Gastric duplication in infants

Clinicians pay close attention to the questions related to the diagnosis and treatment tactics of stomach defects with its obstruction in view of their stable frequency and lack of consensus on these diseases development mechanisms. The insufficient individual experience of every clinician leads to the difficulties in early diagnostic and the most adequate surgical intervention choice, and so, high rates of mortality.


Introduction
More than 100 years history of stomach congenital malformations in children study shows the careful examination of issue on the one hand and its extraordinary relevance today on the other hand. Clinicians pay close attention to the questions related to the diagnosis and treatment tactics of stomach defects with its obstruction in view of their stable frequency in the gastrointestinal tract congenital anomalies structure for many years, and lack of consensus on these diseases development mechanisms [1,5,7].
The matter is also that the stomach congenital pathology is rather rare in the structure of children abdominal cavity surgical diseases, and its congenital obstruction occurs even more rarely. So, the insufficient individual experience of every clinician leads to the difficulties in early diagnostic and the most adequate surgical intervention choice, and thus, high rates of mortality due to this pathology remain until now [5,6].
The congenital stomach diseases accompanied by obstruction include atresia, membranes and duplicates. The gastric duplication was first described by W. Lyons in 1916. Atresia and membranes have a reported incidence of 1 in 50 000-100 000 newborns, and gastric duplication counts for 3.8-7.0 % of all digestive tract congenital obstructions. The literature mainly describes the individual cases of these diseases, which indicates the lack of clinical experience in diagnosis, the rational method of their treatment choice and to a certain extent determines the relevance of this issue [1,8,11].
The absence of clear signs of illness even in the case of modern diagnostic methods use is determined. Therefore, it is often impossible to distinguish between manifestations of double stomach and other abdominal space-occupying processes, accompanied by the upper gastrointestinal obstruction phenomena of varying degrees. Ultimately, the timely detection of these developmental abnormalities and the determination of surgical indications, which finally define the diseases surgical approach, are important.
Differential diagnostics of stomach congenital obstruction rare variants is made, as in the case of the congenital hypertrophic pyloric stenosis, with all diseases of surgical and nonsurgical nature, accompanied by vomiting syndrome. The first include all types of congenital gastrointestinal obstruction and their complications, the second -birth craniocervical trauma, diseases that are accompanied by toxic-hypoxic lesions of the central nervous system, adrenal glands pathology [2,10].
Analysis of indications for surgical treatment in patients with gastric duplication has revealed that the defect was diagnosed accurately before operation only in 25-39 % of patients. In the other 61-75 % of cases the reasons for surgery were the suspicions of various abdominal and thoracic cavity pathologies [3,8].
By the results of analysis based on the modern diagnostic methods capabilities, the diagnostic algorithm of the stomach congenital obstruction, which is caused by gastric duplication, is developed and introduced into practice ( Fig. 1) [1,8,12].
In the diagnosis of gastric duplications the radiological method of examination is relevant up to now, although it does not always yield positive results. The most objective information can be obtained using ultrasound and MRI of the abdominal cavity methods to make accurate diagnosis of the gastric duplication coupled with the disease clinical picture.
Data obtained as a result of additional methods (ultrasound, FGDS, MRI) allow to determine the accurate localization and cystic formations origin, to diagnose the abdominal cavity pathological formation, to timely determine the indications for surgical intervention and to continue the diagnostic process and the final treatment tactics determination on the operating table [8,11].
For gastric duplications surgical correction their removal is used by a method of extracting without its inoculation or with an underlying wall of the stomach in cases of it is adherent tightly to other organs. In the case of large duplication sizes, some authors recommend to remove the partition between the main and the additional organ and to perform anastomosis between them with a common cavity formation. In some cases, the surgery is confined to an anastomosis between the additional stomach and the intestine [4,8,9,13].
The results of rare congenital defects of stomach with obstruction treatment can not be considered satisfactory due to high lethality, which is 12.9-14.4 % for the gastric duplication [1,4,14]. Zaporozhye  Purpose of the work Improvement of the diagnostic and treatment tactic in infants with gastric duplication.

Materials and methods
Literature review and clinical experience of two cases of the newborn children treatment with rare variants of digestive tract developmental defects is presented. In one child it was a case of stomach cystic duplication; and the other had a cystic duplication of stomach and duodenum. The early operative intervention was performed in both infants. Type and extent of the operation depended on the peculiarities of localization, sizes, clinical signs of the defects and the general state of patients. The main stages and methods of medical-diagnostic process of such patients' management are presented.

Results
There have been 5 cases of the stomach duplication treatment in the last 5 years in the Pediatric Surgery Clinic of Zaporizhzhia State Medical University. Two children were diagnosed with this pathology in neonatal period. Clinical analysis of these cases is described.
Clinical case № 1 A boy from Mariupol city, case report form № 8868, was born with a birth weight of 4000g and Apgar scores of 7-8. He passed meconium and was breastfeeding. On the second day of life child presented a vomiting of fermented milk.
Anamnesis: a child was born to a G3 mother, gestation course was complicated by acute respiratory infection at 10 weeks, proteinuria at 25 weeks; ultrasound of the fetus at 25 weeks of pregnancy revealed an abdominal mass.
The infant was delivered to the Clinic of Pediatric Surgery in Zaporizhzhia by sanitary aviation service with provisional diagnosis: "Congenital defect of gastrointestinal tract development. Abdominal cyst? Cyst of pancreatic head? Fetal infection, bilateral focal pneumonia. Perinatal central nervous system hypoxic lesion. Dysmetabolic cardiomyopathy".
The baby was under the care in Neonatal Pathology Department, where the symptoms got worse -vomiting increased in volume, general condition worsened to severe, body weight gain was absent. Turgor and elasticity of soft tissues were reduced. Large fontanel was 1.5 × 1.5 cm. In the lungs breathing was pure. Heart sounds were clear, rhythmic. The abdomen was symmetrically enlarged in size, soft and painless when palpating in all departments. The liver and spleen were not enlarged. Laboratory blood parameters were not significantly altered.
The additional methods of examination were performed. At the abdominal cavity plain radiography the intestinal pneumatic reduction and shadow in the right half of the abdominal cavity were revealed (Fig. 2). In ultrasound of the abdominal cavity the round-shaped cystic mass 7.0 to 7.5 cm in size was determined (Fig. 3). CT examination of the abdomen showed a right-sided round cystic mass measuring 8 × 7 cm with a homogeneous content and a contour up to 0.3 cm. The intestinal loops were displaced peripherally by the mass; homogeneously structured liver was 2 cm protruded below the costal margin; pancreas was homogeneous, with normal size and position. Kidneys and spleen were with inconspicuous findings (Fig. 4).
After the preoperative preparation in the Neonatal Anesthesiology and Intensive Care Department a surgical intervention (laparotomy) was performed. During the abdominal cavity revision an elastic cystic mass originating from the pyloric part of stomach and the lower part of duodenum was revealed. At a distance of up to 30 cm from the ileocecal angle on the antimesenteric border of the terminal ileum, the Meckel's diverticulum on a wide base without any evidence of inflammation was found. The cystic formation of the stomach and duodenum was removed, and gastroenteroanastomosis by Bilrot-1 has been performed. The Meckel's diverticlum resection has been performed and  the ileo-ileoanastomosis end-to-end accomplished. Histological examination confirmed the diagnosis of the stomach and duodenum cystic duplication. Post-operative period was uneventful. Control ultrasound examination was performed in 10 days after surgery: volumetric formations in the abdominal cavity were not detected. The child was discharged from clinic on the 37th day of life. Then he was examined in 4 months, there was no lag in physical development.
Clinical case № 2 An infant, case report form № 8868, was born at 39 week's gestation by an urgent Caesarean section for distress of the fetus with a birth weight of 2790 g, and Apgar scores of 4-6 scores. A child was born to a G1P1 mother, who experienced threatened abortion at the 7 th gestation week. Abdominal ultrasound of the fetus at 22 weeks demonstrated a cystic formation in the abdominal cavity, atresia of the jejunum and enterogenous cysts.
Immediately after birth an infant was hospitalized in the Department of Anesthesiology and Intensive Care of Newborns with a diagnosis of cystic formation in the abdominal cavity. From the first day of the child's hospital stay (the first day of life) there were signs of the passage through gastrointestinal tract disorder. In particular, the enteral feeding was not absorbed, the gastric probe emptied fermented milk with mucus, that exceeded the enteral feeding volume, and there were signs of cholestasis: acholic stool, hyperbilirubinemia due to direct fraction, ALT elevation. The abdominal ultrasound was performed. It confirmed the results of pre-natal examination about the abdominal cystic formation (Fig. 5).
CT scan of abdominal organs also revealed the signs of cystic formation on the right side of abdomen. Considering the signs of partly violated passage through gastrointestinal tract, the results of ultrasound and CT examinations a surgical decision was made. But during the preoperative preparation (fluid management, antibiotic therapy, freshly frozen plasma transfusion) the condition of the child was improved, the signs of partial high intestinal obstruction gradually began to regress: the child began to assimilate the enteral feeding, a colored stool appeared. A case conference was held and as a result the operative intervention was decided to be postponed due to the positive dynamics to a stable state.
The child was transferred to the Pathology of Newborns Department in a state of moderate severity. But in few days, when trying to increase the enteral feeding volume to 60-70 ml, the signs of partial intestinal obstruction (passage through gastrointestinal tract violation) and cholestasis (acholic stool, total bilirubin was 138 and direct one 96 μmol/l) began to increase again. X-ray barium contrast examination was performed and X-ray signs of partial high intestinal obstruction were revealed (Fig. 6).
Operative intervention was performed, which resulted   in the retroperitoneal space cystic formation removal, which was located alongside the duodenum and caused mechanical compression of the intestine. Cystic formation was in capsule, isolated from surrounding tissues. Histological examination confirmed the cystic gastric duplication diagnosis.
The postoperative period was with edema syndrome, which regressed for three days in the adequate therapy course. Control ultrasound examination was performed 10 days after the operation: volumetric structures in the abdominal cavity were not detected. Clinical symptoms of intestinal obstruction were regressed. The child was discharged in satisfactory condition from the hospital. Examined after 2 months, the child condition was satisfactory without any complaints.

Conclusions
1. The analysis shows that the efficacy of stomach obstruction rare forms diagnosis is achieved by usage of algorithms based on the staged modern diagnostic methods, taking into account their resolution and congenital anomaly type.
2. In congenital stomach and duodenum duplication maximal informativness can be achieved using ultrasound and CT (or MRI) of the abdominal cavity. The most effective and non-invasive is ultrasound method by high-resolution devices.
3. The discussed clinical cases are examples of early diagnosis of the stomach duplication and the right choice of active tactics for such children management that has made it possible to obtain a successful treatment outcome.