Duodenal Duplication Cyst in an Old Man A pylorus-preserving pancreaticoduodenectomy (modified Whipple’s operation) was performed 24 days after support- ive treatment. The surgical specimens included the seg- ments of the duodenum and the duplication cyst, the gall- bladder and some portions of the pancreas. The duplication cyst was located along the antimesenteric border and was 9 cm in length and 2.8 cm in the inner diameter (Fig. 4). There was no luminal communication between the cyst and the duodenum. The inner surface of the cyst was flat and showed multiple erosions and ulcers. Histologically, the cyst showed denudation of the mucosal layer, which was replaced by granulation tissue, due to the mucosal inflam- mation, but most parts of the cyst contained a smooth mus- Fig. 1. Duodenoscopic finding. A huge extrinsic mass causing a luminal obstruction in the proximal second portion of the duode- num, with an intact mucosa. 605 cle layer (Fig. 5). The post-operative course of the patient was uneventful, and the patient has been doing well for 6 months after surgery without any complication. DISCUSSION Duplication cysts are congenital anomalies that are formed during the embryonic period of the development of the human digestive system. The most common site for a gastrointesti- nal duplication cyst is the distal ileum followed by the esoph- agus and duodenum (2). Duplication cysts must adhere to a portion of the gastrointestinal tract, contain a smooth mus- cle layer in their walls and be lined with an alimentary epithe- lium. The epithelial lining of the duplication cysts may be that of the adjacent bowel, and ectopic gastric or pancreatic tissue may sometimes be present within (2, 3). Gastric dupli- cations occur along the greater curvature, and intestinal dupli- cation cysts are found on the mesenteric side of the bowel. The cysts may be spherical or tubular, and there may be infre- quent communications with the gastrointestinal tract. DDCs are diagnosed more often in children. They are mostly lim- ited to the first or second part of the duodenum usually adja- cent to the pancreatic surface sharing a common wall and blood supply with the duodenum. DDCs may be silent for many years before they cause any symptoms including bowel obstruction, pain, distention or gastrointestinal bleeding. Bleeding, ulceration, and perforation may occur in the cysts containing ectopic gastric mucosa (2, 3). The clinical presen- tation depends on the size and location of the cysts. In our case, the patient was old and had accompanying symptoms of bowel obstruction, obstructive jaundice, and acute pan- creatitis. The compression caused by the duplicated segment of the duodenum attributed to the above symptoms. The cyst was in the second and third portions of the duodenum and had an ulceration on the inner side. A B Fig. 2. Computerized tomographic finding. A cystic lesion with a distinct wall in the second-to-third portion of the duodenum (A, B) is shown. The duodenum (closed arrow) is compressed by the cystic lesion and is displaced to the medial side of the lesion (open arrow) (A).