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Joana Patena Forte1, Sofia Ferreira de Lima1, Joana Henriques1, Rui Alves1

1 - Cirurgia Pediátrica, Hospital Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central

- Poster, IX congresso Iberoamericano de Cirurgia Pediátrica

Introduction Gastric duplication is a rare congenital malformation, comprising 4-9% of gastrointestinal (GI) duplications, they are mostly cystic and arising from the greater curvature, sharing the muscular wall, but not communicating with the gastric lumen. It can be asymptomatic or incidentally diagnosed, but depending on size, location, and epithelial lining, it can cause obstructive symptoms, ulceration with anemia, melena or hematemesis, or even perforation and peritonitis. It is most often diagnosed in the first year of life, but there are reports of adults treated for gastric duplications, and it carries a risk of malignancy. We present a case of a complicated gastric duplication cyst.
Case report: A 1,5-month-old male baby was referred to our emergency department with a 9 days history of intermittent, and non-bilious projectile vomiting. On physical examination he showed discomfort on the upper abdominal quadrants, without rebound or palpable masses. Blood analysis reported elevated white blood cell count (19.9 X 10 3 / µL), normal C-reactive-protein, and electrolyte balance. On abdominal ultrasound piloric muscle thickness and length was of 3.6mm and 18mm, respectively; this exam also revealed a 35mm wide cyst, anterior and in close relation with the stomach. On laparotomy, he presented a hypertrophic pyloric stenosis (HPS) and a duplication cyst, on the distal portion of the great gastric curvature. There was a perforation on the cyst’s wall, that was covered by the caudal portion of pancreas, transversal colon mesentery and greater omentum, without peritonitis. We performed pyloromyotomy, and wedge ressection of the cyst, after excision of the adherent omentum and dissection from the terminal portion of the pancreas, with a mechanical stapler.  The post operative time was uneventful, and he started oral intake on the 4th day and was discharged on the 7th. Histologic examination showed normal gastric mucosa lining the cyst, and a shared muscular wall.
Discussion: Our patient presented with gastric outlet obstruction caused by hypertrophic pyloric stenosis and the duplication cyst on the distal great curvature. Luckily its perforation was sealed and there was no complication of haemorrhage, pancreatitis, or spillage of gastric contents and peritonitis. Ultrasound examination is a helpful exam in the diagnosis of gastric duplication cyst, and omental, mesenteric, choledochal, ovarian and renal cysts. Complete surgical resection is the best treatment option, even in asymptomatic patients, in order to avoid complications, such as GI bleeding, perforation and malignancy. Because of a tense cyst with adherences to the perforated site, and a shared wall of more than 3 cm we decided on wedge resection, but partial excision of the cyst with mucosal stripping of the shared wall side was another surgical option. Endoscopic and laparoscopic approaches have also been described.

Palavras Chave: gastric duplication cyst, gastric outlet obstruction, vomiting in the new-born