, reported in the literature, are without any attachment to the gastrointestinal tract. We report a case of an IED cyst located in the transverse mesocolon, which was successful treatment with laparoscopy, in Children’s Hospital #1, Ho Chi Minh City, Vietnam. A girl turned 3 years old presented with dull abdominal pain and vomiting. Abdominopelvic computed tomography revealed a lesion located around duodenojejunal flexure with a thick wall. Laparoscopy detected a mobile cystic mass found on the mesentery of the transverse colon, which was not connection or attachment to any part of the adjacent intestine. Histopathology of the cyst wall was compatible with an EDC. The IED cyst is an unusual phenomenon that confuse with other diagnosis in clinical. The definitive diagnosis of IED is based on histopathology. Laparoscopic resection of the cyst is the preferred treatment.

Ladd’s Syndrome in Newborns

Ladd’s syndrome is a violation of intrauterine intestinal rotation. The midgut remains fixed at one point at the origin of the superior mesenteric artery. As a result, conditions are created for the occurrence of a volvulus around the root of the mesentery and acute strangulation intestinal obstruction develops. Ladd’s syndrome includes three features: a high position of the caecum dome, duodenal hyperfixation, and lack of mesenteric fixation. In newborns, this condition is manifested by acute complete high strangulation intestinal obstruction, up to the development of shock. Examination for suspected Ladd’s syndrome should be comprehensive and include a survey abdominal radiography, abdominal ultrasound, gastric and duodenal radiography with oral contrast, irrigography. The article considers clinical cases of Ladd’s syndrome in newborns at the age of 3 and 5 days of life. Echograms made in B-mode using color Doppler sonography are presented. The high informativeness of ultrasound diagnostics for the detection of this syndrome in newborns with a clinic of bile vomiting is shown. In one of the observed cases, a pathognomonic echographic symptom of midgut volvulus was established (a whirlpool sign). In the second observation, a clearly defined vascular ring was not detected due to 180° torsion, which was subsequently confirmed intraoperatively.

Diatoms pass through the gastrointestinal barrier and lead to false-positive: an animal experiment.

The diatom test has been used by forensic pathologist as standard for drowning, but the occurrence of false-positive results (presence of diatoms found in the tissues of subjects who died from causes other than drowning) draws criticism regarding the specificity of the test. Diatoms within food or water can be ingested through the gastrointestinal tract. However, the mechanisms of how the diatoms reach distant organs such as the lung, liver, and kidney have not been studied. In this article, we simulated the process of diatoms entering the gastrointestinal tract using gastric lavage on experimental rabbits. Diatoms are detected in lymph from a lymphatic vessel at the root of the mesentery, portal vein blood, aortic blood, lung, liver, and kidney samples in the gavage group. Of diatoms, 76.24% were the centric diatom, 99.86% of diatoms have a maximum size of less than 50µm, and most of diatoms concentrate in the lung. Our study provided the evidence supporting the theory that the diatoms could pass through the gastrointestinal barrier and reach the rabbits' other internal organs. The diatoms could reach internal organs through the portal vein and lymphatic vessel at the root of the mesentery. This provides us new insight into our understanding of false-positive diatom test in forensic pathology.

WITHDRAWN: Cholelithiasis in Childhood: Report of two cases from Afghanistan and literature review

Mesenteric cysts are uncommon intra-abdominal benign masses that appear in childhood with varying degrees of clinical manifestations, ranging from being asymptomatic to presenting as an acute abdomen. The diagnosis is made incidentally during the work-up for other abdominal pathologies like acute appendicitis, bowel obstruction, etc. The treatment is mostly surgical and varies depending on the clinical type of the lesion. A 26-month-old child was referred to our teaching hospital's pediatric surgery department with an abdominal mass. The patient had previously complained of constipation and been treated symptomatically with laxatives. Following the diagnostic work-up such as ultrasonography (USG) and computerized tomography scanning (CT-scan), the patient was misdiagnosed as having ovarian cysts, but during the surgical procedure she was found to have a duplex cyst, which was mostly incorporated in the mesentery of the distal 1/3 of the transverse mesocolon. We prepared the patient for definite treatment, and the cyst was enucleated through a lower midline laparotomy incision without bowel resection and anastomosis. The histopathological analysis of the specimen confirmed a mesenteric cyst. Mesenteric cysts are rare lesions in children and should be considered when approaching any intra-abdominal mass. Except for the rare cases where intestinal resection and/or partial cyst excision are required, all mesenteric cysts can be excised while preserving intestinal integrity and vascular supply.