Pyloric Duplication Cyst (PDC) is an extremely rare congenital anomaly of the alimentary tract, whose clinical presentation often mimics those of hypertrophic pyloric stenosis in infancy rather than in the immediate neonatal period. Gastrointestinal duplications, mainly intestinal ones, are observed in 1 of every 4500 autopsies, predominantly in white males. Congenital pyloric duplication is extremely rare, few cases being described in the literature.and only six cases with prenatal diagnosis have been reported [13]. However, coexistent infantile pyloric stenosis and pyloric duplication has been reported once [16].

Prenatal diagnosis in our case was done easily with ultrasound scans as the typical alimentary tract duplication with hyperechoic inner and hypoechoic outer wall and associated hydramnios prompted us to look at the gastric outlook obstruction at the same time. Delivery at term at the tertiary centre with neonatal surgical services was helpful. Postnatal diagnosis with plain radiograph, ultrasound-doppler scans and limited water-soluble with or without double contrast study will suffice in most cases of isolated simple pyloric duplication. However, in combined gastric and pancreatic duplication cyst, axial imaging in the form of computed tomography (CT and magnetic resonance pancreatography (MRCP) may be helpful [17]. Endoscopic ultrasonography has been reported for gastric duplication but it involved general anesthesia in the neonate and best avoided [18]. Laparoscopy lends itself to better visualization of the duplication with relation to surrounding structures, especially if pre-operative imaging has not definitively identified the anomaly and can proceed to surgical excision [15].

The alimentary tract duplications diagnosed antenatally can be observed initially and excised later on at an optimum time electively but those who present with symptoms needs urgent intervention. The duplication cyst is better treated as theta are prone to complications such as obstruction, infection, rupture, pressure symptoms and pain, development of cancer at later date, etc.

The literature describes multiple approaches to these benign lesions including: endoscopic mucosal resection, laparoscopic excision, minimal invasive periumbilical approach, partial excision and mucosal stripping, internal drainage, enucleation, resection with Heineke-Mikulicz type pyloroplasty, or even complete pyloroantrectomy with Billroth I reconstruction [19,20]. The majority of these cysts do not communicate with the lumen permitting partial excision of the cyst wall and decompression of the pylorus lumen. This allows the mucosal stripping or cauterisation at the same time leaving the common wall intact, antropyloric function is minimally affected as compared to pyloromyotomy or gastric resection and reconstruction allowing speedy and complete recovery [15].

Although our team has experience and expertise of performing laparoscopic neonatal gastric surgery [4], we prefer to give full account of the current evidence-based options with pros and cons of each of these options and allow the parents to take a final informed decision. We use balanced anesthesia in the form of rectal paracetamol, local anesthesia at the periumbilical incision and laryngeal mask anesthesia which is similar to single port laparoscopic approach but is quick, safe and accurate and does not need endotracheal intubation and prolonged anesthesia.