Treatment of large duodenal duplication cyst using endoscopic submucosal dissection knife

A 21-year-old woman was referred to our hospital for management of a large duodenal duplication cyst. In the preceding 3 months, she had experienced symptoms of bloating, early satiety, and abdominal discomfort. The cyst was first diagnosed 5 years earlier during investigation for her ileal Crohn’s disease, but was not referred because she was asymptomatic at the time.

Magnetic resonance enterography showed a large cystic lesion in the descending duodenum, consistent with a duplication cyst (Fig. 1A). EUS revealed an anechoic submucosal lesion in the descending duodenum, arising from layer 2, and it appeared to have its own muscularis propria layer (Fig. 1B). Duodenoscopy revealed a 3-cm-wide, 6-cm-long cyst on the anterolateral wall of the descending duodenum (Fig. 1C). The major papilla was seen on the inferomedial aspect of the cyst.

Figure 1.

A, Magnetic resonance enterographic view (T-2 weighted) showing large cyst in descending duodenum (arrow).B, EUS view showing anechoic intramural lesion within the descending duodenum. C, Large duodenal duplication cyst. D, Inner wall lined by normal duodenal mucosa. E, Accessory bile duct draining into the cyst. F, Cyst completely laid open.

With the patient intubated and in a left lateral position, a side-viewing duodenoscope was passed to the duodenum. A dissection knife (Endocut Q, effect 3, cut interval 3, cut duration 3; ERBE, Tübingen, Germany) was used to incise the cyst, starting at its most proximal and prominent aspect (Video 1, available online at www.VideoGIE.org). The incision was made in a longitudinal fashion along the long axis of the cyst. The cyst immediately decompressed, draining bile-stained serous-type fluid. No significant bleeding occurred. The inside of the cyst was lined by normal duodenal mucosa (Fig. 1D).

A forward-viewing adult gastroscope was then used to enter the cyst. An accessory bile duct was unexpectedly seen draining from the inner wall of the cyst (Fig. 1E). Injection of contrast material through the gastroscope into the remnant cyst sac demonstrated a residual long cavity distal to the endoscopic incision. Owing to concern regarding the potential for this cavity to act as a sump, the incision was extended, splaying open the entire cyst (Fig. 1F).

The patient was admitted to the hospital after the procedure, kept nil by mouth, and given broad-spectrum intravenous antibiotics with proton pump inhibitor infusion. Her symptoms improved immediately after the procedure. Clear fluids orally were introduced on day 1, and she was discharged home on day 2. Duodenal duplication cysts are rare, but they can be safely and effectively treated endoscopically. Endoscopic submucosal dissection knives can accurately incise a cyst, can effectively cut and coagulate tissue by the use of dedicated electrosurgical settings, allow injection directly through some knives, and are therefore suitably used for this indication.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Endoscopic technique for treatment of a large duodenal duplication cyst.