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Duodenal duplication cyst causing recurrent pancreatitis

A 17-year-old male was referred with a history of recurrent acute pancreatitis. Since the age of 8 years he had experienced more than 15 episodes. By 10 years of age he had already had two abdominal ultrasounds and magnetic resonance cholangiopancreatography (MRCP). Both abdominal ultrasound scans showed a normal biliary tree with no cholelithiasis and both obtained good views of the pancreas, showing only evidence of diffuse pancreatitis on one occasion. The MRCP showed a normal biliary tree, with no stones and a normal appearing pancreas. After referral he underwent a repeat MRCP to investigate his recurrent pancreatitis. This revealed a lesion in the second part of the duodenum and head of pancreas near the major duodenal papilla (see Fig. 1). Endoscopic ultrasound was performed to clarify the nature of the lesion because it was not obviously fluid containing on the MRCP, raising the possibility of a solid lesion. This confirmed a well-circumscribed 3 cm cyst just distal to the major duodenal papilla bulging into the medial duodenal wall. Endoscopic aspiration of the cyst yielded mucinous material. The patient subsequently underwent laparotomy which confirmed a duodenal duplication cyst in the medial wall of the second part of the duodenum. Intra-operative cholangiopancreatography revealed no communication between the pancreaticobiliary ducts and the cyst. The terminal 2 cm of the main pancreatic duct (which opened separately from the bile duct) was embedded in the wall of the cyst. Figure 2 illustrates the operative anatomy. The cyst was completely excised and a sphincteroplasty was performed on the terminal pancreatic duct. A short plastic stent was left in place to optimise drainage of the pancreatic duct during healing because the terminal part of duct had been stretched and compressed by the cyst. The stent was anticipated to be temporary as it was secured with a single absorbable suture. The patient developed a wound infection but made a full recovery. Subsequent histology confirmed a 3 × 2 cm duodenal duplication cyst lined by duodenal mucosa. Sixteen months following the procedure the patient is completely well and has had no further episodes of pancreatitis.