An unusual presentation of intestinal duplication mimicking torsion of Meckel's diverticulum: a rare report of a pediatric case

Background

Enteric duplication is a congenital disease that occurs throughout the entire gastrointestinal tract. Although it may sometimes cause intestinal volvulus, a few reports have described cases of enteric duplication twisted on itself. We experienced a rare pediatric case of long-segment tubular ileal duplication showing torsion. Torsion of enteric duplication is extremely rare. We herein report a pediatric case showing unusual torsion of ileal duplication requiring emergency surgery.

Case presentation

A 3-year-old boy presented with abdominal pain and vomiting. Contrast-enhanced computed tomography (CT) revealed a cystic luminal structure with a blind end and fluid collection in the pelvic cavity. CT also showed no findings of ileus or intestinal dilatation except for a cystic luminal structure. The preoperative diagnosis was torsion of Meckel’s diverticulum. The patient underwent emergent explorative diagnostic laparoscopy. As a result, a necrotic luminal structure and bloody ascites were recognized, and small-scale laparotomy was performed. Long-segment ileal duplication was recognized. The long-segment tubular ileal duplication shared the anti-mesenteric side of the intestinal wall along one-third of its length. The residual two-thirds of its length was free from the ileum and its blind end was twisted in a manner that looked similar to Meckel’s diverticulum. Normal ileum and the duplication, including the twisted necrotic portion, were resected, and ileal anastomosis was performed. The postoperative course was uneventful. A pathological examination confirmed the definitive diagnosis of enteric duplication.

Conclusions

We reported the unusual presentation of intestinal duplication mimicking torsion of Meckel’s diverticulum. Enteric duplication shows various clinical symptoms and presentations. We must understand that the classification of digestive enteric duplication is diverse with a variety of associated clinical symptoms.

Enteric duplication in children

INTRODUCTION

Enteric duplication is a congenital anomaly with varied clinical presentation that requires surgical resection for definitive treatment. This had been approached with laparotomy for resection, but has changed with minimally invasive technique. The purpose of our study was to determine the demographics, natural history, operative interventions, and outcomes of pediatric enteric duplication cysts in a contemporary cohort.

METHODS

With IRB approval, we performed a retrospective chart review of all patients less than 18 years old treated for enteric duplication between January 2006 and August 2016. Demographics, patient presentation, operative technique, intraoperative findings, hospital course, and follow-up were evaluated. Descriptive statistical analysis was performed; all medians were reported with interquartile range (IQR).

RESULTS

Thirty-five patients underwent surgery for enteric duplication, with a median age at surgery of 7 months (2.5-54). Median weight was 7.2 kg (6-20). Most common patient presentations included prenatal diagnosis 37% (n = 13). Thirty-four patients (97%) had their cyst approached via minimally invasive technique (thoracoscopy or laparoscopy) with only three (8%) requiring conversion to an open operation. Median operative time was 85 min (54-133) with 27 (77%) patients requiring bowel resection. Median length of bowel resected was 4.5 cm (3-7). Most common site of duplication was ileocecal (n = 15, 42%). Postoperative median hospital length of stay was 3 days (2-5) and median number of days to regular diet was 3 (1-4). No patients required re-operation during their hospital stay. Median follow-up was 25 days (20-38).

CONCLUSION

In our series, most enteric duplication cysts were diagnosed prenatally. These can be managed via minimally invasive technique with minimal short-term complications, even in neonates and infants.

Cysts of Gastrointestinal Origin in Children: Varied Presentation

PURPOSE

Abdominal cysts of gastrointestinal origin are rare. Their rarity and varied clinical presentations make their pre-operative diagnosis difficult.

METHODS

Fourteen patients with histological diagnosis of cysts of gastrointestinal origin admitted between 2009 and 2015 were retrospectively analyzed with respect to age, sex, clinical presentation, diagnostic modality, site and type of cyst, management, outcome and follow-up.

RESULTS

The mean age at presentation was 4 years and there were six males and eight females. Abdominal pain was the most common presenting symptom. Five patients had an acute presentation-three had distal ileal mesenteric cysts and two had ileal duplication cyst sharing a common wall with ileum. Six patients presented with chronic abdominal pain and lump-three patients had omental cysts and three had mesenteric cysts-two of these in distal ileum and one in sigmoid colon. Two patients presented with antenatally diagnosed palpable abdominal lump. One had a mesenteric cyst of the ileum and the other had a distal ileal duplication cyst which required excision with resection and anastomosis. One patient had an atypical presentation. He was a known case of sickle cell trait and had presented with vague abdominal pain, recurrent cough and multiple episodes of haemoptysis over a period of one year. At laparotomy, gastric duplication cyst was found which was excised completely. Histopathology confirmed the diagnosis.

CONCLUSION

Cysts of gastrointestinal origin are rare and have varied presentation. Surgical excision is the mainstay of treatment. The results and prognosis are good.

[Intestinal duplication, a single experiencie center]

PURPOUSE

Intestinal duplications (DI) are rare congenital anomalies (1/10.000 new born). We analyze the clinical characteristics, management and treatment of intestinal duplications in our center.

MATERIALS AND METHODS

We perform a retrospectively descriptive analysis review by the DI confirmed by histological studies since 1993-2014 in our center. The variables analyzed are: age, sex, clinical presentation, localization, anatomical type, associated diseases, heterotopic tissue, treatment and complications.

RESULTS

We found ten patients diagnosed with DI. 60% were male, the middle age was 2.72 years (12 days-7 years). In the clinical presentation 30% presents acute abdomen, another 30% gastrointestinal bleeding and 30% were prenatal diagnosed. Imaging studies were echography, gammagraphy, magnetic resonance imaging and intestinal transit contrast. The most frequent localization was the yeyuno-ileal (60%) with cystic predominance; the gastric, duodenal colic was 10% respectively; an ectopic localization was a suprarenal mass. The treatment was a complete resection by laparotomy in eight cases and laparoscopic in two In the duodenal duplication, we perform a partial resection and mucosectomy. In 60% was necessary the intestinal resection. In anatomy pathologic results, gastric tissue (heterotopic tissue) was present in 70% and pancreatic tissue in 10%. We report an intussusception postsurgical as a complication.

CONCLUSIONS

The preoperative diagnosis is rare, although prenatal diagnosis is increasing. Clinical manifestations are associated with the location of the DI and the existence of heterotopic gastric mucosa. Laparoscopy is currently the treatment of choice in uncomplicated cases.

Ileocecal duplication cysts: is the loss of the valve always necessary?

BACKGROUND

Ileocecal (IC) duplication cysts are enteric duplications located at the IC junction, not clearly identified in all the published series. The reported treatment is IC resection and ileocolic anastomosis. It is well known that the loss of the IC valve has several adverse effects. This study is aimed at demonstrating that cyst removal together with the common ileal wall and following enterorrhaphy is possible, safe, and effective in preserving the IC region.

METHODS

Medical records of 3 patients who underwent surgery for IC duplication between 2003 and 2013 were retrospectively reviewed evaluating follow-up results.

RESULTS

All patients had an antenatal diagnosis of intraabdominal cystic mass. In two cases associated malformations were reported. The lesions presented at newborn age with intermittent small bowel obstruction and required removal. No patients underwent IC resection. The diagnosis of duplication cyst was confirmed by histo-pathologic examination. The postoperative course was uneventful, even in the long-term follow-up.

CONCLUSIONS

Our conservative approach is a simple and safe technique, effective in avoiding the loss of the IC valve in children with duplication at the IC junction.