Duodenal duplication cyst: beware of the lesser sac collection

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

BACKGROUND

Duodenal duplication cysts are rare gastrointestinal tract malformations. Most patients experience symptom onset in the first decade of life. This review aims to examine clinical presentation, management strategies and outcomes of duodenal duplication cysts in childhood.

METHODS

A Pubmed/Medline (http://www.ncbi.nlm.nih.gov/pubmed/) search in October 2019 for articles published since 1999 using the keywords "duodenal duplication cyst," "child" and "newborn" was carried out. Clinical symptoms, complications, diagnostic examinations, treatment options and outcomes were analyzed and tabulated.

RESULTS

There were 41 citations in the literature providing adequate descriptions of 45 cases of duodenal duplication cysts. The age of presentation ranged from newborn to 18 years. The median interval between initial presentation and definitive diagnosis and treatment was 17 months (range: 2 months to 12 years). Overall, 67% of cases presented with abdominal pain, and 43% were complicated with pancreatitis. Different surgical and endoscopic therapeutic strategies were reported.

CONCLUSIONS

Duodenal duplication cysts may be associated with life-threatening complications and/or recurrent symptoms, impairing quality of life. Early recognition of patients who demonstrate suggestive signs and symptoms is important to ensure success of treatment. This review may be useful to highlight the main diagnostic aspects and limit the risk of a delayed diagnosis.

Two infant cases of intraperitoneal arterial hemorrhage due to a duplication cyst: a case report

Background

Intraperitoneal arterial hemorrhage without trauma is extremely rare. We report two infant cases of intraperitoneal arterial hemorrhage due to intestinal duplication.

Case presentation

In case 1, a 2-month-old girl experienced sudden intraperitoneal hemorrhage from the middle colic artery with no apparent trauma. Hemostasis was achieved with suturing of the hemorrhage point, but the cause of hemorrhage was still unknown. Computed tomography after the first operation revealed a duodenal duplication cyst and a pseudopancreatic cyst. Percutaneous drainage of the pseudopancreatic cyst was performed, and the contents had high pancreatic amylase. As the size of the duodenal duplication cyst also decreased with this drainage, we suspected that the duodenal duplication cyst was connected to the pseudopancreatic cyst and the arterial hemorrhage. We hypothesized that the pancreatic juice inside the duplication cyst leaked into the intraperitoneal cavity and caused rupture of the arterial wall. Therefore, marsupialization of the duodenal duplication was performed to evacuate the pancreatic juice contained in the cyst toward the native duodenum. The postoperative course was uneventful.

In case 2, a 6-month-old boy experienced sudden intraperitoneal hemorrhage without trauma. The hemorrhage site was identified as the ileocecal artery, and hemostasis was achieved with sutures. Tissue near the hemorrhage point was biopsied, because the cause of arterial wall rupture was still unknown. The biopsied tissue was found to be intestinal mucosa. The patient had recurrent abdominal pain after the first operation, and computed tomography showed a duplication cyst located near the hemorrhage point. Therefore, we resected the intestinal duplication. Pathology results showed that the intestinal duplication contained intestinal mucosa, ectopic gastric mucosa, and pancreatic tissue. The postoperative course was uneventful.

Conclusion

Intraperitoneal arterial hemorrhage without trauma is an extremely rare condition, and identifying its cause is difficult. To our knowledge, this is the first report of intraperitoneal arterial hemorrhage due to intestinal duplication. In cases of unexplained intraperitoneal arterial hemorrhage in infants, intestinal duplication near the hemorrhage point should be suspected.

Choledochocele: A Case Report and Discussion of Diagnosis Criteria

A 6-year-old girl presented with intermittent abdominal pain, without jaundice and a palpable mass in the epigastrium. Preoperative imaging and upper endoscopy suggested duodenal duplication. During surgery, the patient was diagnosed with a rare type of choledochal cyst—choledochocele (type 3b). The authors emphasize that, in children, choledochocele should be included in the differential diagnosis of cystic lesions located in the duodenal area and the head of the pancreas area, regardless of jaundice or abnormal liver function. Since mucosal histology showing duodenal mucosa did not match the final diagnosis, we suggest that three criteria should be met for the diagnosis of a choledochocele to be diagnosed: (1) a cyst protruding into the duodenal lumen; (2) filling with contrast during cholangiography and (3) a filling defect on X-ray barium meal.

Alimentary tract duplications in newborns and children: diagnostic aspects and the role of laparoscopic treatment

Alimentary tract duplications are rare congenital lesions normally diagnosed in newborns and children that can occur anywhere from the mouth to the anus and have a reported incidence of approximately 1 in 4500 life births. Symptoms and clinical presentation vary greatly. The presentation varies according to age and location. The treatment finally is surgical; total resection when possible should be the aim of the intervention. In pediatric surgery minimally invasive surgical procedures became more and more important over the last decades. In consequence the operative procedure on alimentary tract duplications changed in this manner. We review on case reports and clinical reports on minimally invasive surgery in the treatment of alimentary tract duplications, determine the importance of minimally invasive techniques in the treatment of this rare entity and rule out that further studies in the field should be performed.

Laparoscopic resection of antenataly identified duodenal duplication cyst

A laparoscopic approach to patients with duodenal duplication cyst may offer a safe alternative to open resection.

We report the first case of complete laparoscopic resection of a duodenal duplication cyst (DDC) in an 8-mo-old patient. The cyst was diagnosed by routine antenatal ultrasound performed at 3 mo of gestational age. Although the baby was born asymptomatic without any congenital abnormalities, the cyst had continued to increase on serial sonographic examinations. Previous reports have described treatment of DDC by surgical resection (laparotomy) or endoscopic marsupialization; we describe here, the first report of laparoscopic approach to resect DDC in a pediatric patient with a favorable outcome.

The anatomy and pathology of the lesser sac: implications for peritoneal dialysis

Pathological conditions involving the lesser sac of the peritoneal cavity in patients on peritoneal dialysis (PD) can pose significant diagnostic and therapeutic challenges. Lack of appreciation of these challenges may delay diagnosis and compromise outcome. A case series by Li and colleagues in this issue of Peritoneal Dialysis International highlights the diagnostic challenges presented by lesser sac infection in PD patients, and in this accompanying commentary we discuss the development and anatomy of the lesser sac, as well as the pathological conditions and investigations relevant to the management of patients on PD.

Meta-analysis: the clinical features of the duodenal duplication cyst

BACKGROUND

Duplication cyst of the duodenum is rare. This study describes a case of duodenal duplication and evaluates its clinical features through a literature review.

METHODS

A case of duodenal duplication is reported, and related articles published from 1999 to 2009 on PubMed were reviewed. Clinical manifestations, diagnostic examinations, and methods of management were analyzed.

RESULTS

Including this report, there had been 38 citations in literature that provide adequate descriptions of 47 cases of duodenal duplication cysts. Nineteen (40.4%) were discovered before 10 years of age, whereas 10 (21.3%) were found in the second decade. The remaining 18 patients (38.3%) were older than 20 years. The case number decreased as age increased. Overall, 80% of cases presented with abdominal pain, and 53% were complicated with pancreatitis.

CONCLUSIONS

The most common symptom in duodenal duplication cysts is abdominal pain with or without nausea or vomiting. The most common complication is pancreatitis. Differential diagnoses of pancreatitis, hepatitis, cholestasis, or intussusception should include duplication cyst of the duodenum.

Treatment of duodenal duplication by trans-umbilical exploratory minimal laparotomy

Duodenal duplication cysts are rare congenital lesions usually diagnosed in infancy, although they may present in adulthood. Prenatal diagnosis is difficult, and postnatal diagnosis relies on ultrasonography, barium swallow, contrast-enhanced computerized tomography, magneticresonance imaging (MRI), and magnetic resonance cholangiopancreatography. A female newborn was diagnosed with an abdominal cyst (size around 6 x 5 x 4 cm) at gestational age (GA) 24 weeks, by regular prenatal examination. After her birth at GA 37 weeks, we performed abdominal ultrasonography and RI, but there was no definite diagnosis. The usual management of an abdominal cyst involves resection by laparotomy (requiring a large incision) or laparoscopy (requiring several small incisions). We performed an exploratory trans-umbilical minimal laparotomy excision for surgery, and the pathology revealed duodenal duplication. In our case, there was no recurrence of the cyst after 18 months follow-up, and the operation scar was almost undetectable. Trans-umbilical minimal laparotomy excision may be considered as an alternative choice for the management of abdominal and duodenal duplication cysts.