Gastric duplications are twice as common in females as in males.
Gastric duplications present with vomiting and GI bleeding.
Gastric duplications are usually associated with an upper abdominal cystic lesion.
Presenting Signs and Symptoms
Gastric duplications usually present before the age of 1 year. They occur twice as often in girls as in boys. The most common symptom at presentation is nonbilious vomiting. Gastrointestinal hemorrhage is frequently seen, either as melena or as hematemesis. Other presenting symptoms include abdominal mass, failure to thrive, and abdominal pain. In a review of 88 gastric duplications, 58 occurred on the greater curve, 7 on the lesser curve, 5 on the anterior wall, 9 on the posterior wall, and 2 in the pylorus.
The most common complication of gastric duplications is gastrointestinal bleeding, which occurred in 27 of 55 cases in 1 review. Other complications include perforation with peritonitis, recurrence of the cyst after incomplete resection, perforation with fistulous connection to the spleen and left lower lobe of the lung, and fistulous connection to the right lower lobe of the lung. Untreated gastric duplications are associated with malignant degeneration.
The suspected diagnosis of gastric duplication has historically been confirmed by upper GI series or by ultrasound (Fig. 51-3). CT scan is an excellent way to delineate the dimensions and anatomic boundaries of the lesion; it has the added advantage of contrast in the GI tract, which will help to determine whether a connection to the stomach is present (Fig. 51-4). Because pancreatic pseudocysts are the most common cysts in the lesser sac, the most common error in diagnosis is mistaking a gastric duplication for a pancreatic pseudocyst.
Abdominal ultrasound exam demonstrating a gastric duplication. An in utero ultrasound of the fetus had demonstrated an upper abdominal cystic structure.
Abdominal CT image showing a greater curvature gastric duplication cyst (arrow).
Few specific anomalies are commonly associated with gastric duplications. Case reports of an imperforate anus and vertebral anomalies do appear in the literature. Pancreatitis has been reported in association with gastric or duodenal duplications and will be discussed subsequently.
Because gastric duplications have a high rate of complications, most commonly bleeding, the presence of the lesion is an indication for resection. Most lesions occur on the greater curve of the stomach and share blood supply with the stomach via the gastroepiploic vessels. Excision of the cyst, including its mucosa, and part of the common wall, with closure of the serosal defect, is the simplest treatment (Fig. 51-5). An alternate but similar method is the technique of White. The cyst is first aspirated under direct vision to prevent spillage and to make the excision easier. The cyst is then opened along its entire length. This produces 2 “flaps” of the cyst, with the base of the flaps on the common wall. Each of these flaps is resected back to the common wall, being careful to protect the gastroepiploic vessels. Next, the small mucosal strip at the base is stripped off the stomach. In the original description of this technique, the transverse colon was sutured to the “bed” of the cyst. Lembert sutures may be used to invert the raw area if it is not too large. One other option for resection is to remove the entire common wall and reconstruct the stomach. This option is best for those lesions that connect to the stomach and in which there is difficulty in separating the cyst from the stomach.
Postresection specimen of a greater curvature gastric duplication cyst.
If the cyst connects to the lumen of the stomach, the connection must be sutured after the duplication is resected. Care should be taken after any such resection to check the integrity of the stomach by filling it with air through the nasogastric tube and checking for leaks.
Pyloric duplications are a rare form of gastric duplication. Figure 51-6 shows a large pyloric duplication attached on the greater curvature of the stomach at the pylorus. A recent review found only 13 reported cases. The average age at presentation was 27 days, with the oldest being 5 months. Unlike gastric duplications that have a significant female preponderance, 7 of 13 patients were male. The size of the cysts ranged from 1 to 8 cm and none of the cysts communicated with the lumen. Most infants were initially felt to have pyloric stenosis. Ten of the 13 patients in the review presented with vomiting, and 7 had a palpable abdominal mass. Upper GI series and ultrasound were the most common diagnostic modalities. The surgical treatment of choice is complete extramucosal excision of the duplication. Other procedures have been done, including gastrojejunostomy and mucosal stripping; however, these more complicated procedures are rarely indicated.
A large pyloric duplication attached to the greater curve of the stomach at the pylorus. The ring forceps are on the greater curve of the stomach, and the DeBakey forceps point to the duodenum. The resection is partially complete circumferentially and you can see the separation of the duplication from the pylorus. The duplication was completely removed without opening the gastric mucosa.
Duodenal duplication's male incidence is equal to that in females.
Duodenal duplications often present with vomiting and GI bleeding.
Duodenal duplications may present with jaundice.
Duodenal duplications present with a cystic mass in the pancreatic and duodenal area.
Duodenal duplications are an unusual form of gastrointestinal duplications. In a review of 281 GI duplications, 5% were duodenal duplications. They occur in the first and second portions of the duodenum, are commonly cystic, and usually do not connect to the duodenal lumen. The most common location is on the mesenteric side of the anterior wall (Fig. 51-7). Most duodenal duplications are single, although they have been reported to occur in association with the Meckel diverticulum and other duodenal, gastric, thoracic, and ileal duplications.
Duodenal duplication located within the “C-loop” of the duodenum. The duplication and the duodenum share a common muscular wall.
Presenting Signs and Symptoms
Duodenal duplications usually present before the age of 10 years, and at least half present in the first few months of life. Males and females are equally affected. In a large review of the literature, vomiting and gastrointestinal bleeding were the most common presenting symptoms. A palpable mass was noted in 22 of 55 cases and 1 patient presented with obstructive jaundice. Both biliary colic and pancreatitis have been described in association with duodenal duplications.
Complications include duodenal obstruction, biliary obstruction, pancreatitis, necrosis of the duplication, and perforation of the duplication.
The diagnosis can be made on upper GI series, although ultrasound and CT scan are excellent, and are better imaging studies for this lesion. The presence of a cyst with motility in its wall as seen on ultrasound is highly suggestive of a duplication. Other helpful studies may include endoscopic retrograde cholangiopancreatography (ERCP) in that some lesions connect to the pancreatic duct, and (2, 6 diisoprepyl acelanilid) technetium-99m iminodiacetic acid scan or magnetic resonance cholangiopancreatography (MRCP) to rule out choledochal cyst.
Several treatment options are available, including resection of the cyst either alone or with the duodenum. Usually, the lesions contain duodenal mucosa; however, they contain gastric mucosa in 21% of cases. The presence of gastric mucosa is an important factor because total resection of those cysts, if possible, may lead to fewer peptic complications in the postoperative period. The original operation described to treat duodenal duplications is the transduodenal opening of a connection or window between the cyst and the duodenum. Care must be taken to protect the bile duct when using this procedure. This same concept has been expanded to include endoscopic creation of a window between the cyst and duodenum. Another option is drainage of the cyst with a Roux-en-Y cystojejunostomy. The advantage of this procedure is its simplicity and a lesser dissection. This option is good if resection of the lesion is likely to compromise the vascularity to the duodenum or disrupt the biliary system. It seems prudent to use this option if the cyst does not contain gastric mucosa on frozen section.