An Ectopic Gastric Duplication Arising From the Pancreas and Presenting With a Pneumoperitoneum By David 1. Schwartz,

Henry B. So, Jerrold M. Becker,

and Keith M. Schneider

Hyde Park, New York 0 This case report describes a large gastric duplication, which had no attachment to the stomach, and it was found in the pancreas. The second unusual feature of this duplication was that it had eroded into the splenic flexure of the colon, resulting in a large pneumoperitoneum. INDEX WORDS: eum.

Gastric duplication;

pneumoperiton-

GASTRIC as early

DUPLICATIONS were reported as 19 11 by Wendell Enteric duplications have occurred throughout the entire gastrointestinal tract; the rarest location being the stomach. In 1967, Bartels* collected a series of 55 stomach duplications. Tschappeler and Smith3 described 33 duplications in which there was not a single case involving the stomach. Favarra et al4 documented 3 gastric duplications in their series of 39 cases. CASE

REPORT

(A.S. #336834) This infant (AS.) was born on June 26, Case #336834. 1977 after an uncomplicated pregnancy. There are seven siblings, all living and well. Nine days after discharge, the patient was admitted to the Queens General Hospital Division of Long Island Jewish Hospital because of a fever of 102°F and failure to thrive. At this time, the heart rate was 140 and respirations 40. Skin turgor was poor. Other findings included several cutaneous capillary hemangiomas of the foot and a first degree hypospadias. There was no abdominal distension, organomegaly, palpable mass, or tenderness. Laboratory data included: hemoglobin 19.4 mg/lOO ml, hematocrit 57%, WBC 10,000, blood sugar 109 mg/lOO ml, and BUN 4 mg/lOO ml. The electrolytes and liver chemistries were normal. A urine culture grew 250,000 Escherichia coli. The infant was treated with Ampicillin and Gentamycin for the urinary tract infection. On the third hospital day he vomited coffee ground material and the abdomen became softly distended. Abdominal x-rays and IVP were normal. Hematologic evaluation did not reveal any coagulapathy. This condition was treated with gastric lavage and antacids. On the eighth hospital day, he again spiked a temperature to 102°F. the WBC rose to 18,800, and intestinal bleeding was manifested by a 3+ guaiac stool. The baby’s nutrition was maintained by i.v. infusion because of poor feedings and occasional vomiting. An upper gastroinestinal series did not show obstruction. A small hiatus hernia was demonstrated and there was a question of a partial malrotation. Between the 8th and 11 th hospital day the patient became edematous and the abdomen became progressively more distended. On hm8/

ofPediatric Surgery. Vol. 14, No. 2 (April). 1979

July 16, 1977 free interperitoneal air was noted and the infant was explored. At operation there was a large pneumoperitoneum. A large hollow mass was found in the lesser sac, measuring 10 cm X 4 cm. The mass was not attached to the stomach and it appeared to be growing out of the pancreas. The distal tip of the mass was loosely attached to the splenic flexure of the colon (Fig. 1). At this site, there wasa free perforation of the colon with an infiammatory exudate around its edges. The mass was freed from its adherence to the colon and then opened. It was felt at this time that the mass was a duplication, arising from deep within the pancreas. Its lining was typical of gastric mucosa. A metal probe was inserted into the duplication, and it transversed the entire length of the pancreas, but did not join the duodenum or the biliary tract. In the head of the pancreas, the duplication became conical in shape, and seemed to be attached to the pancreatic substance by a narrow stalk. A malrotation was present with Ladd’s bands, which were partially obstructing the second portion of the duodenum. The microscopic sections revealed the duplication to be consistent with stomach; it had gastric mucosa, submucosa, both layers of the outer muscula coat, and serosa. There were several small foci of pancreatic tissue in the submucosa. Ladd’s procedure was performed and patency of the duodenum was confirmed by the passage of a Foley character through a gastrostomy. The perforation of the colon was oversewn in two layers, after debriding the necrotic edges. The pancreas was bluntly dissected away from the duplication without difficulty. The blind proximal end of the duplication was funnel-shaped and with the probe inserted, it was found to have extended up to the duodenal wall. It was shelled out of the pancreatic substance and the small area of proximal adherence was electrically cauterized. No pancreas had to be resected, despite the fact that the duplication involved the entire length of the pancreas. At the completion of the operation a Stamm gastrostomy was performed, and a soft sump catheter was placed into the lesser sac. The infant had an uneventful recovery and did not develop pancreatitis; nor was there any significant sump drainage. DISCUSSION Duplications classically share a common blood supply and a common muscular coat between the duplicated segment and the adjacent segment of the gastrointestinal tract. The duplication must also possess an alimentary From the Deportment of Pediatric Surgery, Long Island Jewish-Hi&de Medical Center, New Hyde Park. N. Y. Address reprint requests to Keith M. Schneider, M.D., I300 Union Turnpike, New Hyde Park, N.Y. 11040. 01979 by Grune & Stratton, Inc. 0022-3468/79/1402-0018$01.00/0 187

188

Fig. 1. dupkion:

SCHWARTZ

(A) Sutured perforation of the splenic flexure; (El Normal stomach, posterior wall.

epithelium, which need not mimic the mucosa of the attached organ. Gastric duplications are not only the rarest of the intestinal duplications, but they also have a greater propensity to deviate from the classical criteria. Kremer et al.,’ Gray and Wood,6 and Sheppard and Gilmour’ have described pedunculated gastric duplications. Parker et al.* reported two patients with gastric duplications that were closely related to the tail of the pancreas and free of any communication with the stomach. One of their patients had an abscess that eroded into the transverse colon. Our patient presented with a pneumoperitoneum as a direct result of the duplication eroding into

ET AL.

(BI Pancreas; (C) Gastric duplication; ID) Probe within the opened

the splenic flexure. We believe this feature is unique to the present report. As was noted in one of Parker’s* patients, we were also able to enucleate the duplication from deep within the pancreas by blunt dissection, without necessitating a pancreatic resection. Torma’ reported two gastric duplications that involved the “ventral pancreas anlage looping anterior to the gastric duplication.” In both these patients the duplications were adherent to the greater curvature of the stomach. This case adds documentation to the fact that histologically proven gastric duplications may not only have ectopic origins, but may also have no attachments to the stomach.

REFERENCES 1. Wendel W: Beschreibung enies operativ enfernten congenitalen. Nehenmagens Arch Klin Clui 95:895-898, 1911 2. Bartels RJ: Duplication of the stomach, case report and review of the literature. Am Surg 3:747, 1967 3. Tschappeler J, Smith WB: Duplications of the intestinal tract: Clinical and radiological features. Ann Radio1 20:133-139, 1976 4. Favara BE, Franciosi RA, Akers DA: Enteric duplications. Am J Dis Child 122:501-506, 197 1

5. Kremer RM, Lepoff RB, Izant RJ Jr: Duplication of the stomach. J Pediatr Surg 5:360-364, 1970 6. Gray HK, Ward GA: Cystic tumors of the stomach. Surg Clin N Am 18:1069, 1936 7. Sheppard MD, Gilmour JR: Torsion of a pedumculated cystic cyst. Br J 1:874, 1945 8. Parker BC, Guthrie NE, Atwell JD: Gastric Duplications in infancy. J Pediatr Surg 7:294-298, 1972 9. Torma MJ: Of double stomachs. Arch Surg 109:555556, 1974