Laparoscopic Transduodenal Mucosal Resection with Selective Full-Thickness Excision for Duodenal Duplication in a...

Duodenal duplication is a rare congenital anomaly with nonspecific symptoms, and preoperative diagnosis is often difficult. Complete resection is recommended, but lesions adjacent to the bile or pancreatic duct are challenging to treat safely in pediatric patients. We report a pediatric case of duodenal duplication successfully managed by laparoscopic mucosal resection with selective full-thickness dissection under intraoperative ultrasonographic guidance.

A 5-year-old girl presented with abdominal pain and vomiting. CT revealed a cystic lesion in the pancreatic head region, and the initial differential diagnosis included a pancreatic tumor, pancreatic pseudocyst, choledochal cyst, and lymphangioma. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) showed no communication between the lesion and the pancreaticobiliary system. Although a solid pseudopapillary neoplasm was initially suspected, repeat EUS demonstrated a characteristic double-layered cyst wall, leading to the preoperative diagnosis of duodenal duplication. Because intermittent abdominal pain persisted and recurrent pancreatitis was suspected, surgical treatment was planned. Laparoscopic surgery was performed using intraoperative ultrasonography to localize the lesion, which was not identifiable on the duodenal serosal surface. After transduodenal exposure, the lesion was dissected from the pancreatic side with full-thickness excision where a safe plane was identified, while only the mucosal layer was removed at the shared wall with the native duodenum to preserve the muscular layer. The duodenum was closed primarily. Histopathological examination confirmed duodenal duplication without malignancy. Postoperatively, she developed a pancreatic fistula caused by peripheral pancreatic duct injury, which was successfully managed by temporary pancreatic duct stenting. She was discharged on POD 19 and remained asymptomatic without recurrence at 1 year.

Laparoscopic mucosal resection with selective full-thickness dissection under intraoperative ultrasonographic guidance may be a feasible organ-preserving option for selected pediatric patients with duodenal duplication near the pancreatic head. This case highlights the usefulness of intraoperative ultrasonography for localizing a non-serosal duodenal duplication and tailoring the extent of resection. However, pancreatic-side dissection may cause peripheral pancreatic duct injury, and surgeons should be prepared for postoperative endoscopic management when selecting this organ-preserving approach.