Approach Considerations
Indications for surgical intervention with regard to duplications of the alimentary tract often arise in an acute setting. Specifically, patients with previously undetected duplications may present in the setting of bowel obstruction or severe gastrointestinal (GI) hemorrhage (ie, ulcerating gastric mucosa within a duplication cyst). If incidentally encountered, duplications should be surgically addressed to avoid future complications.
No specific contraindications for the surgical management of alimentary tract duplication are recognized. The contraindications are relative, mostly associated with complicated excision necessitating extensive reconstruction. Anesthetic complications should also be considered during nonemergency surgical procedures.
As with many types of surgical interventions, several reports have been published promoting the use of minimally invasive instrumentation (ie, laparoscopy) for the definitive diagnosis and treatment of alimentary tract duplications. [17, 18]
Medical Therapy
If asymptomatic, these cysts do not require any intervention. Their malignant potential is documented but is rarely realized. Thus, any symptoms are usually treated with surgical resection whenever surgery is feasible.
Surgical Therapy
Surgical treatment of alimentary tract duplications is largely dictated by the specific anatomic location of the lesion and its relation to normal anatomic structures. Close attention must be paid to vital structures (eg, bile duct and named vessels) when an attempt is made to resect an intestinal duplication cyst.
Preparation for surgery
Although the diagnosis of alimentary tract duplication often is not made until the patient is in the operating room, preoperative preparation is based on standard surgical principles of adequate hemodynamic status and the use of appropriate preoperative medications as deemed necessary (eg, antibiotics). Bowel preparation should be considered as part of the preoperative routine.
Operative details
In most instances, cystic duplications can be completely excised. Resection of normal intestine must often accompany removal of the lesion because of the intimate attachment of the common wall or because isolated resection of the cyst would compromise blood flow to the adjacent intestinal segment (see the image below). An alternative approach involves marsupialization of the cystic structure. This consists of a partial cystectomy combined with mucosal stripping of the remaining cyst wall to preserve normal anatomy.
The intimate association of the jejunal duplication cyst with normal jejunum requires a limited small-bowel resection as definitive surgical therapy.
Resection of tubular duplications follows the same principles as cystic duplications but may be more complicated, especially when the patient has a long tubular segment or total intestinal duplication involving the upper GI tract and small bowel (the incidence of gastric mucosa is high).
Again, marsupialization combined with mucosal stripping becomes an important tool in the surgical treatment of these entities. Tubular duplication of the hindgut may be left in situ if adequate drainage (by surgically joining the two lumina) or mucosal stripping of the defunctionalized portion can be achieved.
Postoperative Care
Postoperative care is considered to be routine and is directed at the specific surgical intervention undertaken.
Complications
Complications related to the discovery of an intestinal duplication cyst include bowel obstruction and hemorrhage.
Because most intestinal duplications are cystic and appear in the ileum, requiring a limited resection, complications related to surgical intervention are typically nonspecific and include postoperative bleeding, infection, and bowel obstruction. However, in patients with large tubular duplications, injury to the normal intestine with resultant short-bowel syndrome must be considered. Other complications include scattered reports of intestinal carcinomas found within duplication cysts.
Long-Term Monitoring
Because of the significant incidence of synchronous lesions, follow-up imaging (eg, computed tomography [CT] or ultrasonography) of additional body cavities should be performed in the event that the diagnosis of alimentary tract duplication was made intraoperatively.
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Illustration depicting the many locations where alimentary tract duplications may be found.
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Abdominal radiograph of an infant with acute onset of bilious vomiting and abdominal distention secondary to a duplication cyst at the terminal ileum.
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A small ileal duplication cyst causing complete obstruction of the small bowel (same patient as in the image above).
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The intimate association of the jejunal duplication cyst with normal jejunum requires a limited small-bowel resection as definitive surgical therapy.
