What is the follow-up plan for a duplication cyst in the stomach and esophagus diagnosed via endoscopic ultrasound (EU), and when is resection or aspiration indicated?

Management of Gastric and Esophageal Duplication Cysts

Direct Recommendation

For asymptomatic gastric and esophageal duplication cysts diagnosed on EUS, surveillance is not required and intervention should be reserved only for symptomatic lesions. 1

Diagnostic Confirmation

• EUS confirms the diagnosis by demonstrating an anechoic structure with a well-defined wall that does not communicate with the gastrointestinal lumen 2
• The characteristic appearance shows a smooth, spherical or tubular structure with distinct wall layers 2
• EUS-FNA should be avoided, particularly for mediastinal esophageal lesions, as mediastinitis is a recognized complication 1
• If the cyst is adjacent to the pancreas, EUS-FNA may be necessary to exclude pancreatic pseudocyst or pancreatic cystic neoplasm 2

Follow-Up Strategy

No routine surveillance is recommended for asymptomatic duplication cysts. 1 This represents a critical distinction from other subepithelial lesions:

• Lipomas, pancreatic rests, and duplication cysts have distinct endosonographic features and do not require tissue sampling or surveillance 1
• The 2022 AGA guidelines explicitly state that duplication cysts "do not require surveillance" 1
• This differs markedly from GISTs, which require annual EUS surveillance for lesions <2 cm 1

Indications for Intervention

Resection is indicated when:

• Symptomatic lesions causing pain, dysphagia, bleeding, or obstruction 1
• Rare complications develop (though these are uncommon in adults) 1

Surgical approach:

• Complete surgical resection is the treatment of choice when intervention is needed 3, 4
• Enucleation via seromuscular incision should be considered the procedure of choice as it can be performed with minimal disruption of normal anatomy 3
• Laparoscopic approaches are feasible for appropriately selected cases 5

Aspiration considerations:

• Simple aspiration alone is not recommended as definitive treatment 6
• One case report describes successful endoscopic fenestration (marsupialization) with partial wall resection for an esophageal duplication cyst, but this remains experimental 6
• Aspiration may be diagnostic but does not provide definitive management 7

Critical Pitfalls to Avoid

• Do not confuse duplication cysts with GISTs or other subepithelial lesions that require different management algorithms 1, 5
• A hepatic cyst can mimic a gastric submucosal tumor on EUS; careful evaluation of the anatomic origin is essential 5
• Do not perform EUS-FNA on mediastinal esophageal duplication cysts due to mediastinitis risk 1
• Do not institute surveillance protocols designed for GISTs (annual EUS) as these are unnecessary for duplication cysts 1

Key Distinguishing Features

The evidence clearly separates duplication cysts from other subepithelial lesions in management approach. While GISTs <2 cm require annual surveillance 1, and lesions with uncertain pathology may need repeat evaluation 1, duplication cysts with characteristic EUS features require no follow-up unless symptoms develop 1. This conservative approach is based on their benign natural history and the recognition that most remain asymptomatic throughout life 1.