Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Gastrointestinal Duplications Treatment & Management

  • Author: Amulya K Saxena, MD, PhD; Chief Editor: Harsh Grewal, MD, FACS, FAAP  more...
 
Updated: Apr 28, 2016
 

Approach Considerations

Surgical resection is the preferred method of treatment for most gastrointestinal (GI) duplications; however, for duodenal duplications, surgical resection is inadvisable because of the close proximity of such cysts to the biliary and pancreatic ductal system. Patients presenting with complex tubular colonic duplications may not require a surgical approach if internal communication of the duplication is adequate and the colon is normal.

Next

Medical Therapy

Before treatment begins, GI duplications must be evaluated with respect to their localization in terms of common blood supply and the search for heterotrophic gastric mucosa. In cervical esophageal duplications, the trachea must also be evaluated. Similarly, endoscopic evaluation of the genitourinary tract is recommended in selected hindgut duplications.

The preferred treatment of GI duplications is excision[27, 28] ; however, in colonic duplications, which feature communication proximally and distally between the duplication and the normal colon, administration of stool softeners and enemas can improve symptoms.

Previous
Next

Surgical Therapy

Because most duplications have a mesenteric location, they share a common blood supply with the normal organ.[29] If feasible, segmental resection may be performed (see the image below). Otherwise, one may excise or "shell out" the cyst if an adequate plane is present. Mucosal stripping has also been described. If excision is not possible—for example, because of proximity to the biliary or pancreatic ducts—a drainage procedure may be performed. However, if this is planned, one must determine whether gastric mucosa is present (with technetium scan); if so, it must be excised to prevent future ulceration.

Jejunal duplication in a newborn. Intraoperative i Jejunal duplication in a newborn. Intraoperative image demonstrates a cystic structure found on the antimesenterial side of the jejunum. A segmental resection was performed and the jejunum anastomosed.

 In colon and rectal duplications below the peritoneal reflection, endoscopy of the genitourinary tract should be performed preoperatively to rule out associated anomalies.

Laparoscopic approaches to the resection of alimentary tract duplications in children are being described with increasing frequency.[30]

Cervical esophageal duplications

Surgical treatment involves the excision of the cyst. Total mucosectomy is also curative.

Thoracic and thoracoabdominal duplications

Treatment involves excision of the cyst. Combined thoracoabdominal cysts make up fewer than 2% of all duplications. If staged excision is planned, the duplication remaining after the primary excision should have a communication with the GI tract or be drained externally to prevent compression if it expands because of hemorrhagic secretions.

Gastric duplications

In most cases, resection can be accomplished without entering the stomach by resecting the shared wall between the stomach and the duplication. Gastric resection is generally not required.

Duodenal duplications

Surgical resection is the treatment of choice; however, drainage of the duplication cysts into the duodenum or into a Roux limb of the jejunum is an acceptable alternative if a risk of injury to the biliary or pancreatic ductal system is observed.

Preoperative endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiography (PTC), or magnetic resonance cholangiopancreatography (MRCP) should be performed to evaluate the involvement of the biliary and pancreatic ducts. These studies may also distinguish between duodenal duplication and a choledochal cyst if the diagnosis is unclear. Cholangiography may also be performed intraoperatively to characterize the ductal anatomy in relation to the cyst.

Excision should be performed if gastric mucosa is present to avoid later ulceration. Marsupialization and external drainage have no value.

Pyloric duplications

These are extremely rare but have been detected upon endoscopic investigation.[31]

Small-intestine duplications

Segmental resection along with the adjacent intestine is the preferred treatment for small cystic or short tubular duplications. Cystic duplications (in the absence of gastric mucosa) that cannot be resected may be drained into a Roux limb. Long tubular duplications that cannot be resected because of their length can be managed by means of intestinal lengthening procedures, mucosal stripping through multiple incisions (when separation is not possible), or diversion into the stomach.

Colonic duplications

Cystic

In cases of smaller cysts, complete excision of the duplication and its attached normal colon is preferred. However, because long colonic duplications generally have an opening to the normal colon, enlarging these internal communications by excising a small part of the common wall to permit reentry from the duplication into the normal colon is sufficient.

Tubular

If the duplication is fused with a normal rectum and perineal anus, the duplication can be connected transanally by excising part of the common rectal wall. Smaller duplications may also be treated by excising the fistula wall, making it part of the common rectum. Tubular duplications may also be treated by excising the lesion with the normal colon, by enlarging existing communications with the normal bowel, or by excising the common wall.

Tubular duplications often extend below the peritoneal reflection, and they are associated with abnormalities of the genitourinary tract. Preoperative cystoscopy and vaginoscopy/hysteroscopy should be performed to identify duplication, fistula, or other abnormalities of the bladder, urethra, or genital tract.

Rectal duplications

The general approach to rectal duplications involves transanal exposure of the cyst, incision of the posterior rectal mucosa, drainage of the cyst, and stripping of the the cyst wall mucosa. Total excision may also be performed via the transanal, posterior sagittal, or transcoccygeal (Kraske) approach.

Previous
Next

Complications

GI duplications can be found along the entire length of the GI tract; therefore, the complications that may occur after surgical excision of these duplications depend on the location of the lesions.

Untreated GI duplications may lead to the following complications:

  • Severe and possibly life-threatening respiratory distress may occur in patients with cervical esophageal duplications
  • Ectopic gastric mucosa in a duplication can lead to peptic ulceration, bleeding, perforation, and peritonitis
  • Recurrent pancreatitis may occur from gastric duplications communicating with the pancreatic duct
  • Neoplastic changes have been reported in patients with untreated GI duplications
  • Hematochezia, hemorrhoids, fistulas-in-ano, or anal abscess may recur in patients with untreated rectal duplications
Previous
Next

Long-Term Monitoring

Surgical excision of GI lesions is generally curative; however, follow-up is important after the treatment of certain types of duplications.

Pancreatitis may occur after surgical management of gastric or duodenal duplications because of the proximity of the duplications to the pancreaticobiliary tree.

Recurrent bleeding may occur after mucosal stripping of the duplication in cases where complete excision is not possible.

Patients undergoing medical therapy with stool softeners and who have had cystic colonic duplications require regular clinical evaluation.

Severe duplications of external genitalia associated with tubular colonic duplications pose a cosmetic problem, and counseling is required.

Continence studies (eg, rectal manometry) are advisable for patients who have been treated for rectal duplications.

Previous
 
Contributor Information and Disclosures
Author

Amulya K Saxena, MD, PhD Consultant Pediatric Surgeon, Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Healthcare NHS Fdn Trust, Imperial College London, UK

Amulya K Saxena, MD, PhD is a member of the following medical societies: International Pediatric Endosurgery Group, British Association of Paediatric Surgeons, European Paediatric Surgeons' Association, German Society of Surgery, German Association of Pediatric Surgeons, Tissue Engineering and Regenerative Medicine International Society, Austrian Society for Pediatric and Adolescent Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Deborah F Billmire, MD Associate Professor, Department of Surgery, Indiana University Medical Center

Deborah F Billmire, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Phi Beta Kappa, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Harsh Grewal, MD, FACS, FAAP Professor of Surgery, Cooper Medical School of Rowan University; Chief, Division of Pediatric Surgery, Cooper University Hospital

Harsh Grewal, MD, FACS, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Surgical Education, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons, Southwestern Surgical Congress, Eastern Association for the Surgery of Trauma, Children's Oncology Group, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

Additional Contributors

Rebeccah Brown, MD Associate Director of Trauma Services, Associate Professor, Department of Clinical Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center and University of Cincinnati Hospital

Rebeccah Brown, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, American Medical Womens Association

Disclosure: Nothing to disclose.

References
  1. Yang MC, Duh YC, Lai HS, et al. Alimentary tract duplications. J Formos Med Assoc. 1996 May. 95(5):406-9. [Medline].

  2. Nobuhara KK, Gorski YC, La Quaglia MP, Shamberger RC. Bronchogenic cysts and esophageal duplications: common origins and treatment. J Pediatr Surg. 1997 Oct. 32(10):1408-13. [Medline].

  3. Iyer CP, Mahour GH. Duplications of the alimentary tract in infants and children. J Pediatr Surg. 1995 Sep. 30(9):1267-70. [Medline].

  4. Kumar A, Kumar J, Gadodia A, Chumber S, Aggarwal L. Multiple short-segment colonic duplications. Pediatr Radiol. 2008 May. 38(5):567-70. [Medline].

  5. Puligandla PS, Nguyen LT, St-Vil D, et al. Gastrointestinal duplications. J Pediatr Surg. 2003 May. 38(5):740-4. [Medline].

  6. Stern LE, Warner BW. Gastrointestinal duplications. Semin Pediatr Surg. 2000 Aug. 9(3):135-40. [Medline].

  7. Shah A, More B, Buick R. Pyloric duplication in a neonate: a rare entity. Pediatr Surg Int. 2005 Mar. 21(3):220-2. [Medline].

  8. La Quaglia MP, Feins N, Eraklis A, Hendren WH. Rectal duplications. J Pediatr Surg. 1990 Sep. 25(9):980-4. [Medline].

  9. Nagar H. Duplications of the gastrointestinal tract. Isr Med Assoc J. 1999 Dec. 1(4):254-6. [Medline].

  10. Barlev DM, Weinberg G. Acute gastrointestinal hemorrhage in infancy from gastric duplication: imaging findings. Emerg Radiol. 2004 Feb. 10(4):204-6. [Medline].

  11. Klimopoulos S, Gialvalis D, Marougas M, Zotos D, Orfanos N, Roussakis A, et al. Unusual case of massive hemorrhage of a gastric duplication cyst in a very advanced age. Langenbecks Arch Surg. 2009 Jul. 394(4):745-7. [Medline].

  12. Sharma D, Bharany RP, Mapshekhar RV. Duplication cyst of pyloric canal: a rare cause of pediatric gastric outlet obstruction: rare case report. Indian J Surg. 2013 Jun. 75:322-5. [Medline]. [Full Text].

  13. Brown RL, Azizkhan RG. Gastrointestinal bleeding in infants and children: Meckel's diverticulum and intestinal duplication. Semin Pediatr Surg. 1999 Nov. 8(4):202-9. [Medline].

  14. Temiz A, Oguzkurt P, Ezer SS, Ince E, Gezer HÖ, Hiçsönmez A. Different clinical presentations, diagnostic difficulties, and management of cecal duplication. J Pediatr Surg. 2013 Mar. 48(3):550-4. [Medline].

  15. Karaman I, Karaman A, Arda N, Cakmak O. External cystic rectal duplication: an unusual presentation of rectal duplication cyst. Singapore Med J. 2007 Nov. 48(11):e287-8. [Medline].

  16. Hur J, Yoon CS, Kim MJ, Kim OH. Imaging features of gastrointestinal tract duplications in infants and children: from oesophagus to rectum. Pediatr Radiol. 2007 Jul. 37(7):691-9. [Medline].

  17. Pinter AB, Schubert W, Szemledy F, et al. Alimentary tract duplications in infants and children. Eur J Pediatr Surg. 1992 Feb. 2(1):8-12. [Medline].

  18. Berrocal T, Torres I, Gutierrez J, et al. Congenital anomalies of the upper gastrointestinal tract. Radiographics. 1999 Jul-Aug. 19(4):855-72. [Medline].

  19. Hur J, Yoon CS, Kim MJ, Kim OH. Imaging features of gastrointestinal tract duplications in infants and children: From oesophagus to rectum. Pediatr Radiol. 2007 Jul. 37(7):691-9. [Medline].

  20. Macpherson RI. Gastrointestinal tract duplications: clinical, pathologic, etiologic, and radiologic considerations. Radiographics. 1993 Sep. 13(5):1063-80. [Medline].

  21. Jayaraman MV, Mayo-Smith WW, Movson JS, et al. CT of the duodenum: an overlooked segment gets its due. Radiographics. 2001 Oct. 21 Spec No:S147-60. [Medline].

  22. Liu R, Adler DG. Duplication cysts: Diagnosis, management, and the role of endoscopic ultrasound. Endosc Ultrasound. 2014 Jul. 3 (3):152-60. [Medline].

  23. Faigel DO, Burke A, Ginsberg GG, et al. The role of endoscopic ultrasound in the evaluation and management of foregut duplications. Gastrointest Endosc. 1997 Jan. 45(1):99-103. [Medline].

  24. Kuo HC, Lee HC, Shin CH, et al. Clinical spectrum of alimentary tract duplication in children. Acta Paediatr Taiwan. 2004 Mar-Apr. 45(2):85-8. [Medline].

  25. Segal SR, Sherman NH, Rosenberg HK, et al. Ultrasonographic features of gastrointestinal duplications. J Ultrasound Med. 1994 Nov. 13(11):863-70. [Medline].

  26. Jehangir S, Ninan PJ, Jacob TJ, Eapen A, Mathai J, Thomas RJ, et al. Enteric duplication in children: Experience from a tertiary center in South India. J Indian Assoc Pediatr Surg. 2015 Oct-Dec. 20 (4):174-8. [Medline].

  27. Karnak I, Ocal T, Senocak ME, Tanyel FC, Buyukpamukcu N. Alimentary tract duplications in children: report of 26 years' experience. Turk J Pediatr. 2000 Apr-Jun. 42(2):118-25. [Medline].

  28. Stringer MD, Spitz L, Abel R, et al. Management of alimentary tract duplication in children. Br J Surg. 1995 Jan. 82(1):74-8. [Medline].

  29. Ildstad ST, Tollerud DJ, Weiss RG, et al. Duplications of the alimentary tract. Clinical characteristics, preferred treatment, and associated malformations. Ann Surg. 1988 Aug. 208(2):184-9. [Medline].

  30. Patiño Mayer J, Bettolli M. Alimentary tract duplications in newborns and children: diagnostic aspects and the role of laparoscopic treatment. World J Gastroenterol. 2014 Oct 21. 20 (39):14263-71. [Medline].

  31. Sauer B, Staritz M. [The double pylorus - a rare endoscopic finding]. Dtsch Med Wochenschr. 2012 Feb. 137(8):368-70. [Medline].

 
Previous
Next
 
Jejunal duplication in a newborn. Intraoperative image demonstrates a cystic structure found on the antimesenterial side of the jejunum. A segmental resection was performed and the jejunum anastomosed.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.