Parachute intestine

A 71-year-old lady with no comorbidities presented with a 2-week history of colicky abdominal pain associated with nausea and constipation. There was no history of vomiting, fever, or weight loss. Physical examination was unremarkable. Axial imaging demonstrated a 3-cm soft tissue mass with spiculated margins in the mesentery of the distal ileum (Fig. 1), multiple hyperdense deposits along the mesenteric vasculature with mesenteric retraction. There was no evidence of liver metastases. On exploratory laparotomy, a 5X6 firm-hard tumour was noted in the mesentery of the terminal ileum with multiple enlarged mesenteric nodes and a confluent nodal mass near the superior mesenteric vessels causing clumping of bowel loops (Fig. 2). Segmental ileocolectomy (Fig. 3) with regional lymphadenectomy and ileocolic anastomosis was performed. The post-operative period was uneventful. Histopathology revealed a grade II neuroendocrine tumour (NET) of the ileum with a Ki-67 of 15%. The patient has been kept under close follow-up. ‘Parachute’ intestine occurs due to an intense desmoplastic reaction, secondary to severe mesenteric fibrosis, causing in-drawing of the affected segment of the bowel loop towards the mesenteric vessels, akin to a parachute. This phenomenon is commonly encountered with mid-gut carcinoid tumours, predisposing patients to recurrent episodes of small bowel obstruction. The primary tumour and/or involved nodes can be involved in the obstructive process. Rarely, ischemia of the affected bowel loop can occur if arterial involvement is significant.1 Multiple profibrogenic cytokines like serotonin, TGF-β and so on, are involved in the desmoplastic process.2 Imaging is diagnostic in most cases, although an entity called mass forming sclerosing mesenteritis can radiologically mimic this condition.3 Desmoplastic small round cell tumours (DSCRT) and metastatic disease (from breast, melanoma, and cholangiocarcinoma primaries) can incite a severe desmoplastic reaction in the mesentery and are close clinical differentials.4 Treatment involves surgical excision of the affected bowel loop along with its mesentery. The involved nodes must be meticulously removed, taking care of the underlying mesenteric vessels, to prevent recurrent obstruction. Prognosis in carcinoid tumours depends on the stage of the disease, degree of the desmoplastic process,5 location, and grade of the tumour.