What is the recommended treatment for a duplication cyst?

Management of Duplication Cysts

Surgical removal is the recommended treatment for duplication cysts, especially if symptomatic, due to potential complications including mass effect, rupture, bleeding, and rare risk of malignant transformation. 1

Diagnosis and Assessment

• Duplication cysts are benign congenital lesions resulting from embryonic development errors of the foregut
• They can be found anywhere along the gastrointestinal tract from mouth to anus
• Diagnosis can be made using:
  • Endoscopic ultrasound (EUS) showing anechoic, smooth, spherical or tubular structure with well-defined wall 1
  • If adjacent to pancreas, EUS/FNA can help differentiate from pancreatic pseudocyst or cystic neoplasm 1

Clinical Presentation

• Often asymptomatic, especially in adults (frequently incidental findings)
• When symptomatic, presentations may include:
  • Mass effect
  • Rupture
  • Bleeding
  • Vomiting (most common in pediatric cases) 2
  • Abdominal pain
  • Rectal bleeding (if lower GI tract)
  • Obstruction symptoms

Treatment Algorithm

Asymptomatic Duplication Cysts

• Most guidelines recommend surgical removal even for asymptomatic cysts due to:
  • Risk of enlargement over time
  • Potential for mass effect, rupture, or bleeding 1
  • Rare but documented risk of malignant transformation 3

Symptomatic Duplication Cysts

• Surgical removal is definitively indicated 1
• Approach depends on location:
  1. Endoscopic removal: May be possible for accessible duodenal cysts 4
  2. Laparoscopic excision: Preferred minimally invasive approach for most locations 5
  3. Open surgical resection: May be necessary for complex cases or large cysts

Special Considerations

• For cysts adjacent to the pancreaticobiliary system, 3D reconstruction imaging may help determine the optimal surgical approach 3
• Complete excision is preferred when feasible to prevent recurrence and eliminate malignancy risk 3
• In pediatric cases, additional investigation for associated skeletal, urogenital, and gastrointestinal anomalies is recommended 2

Surgical Options

1. Complete excision with or without segmental intestinal resection (preferred when feasible)
2. Cystectomy alone
3. Marsupialization (creating an opening in the cyst to drain into the GI tract)
4. Mucosectomy (Wrenn procedure) for cysts that cannot be completely removed

Important Caveats

• Avoid biopsy of suspected duplication cysts prior to definitive management due to risk of infection or bleeding
• EUS-FNA should be performed cautiously and only when necessary to rule out other diagnoses 1
• Mediastinal duplication cysts should not undergo EUS-FNA due to risk of mediastinitis 1
• For duodenal duplication cysts, careful assessment of relationship to biliary and pancreatic ducts is essential before surgical intervention 3

Duplication cysts require definitive management due to their potential for complications. While they are generally benign, their tendency to enlarge and rare potential for malignant transformation makes surgical removal the standard of care, particularly when symptomatic.