Thoracoscopic Excision of Symptomatic Esophageal Duplication Cyst in Adult Population-Experience From A Tertiary Care Center

ISSN: 2320-5407 Int. J. Adv. Res.
9(09), 525-529
Journal Homepage: -www.journalijar.com
Article DOI:10.21474/IJAR01/13443
DOI URL: http://dx.doi.org/10.21474/IJAR01/13443
RESEARCH ARTICLE
THORACOSCOPIC EXCISION OF SYMPTOMATIC ESOPHAGEAL DUPLICATION CYST IN ADULT
POPULATION-EXPERIENCE FROM A TERTIARY CARE CENTER
Sankar Subramanian, Niket Shah, Neelendra Yesaswy and Suresh Kumar P.

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Manuscript Info Abstract
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Manuscript History Gastrointestinal duplications are rare congenital anomalies in children.
Received: 25 July 2021 The most common site being jejunum and ileum, followed by
Final Accepted: 29 August 2021 mediastinum, colon, stomach, duodenum and rectum. Esophageal
Published: September 2021 duplication cysts accounts for twenty percent. Majority of them are
detected in childhood and treated. A very small percentage can present
in adult population posing diagnostic challenges due to the clinical
presentations. Minimal access surgery has obviated the need for
thoracotomy. Herein we share our experience of treating four
symptomatic esophageal duplication cysts in adults, by minimally
invasive approach.
Copy Right, IJAR, 2021,. All rights reserved.

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Introduction:-
Gastrointestinal duplications are rare congenital anomalies and most of them manifest with symptoms in childhood.
Small intestine is the most common site for the duplications, which is followed by esophagus, colon, stomach,
duodenum and rectum(1). Nearly one fifth of the duplication cyst involve the esophagus. Majority of the esophageal
duplications are detected in childhood and treated. A very small proportion can present in adult population which
can pose diagnostic challenges, considering the myriad of mediastinal pathologies. Most of the literature on
thoracoscopic management of esophageal duplication cysts are no more than case reports. Herein we share our
experience of treating four symptomatic esophageal duplication cysts in adults, by minimally invasive approach.
Materials and Methods:-

This was an observational study of retrospective analysis of the prospectively maintained database of all the patients
who were diagnosed with esophageal duplication cyst in the department of surgical gastroenterology of Sri
Ramachandra medical center, auniversity hospital and a tertiary referral center located in south India. The period of
study was 10 years (September 2010 to August 2020)
Results:-
There were totally four patients diagnosed in this period. All the four patients were men in the third and fourth
decade of life. The most common clinical presentation was mild to moderate dysphagia which warranted evaluation.
The other associated symptoms include, regurgitation, chest discomfort, chronic dry cough. All the four patients had
the duplication cyst located in the thoracic esophagus, two involving the infra-carinal portion and two involving the
retro cardiac segment of esophagus. The average size of the cyst was 5 centimeters. The diagnosis was achieved in
all the four cases with CT scan and flexible esophagoscopy (picture 1,2,3). None of the patient underwent EUS as;
imaging findings on CT was unambiguous. All the four patients underwent thoracoscopic excision using the
standard technique of right thoracic approach in prone position (picture 4). Our policy is to resort to double lung
Corresponding Author:- Sankar Subramanian 525

ISSN: 2320-5407 Int. J. Adv. Res. 9(09), 525-529
ventilation, and carbondioxide insufflation to a pressure of 10 mm of mercury, achieved the lung collapse needed for
the working surgical space. Standard three ports (5th, 7th and 9th intercostal space, in the mid-clavicular line,
posterior axillary line and scapular line) were used to achieve triangulation. All the patients underwent complete
excision of the cyst. As these cysts are intra mural in location and forms the integral part of the muscular layer of the
esophagus, intra operatively they were decompressed before dissection (picture 5). This technical step facilitated
complete excision of the cyst without opening the esophageal mucosa. However, in all patients, an intra operative
leak test was performed post excision. In two patients where the cyst was projecting into the right hemithorax
(picture 6), post-excision myotomy was sutured, whereas in the remaining two patients the cyst was eccentrically
projecting into the left hemi thorax (picture 7), the myotomy was left unsutured. Postoperative period was
uneventful. ICD tube was removed on the first post-operative day after performing a gastrograffin study
demonstrating integrity of the mucosa. Oral liquids started on the first day and gradually advanced to solid diet. All
the patients stayed in the hospital for three days. Histological confirmation was achieved in all four patients by the
characteristic double layer of muscle, lining epithelium(squamous or pseudostratified columnar) and the absence of
cartilaginous elements(picture 8)
Discussion:-
Gastrointestinal duplications are rare congenital anomalies in children. The most common site being jejunum and
ileum, followed by mediastinum, colon, stomach, duodenum and rectum (1).
Esophageal duplication cysts accounts for twenty percent. Majority of them are detected in childhood and treated. A
very small percentage can present in adult population posing diagnostic challenges due to the clinical presentations.
Clinical presentation includes dysphagia, chest pain and regurgitation. Some cases can be picked up as incidental
findings. Esophageal duplication cyst may be cystic or tubular. It can also be intramural and extramural. The most
common location of these esophageal duplication cysts is the lower thoracic region.
Rarely it may involve the cervical and abdominal esophagus. The embryogenesis is the faulty development of the
posterior division of the foregut. The important differential diagnosis includes bronchogenic cyst, leiomyoma, cystic
degeneration of tumors and hydatid cyst. CT findings are very characteristic which include a well-defined lesion
with homogenous density (2).
However, with the advent of endoscopic ultrasound, the diagnostic accuracy has increased tremendously, making it
a very important tool in the imaging.
The main usefulness of EUS is it helps to differentiate duplication cyst from bronchogenic cyst, by the close
proximity to esophagus, double layer of muscle forming the cyst wall and absence of cartilaginous elements (3). The
duplication cyst may appear anechoic, hypoechoic or mixed echoic depending on the content like, thick fluid, blood
or pus.
EUS guided FNAC is generally avoided for fear of introducing infection and resorted only when there is a
diagnostic dilemma. Esophageal duplication cysts warrant surgery even in asymptomatic patient as it is more prone
for complications like infection, hemorrhage, perforation.
Esophageal duplication cyst can also masquerade as tumors (4). There are reports of malignant transformation
occurring in duplication cyst of the esophagus (5). With the advent of minimally invasive approach, surgical
excision of esophageal duplication cyst has become less morbid procedure (6) and most of the large series of
thoracoscopic excision of esophageal duplication cysts are reported in children.
When it comes to adult population there are only case reports regarding thoracoscopic management. Herein we are
reporting our experience of managing four cases of esophageal duplication cysts managed thoracoscopically.
Conclusion:-
Esophageal duplication cyst is a very rare congenital anomaly and presentation in adult population is even more
rare. Thoracoscopic excision is the standard of care with minimal morbidity.
526
ISSN: 2320-5407 Int. J. Adv. Res. 9(09), 525-529
Picture 1:- CT axial section.
Picture 2:- CT sagittal section.
Picture 3:- CT images.
Picture 4:- Port Positions.
527
ISSN: 2320-5407 Int. J. Adv. Res. 9(09), 525-529
Picture 5:- Intra-Operative Decompression.
Picture 6:- Thoracoscopic Dissection.
Picture 7:- myotomy.
Picture 8:- Two Layers Of Muscles.
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ISSN: 2320-5407 Int. J. Adv. Res. 9(09), 525-529
References:-
1. Karnak I, Ocal T, Senocak ME, et al. Alimentary tract duplications in children: Report of 26 years’ experience.
Turk J Pediatr 2000; 42: 118-25.
2. Jang KM, Lee KS, Lee SJ, et al. The spectrum of benign esophageal lesions: Imaging findings. Korean J Radiol
2002; 3: 199-210.
3. Wiechowska-Kozłowska A, Wunsch E, Majewski M, et al. Esophageal duplication cysts: Endosonographic
findings in asymptomatic patients. World J Gastroenterol 2012; 18: 1270-2
4. Chaudhary V, Rana SS, Sharma V, Sharma AR, Nada R, Gupta R, Dutta U, Singh K, Bhasin DK. Esophageal
Duplication Cyst in an Adult Masquerading as Submucosal Tumor. Endosc Ultrasound 2013; 2(3): 165-167
5. Dai ZJ, Kang HF, Lin S, Bai MH, Ma L, Min WL, Lu WF, Wang XJ. Esophageal cancer with esophageal
duplication cyst. Ann Thorac Surg. 2013 Jul;96(1):e15-6. doi: 10.1016/j.athoracsur.2013.01.019. PMID:
23816110.
6. Michel JL, Revillon Y, Montupet P, Sauvat F, Sarnacki S, Sayegh N, et al. Thoracoscopic treatment of
mediastinal cysts in children. J Pediatr Surg. 1998;33:1745–8.
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ISSN: 2320-5407 Int. J. Adv. Res.

Journal Homepage: -www.journalijar.com

Sankar Subramanian, Niket Shah, Neelendra Yesaswy and Suresh Kumar P.

Copy Right, IJAR, 2021,. All rights reserved.

Materials and Methods:-

Corresponding Author:- Sankar Subramanian 525

Picture 1:- CT axial section.

Picture 2:- CT sagittal section.

Picture 3:- CT images.

Picture 4:- Port Positions.

Picture 5:- Intra-Operative Decompression.

Picture 6:- Thoracoscopic Dissection.

Picture 7:- myotomy.

Picture 8:- Two Layers Of Muscles.

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