Duplication of the stomach

Duplication of the Stomach MAJOR RICHARD E . GREEN, M .C ., Fort Knox, Kentucky

a result of a full term, uncomplicated pregnancy . Her growth and development were considered normal for her age, with the possible exception that she was considered a "feeding problem ." Approximately one year before admission the child began having periodic episodes of severe abdominal pain, during which she would scream loudly, clutch her abdomen, flex her thighs on the abdomen and roll from side to side . Such episodes were sudden in onset, usually occurred one to two hours after the evening meal, were of ten to thirty minutes' duration and occurred on an average of once every two weeks . Emesis occurred with several such episodes . Coincident with the onset of the child's distress, the parents would note the presence of a seemingly tender, left upper abdominal mass, the size of a lemon . After a variable period of time the mass would disappear spontaneously and the child would become comfortable and entirely asymptomatic until the next such occurrence . During the six to eight months before admission the child was examined on several occasions by various physicians . All of these examinations yielded negative results, and on no occasion was

tract duplications are infrequently encountered in the usual general surgical practice . Although the true incidence of such anomalies is difficult to ascertain, it is probably safe to say that this is an unusual and rather rare lesion . Its rarity is evidenced by the report of only twenty-five cases in a twentyone-year period from the surgical service of a children's hospital [8] . In a recent survey of the English medical literature, only twenty-eight instances of gastric duplications were encountered [41 . Of these, sixteen cases occurred in the pediatric age group . It would therefore seem appropriate to record the clinical history of a child with this anomaly. LIMENTARY

A

CASE REPORT

A two year old white female infant was admitted to the hospital on November 26, 1957, for evaluation of periodic abdominal pain . The history, as obtained from the mother, indicated the child was

Fic- r . A section through entire wall of specimen, demonstrating mucosa and muscularis. 721

American Journal of Surgery, Volume g6, November, to98

Green free border of the greater gastric curvature . Attachments to the stomach were thin, fibrous and easily dissected without endangering the gastric wall. Chronic inflammatory reaction caused one end of the structure to be densely attached to the area about the tail of the pancreas . The gastrocolic ligament was intimately attached to the mass by dense, adherent adhesions . The bulk of the cyst was insinuated between the leaves of the transverse mesocolon at this level . Removal of the mass left a small defect in the anterior leaf of the mesocolon but did not compromise the vascularity of this structure. Removal was accomplished completely without undue difficulty . This mass had no intimate gastric attachments ; it did not communicate or share a common wall with any other viscus . The patient's postoperative course was uneventful and she was discharged from the hospital on December 12, 1957 . Since discharge she has done well, has had no further abdominal distress, is eating fairly well and gaining weight . Evaluation of the surgical specimen revealed that it was tensely filled with thin, reddish brown fluid . The wall averaged 0 .4 cm . in thickness and the inner coat consisted of wrinkled, slightly flattened mucosa . On microscopic examination this appeared as well defined gastric mucosa throughout . There was a distinct and rather prominent hypertrophy of the muscularis mucosa and, except for this, microscopic study revealed essentially normal stomach wall throughout . (Figs . 1 and 2 .)

FIG . 2. Mucosa and muscularis of specimen .

an abdominal mass palpated, even though specific attention was directed at such . The past personal and family histories were non-contributory . General examination at the time of admission was essentially normal . It was noted that the child was quite irritable, fretful and ate poorly . Evaluation by several examiners failed to reveal the presence of an abdominal mass . Results of several complete physical examinations during the first few hospital days were normal . Chest x-ray, urinalysis and routine blood studies revealed no abnormalities. The initial hospital period was uneventful . On November 30, 1957, the child began to scream loudly and hold her abdomen . Examination at that time revealed an obvious, well defined, left upper abdominal mass, approximately 4 by 6 cm . in size . It was tense, smooth, rounded, tender and slightly mobile. It had not been apparent during examination several hours earlier . On December 2, 19S7, operation was performed with the child under general anesthesia . The abdomen was entered through a high left paramedian incision . A large (7 .5 by 4 by 3 cm .), tense, subacutely inflamed, thick-walled, gray-white, spherical, cystic structure was encountered low on the

COMMENTS

As noted previously, duplications of the stomach are not often recorded in the literature . Presumably they are congenital in nature and have the common anatomic characteristics of a wall containing all the normal layers of the stomach except in the area where they are attached to the stomach proper . In this region there is no serosa, and the muscularis is common to the cyst and the stomach itself [1,5,6] . In isolated instances cysts have lost their connection with the wall of the intestine and may occupy a position between layers of the mesentery somewhat removed from the parent intestine [3,6,8] . However, this is rare, and a common muscularis between the duplication and the parent intestine is the rule ; in such a case no cleavage plan can be established . In addition, the blood supply to the normal alimentary tract and to the duplication is usually the same [7] . Various theories of origin of the anomaly have been proposed, but as yet no conclusion concerning the exact origin of intestinal dupli722

Duplication of Stomach cations is entirely acceptable . Perhaps one of the most interesting and feasible theories is that of Bremer [4,5] . This theory recognized that in the six week old embryo, the intestinal lumen is occluded by rapid proliferation of epithelium . Thereafter, vacuoles develop, and in the usual trend of events the vacuoles coalesce to form a lumen again . It is postulated that one or more of these vacuoles separate from the lumen of the main channel and may lead to duplication [4,5,7] . Symptoms are variable, may become manifest at practically any age and are centered around obstructive phenomena of colicky pain and emesis . Palpation of a mass is common and this usually leads to investigations, operation and establishment of a diagnosis . Preoperative roentgenologic studies may be of definite value in differentiating an intraluminal from an extraluminal obstructing lesion and thus present a clue to diagnosis . Treatment is surgical . Presumptive diagnosis may often be made preoperatively, but the true diagnosis can only be established at surgery . Because the parent intestine and the duplication usually share a common muscular wall and vascular supply, resection of the involved segment is ordinarily the wisest treatment, with immediate reestablishment of the intestinal continuity [2] . In gastric duplications the main objective is to remove as much of the duplication as is feasible without destroying the physiological and functional mechanism of the stomach . For gastric duplications, local excisions, lateral resections, total resections, marsupializations and enterocystostomies have been described in the literature [1,3,4,5,7] . Whenever possible, total excision should be undertaken, if this can he done with safety and

the maintenance of an adequate amount of stomach . If gastric function would be jeopardized by radical resection, a compromise procedure should be performed [4] . SUMMARY Duplications of the alimentary tract are infrequently seen in the usual surgical practice . Most such anomalies are noted in the ileum . Gastric duplications are most infrequent, only an approximate twenty-eight having been reported in the English literature . The clinical history of a two year old white female infant with such an anomaly is presented . Complete resection of the duplication was possible and the child has had no further difficulties . The possible origin of duplications and the various methods of management are discussed briefly . REFERENCES I . BARBOSA, J . DE C ., CASTRO, V . B ., CAMINHA, N ., OLIVEIRA, C. and RAMOS, C . Duplication of the stomach, report of the fifth case recorded . J. A . M. A ., 149 : 1552, 1952 . 2 . BERG, H . F . and MARX, K. Reduplication of the stomach . J . Pediat., 40 : 334, 1952 . 3 . DEWING, S . B ., ROESSEL, C . W . and OLMSrEAD, E . V. Enterogenous cyst of the stomach wall, a rare benign lesion . Ann. Surg., 143 : 131, 1956 . 4- KIESEWETTER, W . B . Duplication of the stomach : a case report . Ann . Surg., 146 : 990. 1957 . 5 . MAYO, H . J ., JR ., McKEE, E . E . and ANDERSON, R . M. Carcinoma arising in reduplication of the stomach (gastrogenous cyst) : a case report . Ann. Surg ., 144 : 550, 1955 . 6. MCCUTCHEN, G . T . and JOSEY, R. B . Reduplication of the stomach . J. Pediat ., 39 : 216, 1951 . 7 . NOLAN, J . J . and LEE, J . G . Duplication of the alimentary tract in adults with a report of three cases . Ann . Surg., 137 : 342, 1953 . 8. SIEBER, W . K . Alimentary tract duplications . Arcb . Surg ., 73 : 383, 1956.

,1

723