Endoscopic treatment of a duodenal duplication cyst

 

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A young lady presented to the emergency department with pain in the abdomen for 1 day. She had a history of similar pain in the past. Her clinical examination was unremarkable, except for mild abdominal tenderness. Further investigations suggested diagnoses of acute pancreatitis and a duodenal cyst. Magnetic resonance cholangiopancreatography (MRCP) revealed a cystic lesion in the duodenum in close proximity to the common bile duct (CBD) and the main pancreatic duct (MPD) ([Fig. 1] and [Fig. 2]). The patient improved with supportive care.

An endoscopic ultrasound (EUS), performed after recovery, revealed a cystic lesion with typical layered appearance suggestive of bowel wall in the second part of duodenum. The CBD and MPD were proximal to the lesion ([Fig. 3]). There were no vessels in the wall or within the cystic lesion. The findings suggested a duodenal duplication cyst. The patient declined surgery and opted to undergo endoscopic drainage. The procedure is shown in [Video 1].

An attempt was made to deroof the cyst using an oval snare (SJQ-29-2 Jumbo; Cook Medical Systems, Winston-Salem, North Carolina, USA). The snare could only be applied over part of the cyst wall, which led to only partial deroofing without drainage. The cyst wall was then punctured with a cystotome (Cook Medical Systems). The current was supplied with the Endocut I mode (Erbe Medical Systems, Tübingen, Germany; duration 3 seconds/interval 3 seconds). A guidewire was placed into the cyst and the cyst wall was deroofed using a sphincterotome (Clevercut; Olympus, Tokyo, Japan). The opening was further widened using a 15-mm controlled radial expansion (CRE) balloon (Boston Scientific, Natick, Massachusetts, USA) and the contents were allowed to drain out. A biopsy taken from the open cyst cavity revealed normal duodenal mucosa ([Fig. 4]). At follow-up, the patient was doing well.

Duplication cysts are rare congenital abnormalities. Only 2 % – 12 % are found in the duodenum [1]. Duodenal duplication cysts can occur at any age and are found equally in both sexes [2]. The most common symptoms are abdominal pain and pancreatitis; however, asymptomatic duodenal duplication cysts have also been reported [3]. Concern about malignant change makes surgery the preferred management choice [4]. Endoscopic drainage of the duodenal cysts with regular follow-up is a safe alternative; however, bleeding, perforation of the duodenum, and pancreatitis are potential complications [2].

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• References

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• 3 Koh CC, Wang NL, Lee HC et al. Infected congenital splenic cyst associated with duodenal duplication cyst and malrotation – a case report. J Pediatr Surg 2007; 42: e21-e22
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• 4 Seeliger B, Piardi T, Marzano E et al. Duodenal duplication cyst: a potentially malignant disease. Ann Surg Oncol 2012; 19: 3753-3754
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