Effective simple incision or partial snare resection for symptomatic duodenal cystic lesions, duplication cysts, and choledochoceles

We read with interest the article by Tekin et al. [1] on a new endoscopic treatment for a symptomatic duodenal duplication cyst (DDC). They encountered a patient with a history of recurrent abdominal pain and a previous episode of acute pancreatitis, and detected a duodenal cystic lesion. The lesion was diagnosed as a DDC, and was successfully treated with a needle-knife incision, balloon dilation, and implantation of a plastic stent. We suspect that the lesion was not a DDC, and a simple alternative would be effective for the treatment.

DDCs represent 5 % of all gastrointestinal duplications, and have a cystic structure distal to the papilla, protruding inside the duodenal lumen, with a normal pancreatocholangiogram [2] [3]. Like a DDC, a choledochocele (Alonso-Lej classification type III) has an obvious cystic bulging proximal to the papilla and a cystic dilatation of the bile duct terminal protruding into the duodenal lumen [2] [4]. Choledochoceles represent about 1.5 % of congenital choledochal cysts [4]. Biopsy specimens taken from inside the lesions reveal duodenal mucosa in all DDCs and bile duct mucosa in all choledochoceles [2]. Tekin et al. [1] described the lesion as proximal to the papilla, with opacification of the cystic lesion, the common bile duct, and the pancreatic duct through the common channel, and no performance of biopsy inside the lesion. We therefore suspect that the lesion found by Tekin et al. [1] was a choledochocele.

The clinical manifestations of DDC and choledochocele are nonspecific and include intestinal occlusion, pancreatitis, cholangitis, biliary stricture, choledocholithiasis, and bleeding [5] [6]. Although surgical resection of such lesions is the traditional management, endoscopic therapy is preferable as a less invasive approach [3] [7]. Endoscopic simple incision or partial snare resection for symptomatic DDCs [2] [3] [5] [8] and choledochoceles [7] [9] is an effective method of treatment without major complications. Snare resection provides a better specimen than biopsy for accurate histological diagnosis [3] [7]. Despite lack of pancreaticobiliary malunion [10], an elevated amylase level in the bile and subsequent biliary cancer are reported in patients with choledochocele [4] [6] [7], which is a main drawback of endoscopic therapy.

Although Tekin et al. [1] treated the cystic lesion with a needle-knife incision, balloon dilation, and plastic stent implantation, we suspect that simple incision or partial snare resection would be a safe and effective alternative for symptomatic DDCs and choledochoceles. Adequate tissue sampling is essential for accurate diagnosis of these lesions, and close follow-up is recommended, even after endoscopic therapy, for early detection of malignancy in patients with choledochocele.

Competing interests: None

References

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