Endoscopic marsupialization of a large duodenal duplication cysts. The primary author is Danial Abbas. The authors have no financial disclosures. A 38-year-old female with past medical history of morbid obesity presented for evaluation of hematemesis. She underwent an upper endoscopy which demonstrated a large mass in the second portion of the duodenum. Endoscopic ultrasound confirmed this large cystic mass in the second portion of the duodenum. The cystic lesion was separate from the distal common bile duct, pancreatic duct, and the ampulla. She underwent imaging to define the anatomic relationship with the biliopancreatic duct. MRI demonstrated a bilobed cystic mass within the second and third portion of the duodenum. On EUS, the lesion appeared to originate from the mucosa and submucosa and the outer margins were well defined. A multidisciplinary approach was taken and the decision was made to proceed with endoscopic marsupialization given her high surgical risk due to morbid obesity. A large submucosal mass is seen in the second portion of the duodenum without any evidence of bleeding. Decision was made to perform endoscopic excision and marsupialization of the cyst. Color Doppler imaging was utilized to confirm the lack of significant vascular structures in the needle path. Using a needle knife, an incision was made in the most dependent portion of the cyst. Then a wire 0.025 cm in diameter and 450 cm in length was advanced into the cyst. Contrast was injected to confirm wire placement within the cyst. A sphincter tube was advanced over the wire and the incision was extended to complete the excision of the cyst wall. The lining of the cyst wall was consistent with duodenal mucosa. The lateral margin of the duodenal cyst wall was excised using a hot snare and sent for histology. There was mild bleeding at the excision site which was controlled with injection of epinephrine and endoscopic clips. These were the endoscopic images of the duplication cyst before and after marsupialization. There were no delayed complications and the patient was discharged on hospital day one. The pathology demonstrated benign duodenal mucosa. Follow-up endoscopy at nine months showed complete resolution of the duodenal duplication cyst without evidence of recurrence. Given the proximity of duodenal duplication cysts to the biliopancreatic ducts and the vascular supply of the duodenum, patients may need total pancreatic duodenectomy. This is a major abdominal surgery and patients at high risk for surgical complications may not withstand a VIPL procedure. Endoscopic marsupialization is a minimally invasive option in high-risk patients. This case demonstrates successful management of a large duodenal duplication cyst with endoscopic marsupialization.

obesity

hematemesis

upper endoscopy

duodenum

endoscopic marsupialization