Duodenal Duplication Cyst

We read with interest the article by Wada et al. [1], reporting a case of duodenal duplication cyst (DDC) treated with endoscopic partial resection using the O-ring ligation kit. The method described is an ingenious solution, but we would like to ask Dr. Wada whether it might not be dangerous to aspirate and ligate the soft wall of a DDC?

As the authors mention, other types of endoscopic treatment also exist [2] [3] [4] [5]. Last year, a 19-year-old girl presented in our department with intermittent upper abdominal pain. Transabdominal ultrasonography revealed a cystic mass 6.5 × 3.0 × 3.0 cm in size in the right hypochondrium. Endoscopic ultrasonography, hypotonic duodenography, and computed tomography supported the suspected diagnosis of an intraluminal duodenal diverticulum. At duodenoscopy, the orifice of the diverticulum was not found above the cystic pouch, so the final diagnosis was modified to DDC. The papilla of Vater was located 2 cm distal to the cyst. After a cystoduodenostomy had been created according to our routine technique [6], injection of contrast medium into the cyst clearly demonstrated the true nature of the lesion. A needle-knife papillotome with blended current was used to enlarge the incision on the bulging wall of the cyst. Some bleeding occurred. A nasocystic catheter, forming multiple loops, was introduced into the cystic cavity (Figure [1]) for three days to stop bleeding and prevent early collapse and scarring of the hole. A standard papillotome was then used to extend the hole upwards (Figure [2 a]), and a needle-knife to extend it downwards (Figure [2 b]) until an aperture 2 cm in diameter had been created. Histological examination of the biopsy specimen obtained from inside the cyst revealed duodenal mucosa. After a 1-year follow-up period, the patient is symptom-free, and the duodenocystic communication remained largely open, confirming definitive and effective drainage of the DDC.

Figure 1 A nasocystic catheter placed in the cystic cavity, forming multiple loops

Figure 2 A standard papillotome was applied to enlarge the hole upwards (a), and a needle-knife papillotome was used to extend it downwards (b)

References

• 1 Wada S, Higashizawa T, Tamada K. et al . Endoscopic partial resection of a duodenal duplication cyst.  Endoscopy. 2001;  33 808-810
• 2 Hajiro K, Yamamoto H, Matsui H. et al . Endoscopic diagnosis and excision of intraluminal duodenal diverticulum.  Gastrointest Endosc. 1979;  25 151-154
• 3 Hiraoka T, Nakamura M, Ohno K. et al . Endoscopic excision of intraluminal duodenal diverticulum.  Dig Dis Sci. 1985;  30 274-281
• 4 Ravi J, Joson P M, Ashok P S. Endoscopic incision of intraluminal duodenal diverticulum.  Dig Dis Sci. 1993;  38 762-766
• 5 van Os E C, Petersen B T, Kelly D G. et al . Endoscopic management of an intraluminal duodenal diverticulum.  Gastrointest Endosc. 1996;  44 494-497
• 6 Gyökeres T, Topa L, Marton I. et al . Endoscopic cystogastostomy during pregnancy.  Gastrointest Endosc. 2001;  53 516-518