Case Report Duplication Cyst in the Third Part of the Duodenum Presenting with Gastric Outlet Obstruction and Severe Weight Loss

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1 Case Reports in Surgery Volume 015, Artile ID , 4 pages Case Report Dupliation Cyst in the Third Part of the Duodenum Presenting with Gastri Outlet Obstrution and Severe Weight Loss Osama Shaheen, 1 Samer Sara, 1 Mhd Firas Safadi, 1 and Bayan Alsaid 1, 1 Department of Surgery, Almouwasat University Hospital, Damasus, Syria Laboratory of Anatomy, Faulty of Mediine, University of Damasus, Damasus, Syria Correspondene should be addressed to Mhd Firas Safadi; dotor.safadi@gmail.om Reeived 5 August 015; Aepted 8 Otober 015 Aademi Editor: Boris Kirshtein Copyright 015 Osama Shaheen et al. This is an open aess artile distributed under the Creative Commons Attribution Liense, whih permits unrestrited use, distribution, and reprodution in any medium, provided the original work is properly ited. Duodenal dupliation is a rare developmental abnormality whih is usually diagnosed in infany and hildhood, but less frequently in adulthood. We report a ase of a 16-year-old female with a dupliation yst in the third part of the duodenum. The patient presented with symptoms of gastri outlet obstrution, inluding severe anorexia and weight loss. The diagnosis was made preoperatively by CT san and upper endosopy. The yst was suessfully treated by marsupialization on the duodenum using a GIA stapler. Duodenal dupliation presents with a wide variety of symptoms. Although illusive, many ases an be properly diagnosed preoperatively by using the appropriate imaging modalities. Treatment hoies are tailored aording to the size and loation of the yst, in addition to its relation to adjaent strutures. The outomes are favorable in the majority of patients. 1. Introdution Dupliations of the alimentary trat are rare developmental abnormalities. The overall inidene of this ondition is 1 : 5,000, and duodenal dupliation onstitutes 5 1% of all ases [1]. Most ases of duodenal dupliation are seen at the medial border of the first and seond portions of the duodenum. Dupliation of the third portion is even less frequent [, 3]. Here, we report a rare ase of a dupliation yst that ompresses the third part of the duodenum. The yst presented with gastri outlet obstrution and severe anorexia. To our knowledge,thisisthefirstreportedasethatpresentswith severe weight loss and malnutrition in adolesene.. Case Presentation A 16-year-old female presented to the emergeny department of our hospital omplaining of reurrent abdominal pain in the epigastrium espeially after meals, with oasional radiation to the left shoulder. She reported a reent history of persistent nausea and vomiting in addition to severe anorexia and weight loss. The patient looked anxious, dehydrated, and debilitated. She had tahyardia and her BMI was only 15.8 kg/m. Abdominal examination revealed mild tenderness in the epigastrium without rigidity or palpable masses. Laboratory findings showed anemia (hemoglobin 8. g/dl), hypokalemia (potassium 3.1 meq/l), and hypoalbuminemia (albumin. g/dl). Gastri aspiration yielded about one liter of nonbloody aspirate. Abdominal ultrasonography (US) showed severe gastri distension with a big ysti mass in the upper abdomen. Abdominal omputed tomography (CT) showed a ysti lesion measuring m, whih extends along the third part of the duodenum in the retroperitoneum. The lumen of the third part of the duodenum was ompletely obsured. The yst was suspiious for duodenal dupliation (Figure 1). Upper endosopy showed a opious amount of fluids in the stomah with severe gastri dilatation. The third part of the duodenum was nearly oluded, supposedly due to external ompression. Upon laparotomy, a ysti struture was found behind the transverse mesoolon. An extended Koher maneuver was performed, and exploration revealed a big yst along the third part of the duodenum with lose relation to the head

2 Case Reports in Surgery Figure 1: Oral and intravenous ontrast-enhaned CT san of the abdomen. The nonommuniating yst extends along the third portion of the duodenum (: yst). of the panreas (Figure (a)). The duodenum was opened on thelowerlateralwall,andduodenotomyrevealedtheyst whih was protruding inside the lumen of the third duodenal portion (Figure (b)). The yst was opened widely through the ommon wall, and blood lots were extrated from the yst. No abnormal pathologywasnotedinsidetheyst.partoftheommon wall was reseted, and the yst was marsupialized on the duodenum with the aid of a GIA stapler. Finally, a side-toside anastomosis was performed between the duodenotomy site and a jejunal loop about 30 m after the ligament of Treitz (Figure ()). Histopathologi examination onfirmed the diagnosis by identifying a duodenal muosa that lines a smooth musle oat within the wall of the yst (Figure 3). The patient was well and free from symptoms after 1 months of follow-up. She regained her nutritional state and her BMI was 0.5 kg/m. 3. Disussion Dupliation ysts of gastrointestinal trat were first doumented in the mid-19th entury by Reginald Fitz [4]. Three riteria are required for the diagnosis of a dupliation yst: an intimate relation to the gastrointestinal trat, the presene of a smooth musular oat, and the presene of an alimentary muosal lining [4]. Duodenal dupliations represent a low perentage of all dupliations. They an be ysti or tubular, and they may ommuniate with the duodenal lumen, the panreati dut, or rarely the biliary system [4]. These ysts often ontain muosal seretions from the epithelial lining, but many authors reported the presene of purulent ontent or bile [5, 6]. The abnormality is usually diagnosed in infany and hildhood [1]. However, many patients an remain asymptomati until adulthood, and about one third of patients present after 0 years of age [7]. The linial features of duodenal dupliation ysts vary from asymptomati ases to nonspeifi symptoms suh as abdominal pain, abdominal distention, and vomiting [5, 7]. Some patients develop symptoms of gastri outlet obstrution or small bowel obstrution. Uleration or perforation due to thepreseneofanetopimuosamayauseduodenalbleeding or peritonitis, respetively [8]. Duodenal dupliation ysts may also ause reurrent episodes of aute panreatitis beause of the diret pressure applied against the panreati dut. Stone formation was reported in some ases due to stasis inside the yst. Jaundie and intussuseptions have also been reported[6].hemorrhagiasitesisaveryrareompliation of dupliation ysts [9]. Most ysts are 5 m in size. The largest diameter of the yst in our ase was 8 m, whih is relatively large. Only few ases in the literature were larger than 5 m [6]. This was responsible for the severe ompressive symptoms whih inluded anorexia, vomiting, malnutrition, and weight loss. The BMI of our patient was 15.8 kg/m with severe laboratory derangement, and this was not previously reported in any ase of duodenal ysts. The preoperative diagnosis of intestinal dupliations is rarely aurate. The differential diagnosis enompasses all ysti lesions in this region, whih inlude holedohoeles, panreati pseudoysts, ysti tumors of the panreas, mesenteri ysts, and duodenal divertiulums [6]. Endosopi US ould differentiate the dupliation yst by the gut signature or the double-layer wall sign of its wall.ctisvaluableinidentifyingthetype,loation,and the size of the dupliation yst, and the tehnetium san an aid in the detetion of heterotopi gastri muosa in ases ompliated with bleeding [10]. Magneti resonane imaging (MRI) and gastroduodenosopy are other modalities that an be used for diagnosis. Magneti resonane holangiopanreatography (MRCP) is a valuable noninvasive tool for the identifiation of ysts that ommuniate with the biliary tree. Endosopi retrograde holangiopanreatography (ERCP) was also reommended to visualize the panreatiobiliary trat and to determine its relationship with the yst, but ERCP-related ompliations limit its role [9, 11]. The appropriate surgial proedure for a duodenal dupliation yst depends on its type and loation. Consequently, several operative hoies are feasible [1]. Total exision is indiated when the yst is small and not related to the panreatiobiliarytreeortheheadofthepanreas,orwhen the yst is ompliated with an uler, either in the ysti muosa or in the adjaent muosa. Exision is onsidered the proedure of hoie to avoid possible malignant transformation, whih was reported in three ases in the literature [7, 13]. Panreatioduodenetomy is rarely required, but it may be the only hoie in ompliated ysts whih are intimately related to the head of the panreas or the panreatiobiliary tree [11]. Partial resetion of the ommon wall with internal marsupialization on the duodenum is a good management option to avoid injury to the panreas, panreati and bile duts, or any related struture as we did in our ase. Other possibilities inlude ystojejunostomy by a jejunal loop or Roux-en-Y anastomosis [8]. Thesurgeonshouldjudgethebesttreatmentthatrelieves the symptoms without ausing serious ompliations. Total exision was not possible in our ase due to the lose relation oftheysttotheheadofthepanreas,andmarsupialization

3 Case Reports in Surgery 3 1 j 4 (a) (b) () Figure : Operative views of the yst illustrating management steps. (a) Extended Koher maneuver revealed a big yst ompressing the third part of the duodenum, with lose relation to the head of the panreas. (b) The duodenum was opened through the lateral wall of the seond part, whih showed the internal ommon wall between the yst and the third part of the duodenum. The lumen of the of the third part of the duodenum was ompletely oluded. The ommon wall was opened using a GIA-stapler (not shown). () The yst ollapsed after marsupialization and duodenojejunal anastomosis was performed (: yst, j: jejunum, numbers: orresponding parts of the duodenum). Conflit of Interests B The authors delare that there is no onflit of interests regarding the publiation of this paper. V MM Figure 3: Histologial view of the yst wall showing typial struture of duodenal muosa (hematoxylin and eosin, 100) (B: Brunner s glands, MM: muosa musularis, V: duodenal villi). was a safer option for draining the yst and relieving the ompressive symptoms. Advanes in therapeuti endosopy, suh as endosopi muosal resetion, were reently used in the management of some duodenal ysts [5]. More reently, many ases of duodenal dupliation were managed laparosopially, inluding resetion or anastomosis, with favorable outomes [14]. Although duodenal ysts are onsidered a rare entity, we believe that further researh is needed to design a speifi lassifiation system and management riteria for these lesions. Suh diagnosti and therapeuti riteria would spare many patients the sequelae of laparotomy by taking advantage of the reent advanes in minimally invasive and endosopi tehniques. This would only be possible through aumulation of more ases. Therefore, we enourage surgeons to report any lesion of this type with enough details about loation and appropriate treatment options. 4. Conlusion Duodenal dupliation should be onsidered in the differential diagnosis of vague upper abdominal symptoms, espeially when a ysti struture neighboring the duodenum is demonstrated on radiology. Ideal treatment is total exision when feasible. Otherwise the yst may be treated with subtotal exision and/or internal anastomosis. When treated properly, these lesions usually have favorable outomes. Aknowledgments The authors would like to thank Dr. Hadeel Shamma for her help with histopathologi onsiderations and Dr. Anas Shawa for his help with referene material. Referenes [1] R. W. Browning, Duodenal dupliations, Review of Surgery, vol. 0, pp. 6 9, [] W. Y. Inouye, C. Farrell, W. T. Fitts, and T. A. Tristan, Duodenal dupliation: ase report and literature review, Annals of Surgery, vol. 16, no. 5, pp , [3] H. Hata, N. Hiraoka, H. Ojima, K. Shimada, T. Kosuge, and T. Shimoda, Carinoid tumor arising in a dupliation yst of the duodenum, Pathology International, vol. 56, no. 5, pp. 7 78, 006. [4] R. E. Gross, G. W. Holomb Jr., and S. Farber, Dupliations of the alimentary trat, Pediatris, vol. 9, no. 4, pp , 195. [5] H. S. You, S. B. Park, J. H. Kim et al., A ase of duodenal dupliation yst manifested by duodenal polyp, Clinial Endosopy, vol. 45, no. 4, pp , 01. [6] J.-J. Chen, H.-C. Lee, C.-Y. Yeung, W.-T. Chan, C.-B. Jiang, and J.-C. Sheu, Meta-analysis: the linial features of the duodenal dupliation yst, Pediatri Surgery, vol. 45, no. 8, pp , 010. [7] B. Seeliger, T. Piardi, E. Marzano, D. Mutter, J. Maresaux, and P. Pessaux, Duodenal dupliation yst: a potentially malignant disease, Annals of Surgial Onology, vol. 19, no. 1, pp , 01. [8] B. K. Rai, S. Zaman, B. Mirza, G. Hanif, and A. Sheikh, Duodenal dupliation yst having etopi gastri and panreati tissues, APSP Case Reports, vol. 3, no., artile 15, 01. [9] E. Redondo-Cerezo, J. Pleguezuelo-Diaz, M. L. de Hierro et al., Duodenal dupliation yst and panreas divisum ausing aute panreatitis in an adult male, World Gastrointestinal Endosopy, vol., no. 9, pp , 010.

4 4 Case Reports in Surgery [10] N. S. Salemis, C. Liatsos, M. Kolios, and S. Gourgiotis, Reurrent aute panreatitis seondary to a duodenal dupliation yst in an adult. A ase report and literature review, Canadian Gastroenterology,vol.3,no.11,pp ,009. [11] Y. C. Jo, K. R. Joo, D. H. Kim et al., Duodenal dupliated yst manifested by aute panreatitis and obstrutive jaundie in an elderly man, Korean Medial Siene, vol. 19, no. 4, pp ,004. [1]T.Merrot,R.Anastasesu,T.Pankevyhetal., Duodenal dupliations: linial harateristis, embryologial hypotheses, histologial findings, treatment, European Pediatri Surgery,vol.16,no.1,pp.18 3,006. [13] M.M.OrrandA.J.Edwards, Neoplastihangeindupliations of the alimentary trat, British Surgery, vol. 6, no. 4, pp , [14] U. K. Ballehaninna, T. Nguyen, and S. C. Burjonrappa, Laparosopi resetion of antenataly identified duodenal dupliation yst, the Soiety of Laparoendosopi Surgeons, vol. 17,no.3,pp ,013.

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