Jordan Boudreaux, MD, Ruona Ebiai, MD, James Gore, DO, Ricardo Romero, MD, John A. Evans, MD, Neej J. Patel, MD, Janak N. Shah, MD Ochsner Clinic Foundation, New Orleans, LA
Introduction: Duplication cysts are rare congenital abnormalities of the GI tract. Here we present a case of a duodenal duplication cyst causing gastric outlet obstruction treated with EUS-guided marsupialization using a LAMS.
Case Description/Methods: A 40-year-old female was admitted with abdominal pain, nausea, and vomiting for 10 days. CT revealed 3 cm cystic structure along the medial aspect of the proximal duodenum with gastric distension consistent with outlet obstruction (Fig A). EGD and EUS revealed an area of extrinsic compression causing stenosis with a corresponding 3 cm cystic structure, either originating from the duodenal wall or the periduodenal/peripancreatic space (Fig B). Diagnostic and therapeutic EUS-FNA was performed. Cyst fluid was aspirated completely and sent for biochemical analysis and cytology evaluation. Results were most consistent with a duplication cyst. After complete aspiration and collapse of the cyst, her outlet obstruction and symptoms resolved and she was discharged. She returned 10 days later with a similar presentation. Repeat CT showed recurrence of the cystic lesion with gastric outlet obstruction. After discussion with our surgical service, a decision was made to address this endoscopically. EUS-guided cystenterostomy was created with a cautery-tipped, 15 x 10 mm LAMS (Hot Axios, Boston Scientific, Marlborough, MA). Her symptoms resolved after LAMS placement. CT performed at a 4-week interval showed resolution of the duplication cyst cavity and no outlet obstruction (Fig C). At time of EGD for stent removal 3 weeks later, the LAMS had migrated into the duodenal lumen and was removed. A small ulceration was seen in the duodenal bulb (Fig D), likely representing the cystenterostomy site. She has not had recurrence of symptoms for 5 months since LAMS removal.
Discussion: GI duplication cysts leading to obstructive symptoms usually require surgical management. Newer endoscopic interventions utilizing electrosurgical techniques (e.g. needle-knife/sphincterotome incision, snare resection/’unroofing’) to ‘marsupialize’ the cyst and allow for ongoing decompression of cyst contents in the GI tract lumen have been recently reported. To our knowledge, we report the first case of using a temporarily-placed LAMS for the same purpose.
Figure: A) Duodenal duplication cyst causing gastric outlet obstruction. B) Duplication cyst on EUS. C) LAMS in place with resolution of duplication cyst. D) Prior cystenterostomy site in duodenal bulb
Jordan Boudreaux indicated no relevant financial relationships.
Ruona Ebiai indicated no relevant financial relationships.
James Gore indicated no relevant financial relationships.
Ricardo Romero indicated no relevant financial relationships.
John Evans indicated no relevant financial relationships.
Neej Patel indicated no relevant financial relationships.
Janak Shah indicated no relevant financial relationships.
Jordan Boudreaux, MD, Ruona Ebiai, MD, James Gore, DO, Ricardo Romero, MD, John A. Evans, MD, Neej J. Patel, MD, Janak N. Shah, MD. P0870 - Duodenal Duplication Cyst Causing Gastric Outlet Obstruction Treated with Endoscopic Ultrasound-Guided Marsupialization Using a Lumen-Apposing Metal Stent, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.