VM59 - Large Retroperitoneal Cyst Causing Extrinsic Compression Of The Colon And Chronic Constipation

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Purpose/Background: Chronic constipation is one of the most common complaints in gastroenterology and Colon and Rectal Surgery with an estimated prevalence of 15%. Current algorithms and guidelines do not recommend routine imaging testing in the absence of alarm signs. Attention is directed to motility, pelvic floor and identifying patients as functional constipation or IBS-C. Extrinsic compression of the colon has been described as a rare cause for chronic constipation and ischemic colitis. If not suspected on initial evaluation and in the absence of imaging, it´s diagnosis may be missed or delayed.
We present the case of a retroperitoneal cyst causing extrinsic compression of the colon manifesting as long standing chronic constipation, nausea and abdominal pain having received management as IBS-C for years.

Methods/Interventions: 60 yo female, history of left donor nephrectomy, hypothyroidism, dyslipidemia, and hyperuricemia. Sought surgical consultation per abdominal pain attributed to gallstones. H&P with long standing constipation (4-5 days between bowel movements) despite treatment for IBS-C. Nausea, severe bloating, pain lower than expected for gallbladder and palpable RLQ mass. FOBT +. Colonoscopy with extrinsic compression right colon, CT large, unilocular cystic lesion in RLQ and RUQ displacing right colon . MRI: Retroperitoneal cyst possible inclusion or duplication cyst. Negative history for pancreatitis, tb or ovarian cyst.
Laparoscopy: Retroperitoneal cyst displacing cecum and ascending colon medially. Lateral to medial dissection performed. Intact cyst enucleated. No relation with colon mesentery or right kidney was noted.

Results/Outcomes: Postoperative recovery was uneventful. BAAR and cultures are negative. Pathology reports retroperitoneal simple cyst negative for malignancy.
Currently asymptomatic with daily bowel movements without the use of laxatives.
Nausea, bloating and abdominal pain subsided after removal of the cyst. She has discontinued medication used for IBS-C.
Follow up of 15 months without recurrence or complications.

Conclusion/Discussion: This case highlights the importance of awareness for secondary causes of constipation in patients refractory to medical treatment. Delay in the diagnosis and treatment of these may be catastrophic in malignant tumors, and cause progression in size or malignant degeneration of benign cases with the ensuing complications.
A thorough and detailed initial evaluation identifying risk factors and alarm signs remains as the cornerstone for success.
Cystic lesions in the retroperitoneum have a wide differential diagnosis which must be taken in account preoperatively, complete evaluation is warranted and multidisciplinary management may be required. For this case a preoperative OB Gyn consultation was performed, and preoperative and intraoperative Urology consultation was obtained.