Duodenal Duplication Cysts in Children: Clinical Features and Current Treatment Choices

Duodenal Duplication Cyst in Adulthood: Case Report and Brief Review of Literature

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Duodenal duplication cyst at the second part of the duodenum with congenital duodenal position anomaly completely resected by laparoscopic partial duodenectomy: a case report

BACKGROUND

Duodenal duplication cysts (DDC) are rare duplications of the alimentary tract. Their treatment depends on their size and location. A radical treatment is total resection, if possible. However, partial excision, puncture, and marsupialization can be selected to prevent surgical injury to the pancreaticobiliary tract despite the risk of recurrence. There are some reports of pancreaticoduodenectomy for DDC because of the risk of recurrent symptoms and malignancy. However, this is considered excessively invasive for DDC, particularly in pediatric cases, because of its extremely low rate of malignancy and high morbidity and mortality rates. We encountered a case of DDC with a congenital duodenal position anomaly occurring in the second part of the duodenum. Taking advantage of the congenital duodenal position anomaly, the DDC was completely resected without injuring the pancreaticobiliary duct.

CASE PRESENTATION

A 6-year-old boy was diagnosed with a duodenal duplication cyst with obstruction. There was a congenital duodenal position anomaly. The distal second part of the duodenum was the dorsal side of the proximal second part of the duodenum and ascended upward from the proximal second part of the duodenum. The third and fourth parts of the duodenum ran downward to the left and posterior parts of the portal vein, forming the ligament of Treitz. Complete laparoscopic resection of the duodenal duplication cyst and the second to fourth parts of the duodenum, and duodenojejunostomy with retrocolic reconstruction was performed because the duodenum was easily mobilized to the ligament of Treitz owing to the duodenal position anomaly. The duodenojejunostomy with retrocolic reconstruction achieved a more physiologically normal appearance compared to what would have been achieved with a Roux-en-Y reconstruction. The patient was discharged on postoperative day 12 without any complications.

CONCLUSIONS

The procedure used in this case might not be easily applied in all laparoscopy cases. However, it could be an option for duodenal duplication cysts with congenital duodenal position anomalies.

Age-specific causes of upper gastrointestinal bleeding in children

The etiology of upper gastrointestinal bleeding (UGIB) varies by age, from newborns to adolescents, with some of the causes overlapping between age groups. While particular causes such as vitamin K deficiency and cow's milk protein allergy are limited to specific age groups, occurring only in neonates and infants, others such as erosive esophagitis and gastritis may be identified at all ages. Furthermore, the incidence of UGIB is variable throughout the world and in different hospital settings. In North America and Europe, most UGIBs are non-variceal, associated with erosive esophagitis, gastritis, and gastric and duodenal ulcers. In recent years, the most common causes in some Middle Eastern and Far Eastern countries are becoming similar to those in Western countries. However, variceal bleeding still predominates in certain parts of the world, especially in South Asia. The most severe hemorrhage arises from variceal bleeding, peptic ulceration, and disseminated intravascular coagulation. Hematemesis is a credible indicator of a UGI source of bleeding in the majority of patients. Being familiar with the most likely UGIB causes in specific ages and geographic areas is especially important for adequate orientation in clinical settings, the use of proper diagnostic tests, and rapid initiation of the therapy. The fundamental approach to the management of UGIB includes an immediate assessment of severity, detecting possible causes, and providing hemodynamic stability, followed by early endoscopy. Unusual UGIB causes must always be considered when establishing a diagnosis in the pediatric population because some of them are unique to children. Endoscopic techniques are of significant diagnostic value, and combined with medicaments, may be used for the management of acute bleeding. Finally, surgical treatment is reserved for the most severe bleeding.

Jejunal duplication cyst in a female neonate: a case report

Introduction and importance

Duplications are the abnormal portion of the intestine, either externally attached to the intestine or intrinsically placed within the bowel lumen. Their prevalence is noted to be around one in 25 000 deliveries. The rare gastrointestinal tract duplication may be located in any part of the gastrointestinal system from the oral cavity to the anus. The most common site of enteric duplication cyst (DC) is the terminal part of the ileum. Hence, duplications in jejunum are rare.

Case presentation

Hereby, the authors report a case of jejunal DC in a female neonate which was managed successfully via surgery and adequate post-operative care without any complications.

Clinical discussion

Duplications are more frequently single. They are usually located in the mesenteric border of the associated native bowel and may vary in shape and size. Most of them are cystic, followed by tubular and mixed type, with or without other congenital anomalies. More than 80% of the cases present before the age of 2 years as an acute abdomen or bowel obstruction, but many duplications remain silent unless complications occur, and therefore may not be diagnosed until adulthood. Complications of enteric DC include volvulus, bleeding, and, rarely, malignant degeneration.

Conclusion

It is important for paediatric surgeons to include DC in the differential diagnosis if a neonate presents with features of intestinal obstruction.

Tubular intestinal duplication extending from the stomach to the ileum associated with multiple intestinal atresia and situs inversus: a case report

BACKGROUND

Duplication of the alimentary tract can occur in any of its parts. For duodenal duplication, complete resection is particularly difficult when the ampulla of Vater is on the duplicated lumen and a deliberate management is necessary.

CASE PRESENTATION

A 0-day female baby was referred to our department due to abdominal distention. The X-ray examination showed dextrocardia and opacity of the liver on the left side and abdominal ultrasonogram revealed remarkable intestinal dilatation. Therefore, urgent laparotomy was performed on the day of birth. Complete situs inversus of the abdominal organs was revealed, and the origin of the jejunum was on the left side and was accompanied by tubular intestinal duplication. The origin of the duplicated intestine was at the pancreatic head's dorsal area. There were two points of type Шa atresia on the ileum. Therefore, we spared the duplicated intestine with a length of 3 cm to secure the passage of the biliary and pancreatic juices by a functional-side-to-side anastomosis with a 45-mm Endo-GIA™ camel load (Medtronic, Minneapolis, MN, USA). The ileum was transected at the distal side of the atresia point, and end-to-end jejunoileostomy was performed. Postoperative gastrointestinal series revealed remnants of the duplicated alimentary tract on the dorsal area of the stomach.

CONCLUSIONS

Identifying the position of the ampulla of Vater is crucial in the surgery of alimentary tract duplication with duodenal involvement. However, in the present case, it was difficult to identify whether the ampulla of Vater was on the true or duplicated lumen, and we had to spare the duplicated duodenum. Stapler anastomosis could be performed safely even in neonatal cases.

All Vomit Is Not Viral

Duplication cysts are congenital malformations of the gastrointestinal tract. They are rare, occurring in 1 in 4,500 births.1 Although the age of symptomatic onset is typically 2 years, current literature shows reports of presentation from newborn to adulthood. Presentation of duplication cysts may vary widely and can occur during outbreaks of acute infectious gastroenteritis cases. Thus, it is important to consider these cysts in the differential diagnosis of the vomiting child. We report the case of a 7-year-old boy with persistent bilious vomiting who was found to have a bilobed duplication cyst. [Pediatr Ann. 2023;52(7):e273-e276.].

Diagnosis and surgical management of a rare case of duodenal duplication cyst in a neonate: Case report and literature review

INTRODUCTION AND IMPORTANCE

Duodenal duplication cysts are a rare subtype of alimentary tract duplications cysts, consisting of 7 % of all the duplications. The clinical presentation is variable, depending on the size, location and mass effect. Most duodenal duplication cysts abut the second or third portion of the native duodenum. The standard treatment of choice for symptomatic enteric duplication cysts is complete surgical removal. In our case, by examining the abdomen, ectopic pancreatic tissue was found on the wall of the transverse colon, along with Meckel's diverticulum, 50 cm from the ileocecal junction.

CASE PRESENTATION

We present a newborn case presented to the hospital with a history of abdominal mass with jaundice. Abdominal ultrasonography and CT scan show the presence of a cystic mass without specifying its exact source. By opening the abdomen, it was found at the expense of the duodenum, and it was excised and On histopathological analysis, a duodenal duplication cyst was diagnosed. The literature was reviewed and the approach to duodenal duplication cyst in neonates is discussed.

CLINICAL DISCUSSION

Duodenal duplication cysts are rare, even so should be taken into consideration when a mass is found. A thorough imaging investigation is crucial in establishing the diagnosis along with histopathology.

CONCLUSION

When diagnosing a Duodenal duplication cysts, the cyst must be completely removed because potential risk of malignant transformation.

Laparoscopic cyst enucleation is a promising technique for treatment of gastrointestinal tract duplications in children

BACKGROUND

Laparoscopic cyst enucleation has its advantages and limitations in treatment of gastrointestinal tract (GIT) duplications. It allows to avoid bowel resection in such locations as ileocecal valve. We introduced laparoscopic cyst enucleation with further bowel plasty using cyst muscle layer and without monopolar coagulation, for cyst dissection we used straight scissors.

MATERIALS AND METHODS

Our study included 20 children with GIT duplications, who underwent cyst enucleation from 2018 to 2021. Laparoscopy was performed in all cases with various cyst locations (stomach - 2, duodenum - 3, small bowel - 14, ileocecal area - 1). Mean age of surgery was 40 ± 35,3 days (min 6 days, max 150 days).

RESULTS

Mean operation time was 84,4 ± 27,35 min (min - 40 min, max - 160 min). We had no intraoperative complications. All patients received parenteral feeding for 3-5 days after the operation. Postoperative complications occurred in 3 cases: bowel perforation which required enterostomy (10%) and bowel volvulus required resection (5%). To our opinion, perforations occurred due to monopolar coagulation used for cyst enucleation in these children. No complications were observed in patients who underwent enucleation by straight scissors. Mean postoperative hospital stay was 15.6 ± 10.48 days (min - 4 days, max - 58 days). We observed neither stenosis nor any other complications in the long-term follow-up.

CONCLUSIONS

Laparoscopic cyst enucleation is a feasible and safe approach for GIT duplications. It allows to avoid bowel resection, and the use of straight scissors instead of monopolar coagulation provides less postoperative complications such as perforation.

THE LEVEL OF EVIDENCE

III.

[A 19-year-old female patient with acute pancreatitis of unusual cause]

We report the case of a 19-year-old woman with abdominal pain and diarrhea. The diagnosis of acute pancreatitis could be made clinically and through laboratory tests. The cause was a duodenal duplication cyst in the area of the papilla, which was initially relieved endoscopically. Once the acute inflammation had healed, the cyst was resected endoscopically to prevent recurrence and the increased risk of malignancy. Duodenal duplication cysts in the papillary area are a very rare (congenital) cause of acute pancreatitis. If a cyst is present in the area of the duodenal wall, however, this differential diagnosis should be considered. Resection is indicated for therapy.

[Upper gastrointestinal duplication complicated by perforation in a child]

Gastrointestinal duplications are rare congenital malformations occurring in embryonic period of development of digestive system. These abnormalities are usually found in infancy or early childhood. Clinical presentation is extremely diverse depending on dimensions, localization and type of duplication. The authors present duplication of antral and pyloric parts of the stomach, the 1st segment of the duodenum and pancreatic tail. Mother with a 6-month-old child turned to the hospital. According to the mother, the child was sick for about 3 days when episodes of periodic anxiety first appeared. Upon admission, abdominal neoplasm was suspected after ultrasound. On the second day after admission, anxiety increased. There was impairment of appetite, and the child rejected food. Abdominal asymmetry in umbilical area was observed. Considering clinical data on intestinal obstruction, emergency transverse right-sided laparotomy was performed. A tubular structure was found resembling intestinal tube was found between the stomach and transverse colon. Surgeon found duplication of antral and pyloric parts of the stomach, the 1st segment of the duodenum and its perforation. During further revision, additional pancreatic tail was diagnosed. En-bloc resection of gastrointestinal duplications was carried out. Postoperative period was uneventful. Enteral feeding was initiated after 5 days, and the patient was transferred to surgical unit. The child was discharged after 12 postoperative days.

Isolated duodenal duplication cyst in a neonate

Duodenal duplication cysts are a rare subtype of alimentary tract duplications cysts, consisting of 7% of all the duplications. We report a rare case of neonatal duodenal duplication cyst presenting as a palpable abdominal mass and features of gastric outlet obstruction. A 27-day-old male child presented with complaints of icterus, non-bilious vomiting after every feed and right-sided abdominal lump for the last 15 days. A computed tomography scan of the abdomen revealed well-defined peripherally enhancing cystic lesion noted in the subhepatic region extending up to the right lumbar region. On surgical exploration, a cystic mass was found attached to the pyloric part of the stomach along the mesenteric border of the first, second and third part of the duodenum, which was marsupialised, and no communication was found with the duodenum. On histopathological analysis, a duodenal duplication cyst was diagnosed without any heterotopic mucosa. The literature was reviewed and the approach to duodenal duplication cyst in neonates is discussed.

Endoscopic Management of Symptomatic Duodenal Duplication Cysts: Two Case Reports

Background

Duodenal duplication cysts (DDCs) are rare congenital anomalies typically manifesting during childhood. Clinical manifestations are uncommon in adulthood. DDCs were classically treated surgically, but endoscopic treatment has been increasingly reported. Endoscopic cyst marsupialization establishes a communication between the cyst cavity and the duodenal lumen so that the cystic content can be drained continuously into the duodenum. We herein describe two cases of symptomatic DDCs diagnosed in adulthood and submitted to endoscopic marsupialization using different techniques and devices.

Case Summary

Case 1: A 23-year-old female patient was admitted with the diagnosis of acute pancreatitis. Endoscopic ultrasound revealed a 35-mm duodenal subepithelial lesion whose proximal limit was immediately distal to the ampulla of Vater and filled with fluid and calcifications. Using a duodenoscope, deroofing of the lesion was made with a diathermic snare. Pathology confirmed the diagnosis of DDC. Case 2: A 41-year-old female, submitted to laparoscopic cholecystectomy 1 month earlier due to suspected lithiasic acute pancreatitis, was admitted due to suspicion of iatrogenic biliary fistula. An endoscopic retrograde cholangiopancreatography was performed and the bile leak was treated. Immediately distal to the papillary orifice, a 20-mm subepithelial lesion was also detected. A biopsy forceps was used to fenestrate its wall, allowing the exit of mucous fluid and stones, and a sphincterotome was used to expand the incision. No recurrence was documented in both cases.

Conclusion

These cases highlight DDC as a potential cause for acute pancreatitis in adults and endoscopy as an easy treatment option.