Malignant Transformation of Ectopic Pancreas

Novel classification of gastric polyps: The good, the bad and the ugly

Gastric polyps (GPs) are increasingly common. On upper endoscopy, they should be examined with white light and occasionally chromoendoscopy, and their morphology classified according to the Paris classification. Most GPs have a typical endoscopic appearance and can be associated with diseases like Helicobacter pylori infection. Histological examination is necessary for an accurate diagnosis. While most polyps are non-neoplastic and do not require treatment, some carry a risk of malignancy or are already malignant. Therefore, understanding the diagnosis, classification, and management of GPs is crucial for patient prognostication. Our new classification categorizes GPs into "good", "bad", and "ugly" based on their likelihood of becoming malignant. We aim to provide descriptions of the endoscopic appearance, pathology, treatment, and follow-up for different GPs, as well as clinical management flowcharts.

Heterotopic pancreas in the gallbladder: A case report

BACKGROUND

Heterotopic pancreas (HP) refers to pancreatic tissue located in areas with no vascular or anatomical connection to the pancreas. HP occurs mostly in the stomach, duodenum, and colon, and rarely in the gallbladder.

CASE SUMMARY

A 57-year-old woman was referred to our hospital complaining of right upper quadrant discomfort for 3 years. An abdominal computed tomography scan revealed adenomyomatosis with a thickened fundus of the gallbladder. The patient underwent a laparoscopic cholecystectomy, and pathological examination unexpectedly showed heterotopic pancreatic tissue in the gallbladder. The patient had a favorable recovery and was discharged on postoperative day 3. She did not report any symptoms or complications at the 6-mo postoperative follow-up. Pathologists should pay close attention to such pancreatic tissue and carefully examine it for dysplasia or malignancy.

CONCLUSION

This case provides more information about HP in the gallbladder, a rare occurrence.

Acute on chronic pancreatitis affecting the ectopic pancreas located in the jejunal mesentery: A case report

Ectopic pancreas within the mesentery is rare. In this case report, a 61-year-old man with an ectopic pancreas within the jejunal mesentery for over 20 years developed chronic pancreatitis that progressed to acute exacerbation. Our computed tomography (CT) performed for acute abdomen assessment suggested acute appendicitis or Meckel's diverticulitis. However, a CT scan taken 20 years ago revealed a structure indicative of an ectopic pancreas in the mesentery, and further imaging findings taken 10 and 4 years ago confirmed progression to chronic pancreatitis. Furthermore, we found a pancreatic stone confined in the luminal structure that corresponded to the main pancreatic duct; this stone eventually caused acute exacerbation. In summary, we report a case of mesenteric ectopic pancreas that showed typical findings of progression and acute exacerbation of chronic pancreatitis on CT.

A Case Report of an Unusually Large Heterotopic Pancreas

Heterotopic pancreas (HP) is the presence of pancreatic tissue outside of its normal anatomical position without vascular continuity from the main pancreas. HP is most commonly found within the gastrointestinal tract, particularly the stomach through the jejunum. This report shares the case of a 57-year-old man who presented with persistent vomiting despite medical therapy. Given the nonspecific and broad differential diagnosis, a histopathological examination was warranted for a definitive diagnosis that showed a uniquely large and well-differentiated type I HP in the lesser curvature of the stomach. Resection was completed which was followed with resolution of symptoms.

Clinical features and treatment of heterotopic pancreas in children: a multi-center retrospective study

OBJECTIVE

Heterotopic pancreas, an uncommon condition in children, can present with diagnostic and treatment challenges. This study aimed to evaluate the clinical features and treatment options for this disorder in pediatric patients.

METHODS

We conducted a retrospective analysis, including patients diagnosed with heterotopic pancreas at four tertiary hospitals between January 2000 and June 2022. Patients were categorized into symptomatic and asymptomatic groups based on clinical presentation. Clinical parameters, including age at surgery, lesion size and site, surgical or endoscopic approach, pathological findings, and outcome, were statistically analyzed.

RESULTS

The study included 88 patients with heterotopic pancreas. Among them, 22 were symptomatic, and 41 were aged one year or younger. The heterotopic pancreas was commonly located in Meckel's diverticulum (46.59%), jejunum (20.45%), umbilicus (10.23%),ileum (7.95%), and stomach (6.82%). Sixty-six patients had concomitant diseases. Thirty-three patients had heterotopic pancreas located in the Meckel's diverticulum, with 80.49% of cases accompanied by gastric mucosa heterotopia (GMH). Patients without accompanying GMH had a higher prevalence of heterotopic pancreas-related symptoms (75%). Treatment modalities included removal of the lesions by open surgery, laparoscopic or laparoscopic assisted surgery, or endoscopic surgery based on patient's age, the lesion site and size, and coexisting diseases.

CONCLUSIONS

Only one-fourth of the patients with heterotopic pancreas presented with symptoms. Those located in the Meckel's diverticulum have commonly accompanying GMH. Open surgical, laparoscopic surgical or endoscopic resection of the heterotopic pancreas is recommended due to potential complications. Future prospective multicenter studies are warranted to establish rational treatment options.

Adenocarcinoma developing from gastric heterotopic pancreas: a case report and short review

Heterotopic pancreas is a relatively rare condition that may be associated to clinical complaints or signs. Here, we report a case of gastric heterotopic pancreas assictaed to ductal adenocarcinoma. Obstructive jaundice was the initial symptom prompting medical intervention. A 73-year-old male patient presented with yellow staining of the skin and sclera, and dull epigastric pain. Contrast-enhanced computed tomography showed stenosis of the extrahepatic distal bile duct and mass lesions of the antrum. The patient underwent tumor resection, distal gastrectomy (Billroth II), and common bile duct exploration. Postoperative pathological examination revealed an adenocarcinoma located in the wall of the gastric antrum. Immunohistochemical results suggested that the tumor originated from the pancreas. Heterologous pancreatic tissue and a dilated pancreatic duct were found in the tumor. These findings suggest malignant transformation of the gastric heterotopic pancreas. Of note, jaundice as clinical complaint for adenocarcinoma associated to gastric heterotopic pancreas.

Endoscopic management of gastric ectopic pancreas with repeated ulcerations and bleeding: A case report

A 25-year-old man was referred to our center for investigation of a gastric submucosal tumor and an ulcer that had developed on its oral side. Endoscopic ultrasonography findings suggested the presence of an ectopic pancreas, and treatment with an oral proton pump inhibitor was planned for the ulcer. Over the subsequent 3 years, the patient endured recurring epigastric pain and episodes of passing black stools. Emergency endoscopy revealed that the morphology of the gastric submucosal tumor had transformed into a pedunculated polyp-like morphology with a bleeding ulcer at the apex of the lesion. Endoscopic hemostasis using hemostatic forceps was performed. However, the patient continued to pass black stools. In light of the persistent symptoms and unique morphology of the lesion, endoscopic resection was attempted as a curative approach. The lesion was excised by hot snare polypectomy. Post-treatment, the patient exhibited no signs of recurrence, marking a successful resolution. Three months later, a gastroduodenal endoscopy showed that the excised site had undergone scar formation without recurrence of the lesion. This case holds significant clinical value as it demonstrates the efficacy of a minimally invasive treatment strategy in managing repeated bleeding ulcerations of an ectopic pancreas, ultimately achieving a complete cure.

FDG PET/CT in Pancreatic Ductal Adenocarcinoma Arising From a Heterotopic Pancreas of the Pylorus

ABSTRACT

Malignant transformation of heterotopic pancreas is extremely rare. We describe FDG PET/CT findings in a case of pancreatic ductal adenocarcinoma arising from a heterotopic pancreas in the submucosa of the pylorus with peripyloric lymph node metastasis and elevated serum carbohydrate antigen 19-9 level. The heterotopic pancreatic adenocarcinoma showed intense FDG uptake, and the peripyloric lymph node metastasis showed mild FDG uptake. This case indicates that heterotopic pancreatic adenocarcinoma should be included in the differential diagnosis of FDG-avid gastric submucosal lesions, especially in patients with elevated serum carbohydrate antigen 19-9 level.

The tale of 2 pancreases: Jejunal mesenteric ectopic pancreas causing recurrent ectopic pancreatitis

Ectopic pancreas, or the presence of pancreatic tissue separate from the anatomic pancreas, is rarely reported in locations other than the stomach or duodenum. A 43-year-old female was found to have a large jejunal mesenteric ectopic pancreas causing ectopic pancreatitis during workup for frequent episodes of abdominal pain. We present the imaging findings and postresection pathology findings of a rare jejunal ectopic pancreas and discuss the potential complications of this unique condition.

Acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication, in an adult with intestinal malrotation: a case report

BACKGROUND

Intestinal duplication and ectopic pancreas are two rare independent congenital anomalies. Few reports describe cases of patients with ectopic pancreas in an intestinal duplication causing acute peritonitis.

CASE PRESENTATION

A 31-year-old man was admitted to the hospital for epigastric pain. The patient was diagnosed with acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication, with intestinal malrotation. The patient underwent the partial resection of the jejunum and Ladd's procedure. The histopathological findings indicated ectopic pancreatitis in the jejunal duplication.

CONCLUSIONS

We presented the case of acute peritonitis caused by the acute pancreatitis of an ectopic pancreas in a jejunal duplication in an adult with intestinal malrotation. Surgery is the primary treatment and is necessary for a definitive diagnosis.

Expression and clinicopathological characteristics of PDX1, PTF1A, and SALL4 in large and small ducts of ectopic pancreas located in gastro-duodenum and jejunum

An ectopic pancreas is defined as pancreatic tissue outside its normal location, anatomically separated from the pancreas. The transcription factor pancreas/duodenum homeobox protein 1 (PDX1) is involved in maintaining the pancreas and functions in early pancreatic development, beta cell differentiation, and endocrine non beta cells. Pancreatic transcription factor 1 subunit alpha (PTF1A) affects exocrine cell formation and regulation of acinar cell identity, and is expressed in exocrine cells as a transcription factor. The depletion of SALL4 disrupts self-renewal and induces differentiation. To clarify which of PDX1, PTF1A, or SALL4 determines the difference in Heinrich's classification, we examined the localization and number of positive cells. We analyzed the differential expression of PDX1, PTF1A, and SALL4 in large and small ducts in ectopic pancreas by immunohistochemistry. Results showed that the number of PTF1A-positive cells in large ducts was more widespread in type I than in type II in the gastro-duodenum, and more SALL4-positive cells were noticed in large ducts than in small ducts in the gastro-duodenum of type II. Our results revealed that PTF1A might promote exocrine differentiation in developing the pancreatic tissues, and that those with widespread expression differentiate into exocrine cells.

Metastasis from Renal Cell Carcinoma to Ectopic Pancreas Diagnosed after Resection

We herein report a 68-year-old man who underwent nephrectomy for right renal cell carcinoma 10 years prior. He remained under regular medical observation, and abdominal computed tomography showed tumors in the head and tail of the pancreas. He was diagnosed with pancreatic metastasis from renal cell carcinoma. He underwent surgical excision. The pathologic diagnosis proved that the pancreatic tumors were metastases from renal cell carcinoma and clarified that an ectopic pancreas in the duodenum had metastases as well. To our knowledge, this is the first case of metastasis to an ectopic pancreas.

Colonic ductal adenocarcinoma case report: New entity or rare ectopic degeneration?

BACKGROUND

Ectopic pancreatic tissue is a congenital anomaly where a part of pancreatic tissue is located outside of the pancreas and lacks vascular or anatomical communication with it but shows the same histological features. Currently, the literature reports only two anecdotal cases of malignant transformation of colonic ectopic pancreas.

CASE SUMMARY

We present a case of an 81-year-old patient presenting with anemia, with right colonic neoplasia and carbohydrate antigen 19-9 above the normal values. She underwent laparoscopic right hemicolectomy. The final histology was consistent with a primitive adenocarcinoma with ductal morphology and solid-predominant growth pattern. Benign ectopic pancreatic tissue was absent in the surgical specimen.

CONCLUSION

The case describes a very rare complete degeneration of a colonic ectopic pancreatic tissue. However, the absence of benign ectopic pancreatic tissue in the surgical specimen is suggestive of the first description of a primitive ductal adenocarcinoma of the colon.

Extensive heterotopic pancreas in a rare site: A case report and a review of literature

RATIONALE

Heterotopic pancreas is a pancreatic tissue that occurs outside the normal anatomical site, the most common site is antrum. Due to the lack of specific imaging and endoscopic signs, heterotopic pancreas especially those occurring in the rare site, are often misdiagnosed, and leading to unnecessary surgical treatment. Endoscopic incisional biopsy and endoscopic ultrasound-guided fine-needle aspiration are effective means for diagnosing heterotopic pancreas. We reports a case of extensive heterotopic pancreas in a rare site, which was finally diagnosed by this way.

PATIENT CONCERNS

A 62-year-old man was admitted due to the presence of an angular notch lesion, which was suspected as gastric cancer before. He denied any history of tumor or gastric disease.

DIAGNOSES

No abnormality was found in the physical examination and laboratory testing after admission. Computed tomography showed localized thickening of the gastric wall measuring 30 mm in the long diameter. Gastroscope revealed a nodular-like submucosal protuberance at the angular notch with size of about 3*4 cm. Ultrasonic gastroscope showed that the lesion was located in the submucosa. The lesion exhibited mixed echogenicity. The diagnosis can not be identified.

INTERVENTIONS

2 times of incision biopsy were performed to make a clear diagnosis. Finally, appropriate tissue specimens were obtained for pathology testing.

OUTCOMES

The patient was diagnosed as heterotopic pancreas according to pathology. He was recommended to undergo observation and regular follow-ups rather than surgery. Then he was discharged home with no discomfort.

LESSONS

Heterotopic pancreas occurring in the angular notch is extremely rare, the site is scarcely reported in the relevant literature. Therefore, it is easy to be misdiagnosed. In the cases of an vague diagnosis, endoscopic incisional biopsy or endoscopic ultrasound-guided fine-needle aspiration may be a good choice.

Aberrant pancreas adenocarcinoma in the stomach: A case report and literature review

RATIONALE

Aberrant pancreatic tissue in the gastrointestinal tract is a relatively common finding. However, malignant transformation is extremely rare. Herein, we report a case of ectopic pancreatic ductal adenocarcinoma in the stomach wall.

PATIENT CONCERNS

A 38 year old male presented with nausea, bloating, abdominal distention and weight loss for 4 months.

DIAGNOSES

Endoscopy of upper gastrointestinal tract was performed twice with 2 months interval and a stenotic pyloric part was observed with a suspected submucosal lesion. It was sampled both times, however the pathology findings of the mucosal biopsies were unremarkable with no identifiable neoplastic structures. CT scan and MRI was performed and showed a thickened pyloric wall with a submucosal lesion 15 × 15 mm in diameter. Blood levels of tumor markers carcinoembrionic antigen and carbohydrate antigen 19-9 were within a normal range.

INTERVENTIONS

Pyloric stenosis progressed and the patient underwent a Billroth type I distal gastric resection with D2 lymphadenectomy. Pathologic examination revealed a well differentiated ductal adenocarcinoma arising in the heterotopic pancreatic tissue (Heinrich type III). The resection margins and lymph nodes were free of tumor. The patient received adjuvant chemotherapy with 6 courses of XELOX.

OUTCOMES

No disease recurrence is reported in 12 months follow-up.

LESSONS

Aberrant pancreatic ductal adenocarcinoma in the stomach is a rare finding, however this pathology should be included in the differential diagnosis of gastric submucosal lesion causing pyloric stenosis.

Case Report: The ectopic pancreas in the adrenal glands: It was found due to elevated blood pressure and initially diagnosed as adrenal adenoma

Background

The ectopic pancreas is a kind of congenital malformation formed during embryonic development, which has no anatomical relationship with the normal pancreas and is a rare solid disease. The ectopic pancreas in the adrenal glands is extremely rare.

Case summary

A 32-year-old man was admitted to the hospital after experiencing elevated blood pressure for 2 years as well as dizziness and blurred vision for 2 weeks. He had an elevated blood pressure of 170/110 mmHg (1 mmHg = 0.133 kPa) on physical examination 2 years ago, without palpitations, chest pain, and chest tightness. Two weeks ago, he presented with dizziness and blurred vision. Blood renin and aldosterone levels were elevated. Plain CT and contrast-enhanced CT scan showed nodular thickening of the left adrenal and homogeneous enhancement, which was initially considered adrenal adenoma. The postoperative pathology supported the ectopic pancreas in the left adrenal. After 78 months of postoperative follow-up, no recurrence was observed, but his blood pressure remained persistently high.

Conclusion

The ectopic pancreas occurring in the adrenal glands is extremely rare, has no specific clinical symptoms, and is mainly found for other reasons. It can easily be misdiagnosed as an adrenal adenoma. The final confirmation of the diagnosis still depends on the pathological biopsy. A great deal of reporting is still required for whether there is a correlation with elevated blood pressure.

Case report of retroperitoneal ectopic pancreas with adrenal adenoma

Background

Ectopic pancreas is a congenital anomaly in which pancreatic tissue is anatomically separated from the main gland and without vascular or ductal continuity. A case of retroperitoneal ectopic pancreas with adrenal adenoma has never yet been reported.

Case Presentation

A 54-year-old man presented three masses in the left retroperitoneum, and two of them were resected. The pathologic findings were a retroperitoneal ectopic pancreas with adrenal adenoma.

Conclusion

We report an extremely rare case of a retroperitoneal ectopic pancreas and its characterization with dynamic gadolinium-enhanced magnetic resonance imaging (MRI).

Pancreatic Heterotopia in the Small Bowel: A Case Report and Literature Review

ABSTRACT

Diagnosing pancreatic heterotopia (PH) is challenging, because it is a rare congenital anomaly. We report the case of a 66-year-old man who presented with ileus and jejunal PH diagnosed using single-balloon enteroscopy. Reviewing 178 cases of small intestinal PH in the literature showed that (1) PH mostly occurred at the duodenum (61.8%), followed by the jejunum (22.5%) and ileum (14.6%); (2) patients with ileal PH were younger (mean, 40.7 vs 54.6 years; P < 0.001), while those with jejunal PH were older (mean, 59.5 vs 51.7 years; P = 0.006); (3) most patients with jejunal PH were females, while those with duodenal or ileal PH were predominantly males (M:F = 0.8:1 vs 2.5:1; P = 0.003); (4) asymptomatic cases were rare (15.2% vs 83.4% in small and nonsmall bowel, respectively); (5) most patients with ileal PH presented with bleeding (61.5%), while the remaining had abdominal pain (42.8%); (6) emergent operation was performed in 11 cases (6.2%), mainly at the jejunum (12.5%) and Meckel's diverticulum (25%); and (7) Heinrich's classification may be inconclusive. Enteroscopy was performed in only 6 cases (3.4%), and earlier diagnosis and further minimally invasive procedures could have been achieved with enteroscopy.

Granulocytic epithelial lesion (GEL) in heterotopic pancreas

BACKGROUND

The diagnosis of type 2 autoimmune pancreatitis (AIP) is dependent on typical radiologic imaging and the presence of the granulocytic epithelial lesion (GEL), which is characterized by ductal neutrophilic infiltration with or without neutrophilic acinar infiltration.

METHODS

We evaluated GEL and related clinicopathologic factors in 165 resected heterotopic pancreata (HPs) [57 gastric (35%), 56 duodenal (34%), 30 omental (18%), and 22 jejunal (13%)] and 29 matched orthotopic pancreata routinely examined during surgery.

RESULTS

GEL was noted in 8% (13/165) of HPs, including ductal epithelial (6/13, 46%) and intraluminal (8/13, 62%) neutrophilic infiltrations. However, there was no GEL in orthotopic pancreata. Abdominal pain was observed in 6 (46%) patients with GEL-positive HPs. GEL was more commonly observed in HPs having symptoms (p = 0.029), a larger size (p = 0.028), and an infiltrative growth pattern (p = 0.006). In addition, periductal lymphoplasmacytic infiltration and fibrosis (both p < 0.001), interstitial fibrosis (p = 0.017), acinar neutrophilic infiltration (p = 0.032), venulitis (p = 0.050), acinar ductal metaplasia (ADM; p = 0.040), and pancreatic intraepithelial neoplasia/intraductal papillary mucinous neoplasms (PanIN/IPMN; p < 0.001) were more commonly seen in HPs with GEL than in those without GEL. Inflammatory bowel disease was present only in one patient with GEL-negative HP.

CONCLUSIONS

GELs are detected in a subset of HPs without clinical evidence of AIP. Therefore, for the diagnosis of AIP, GEL should be carefully interpreted with the context of other histologic, clinical, and radiologic findings.

The Diagnosis of Small Gastrointestinal Subepithelial Lesions by Endoscopic Ultrasound-Guided Fine Needle Aspiration and Biopsy

Endoscopic ultrasonography (EUS) has been widely accepted in the diagnosis of all types of tumors, especially pancreatic tumors, lymph nodes, and subepithelial lesions (SELs). One reason is that the examination can provide a detailed observation, with tissue samples being immediately obtained by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). Many SELs are detected incidentally during endoscopic examinations without symptoms. Most SELs are mesenchymal tumors originating from the fourth layer, such as gastrointestinal stromal tumors (GISTs), leiomyomas, and schwannomas. GISTs are potentially malignant. Surgical treatment is recommended for localized GISTs of ≥20 mm. However, the indications for the diagnosis and follow-up of GISTs of <20 mm in size are controversial. There are several reports on the rapid progression or metastasis of small GISTs. Therefore, it is important to determine whether a SEL is a GIST or not. The main diagnostic method is EUS-FNA. Recently, endoscopic ultrasound-guided fine needle biopsy (EUS-FNB) using a new biopsy needle has been reported to obtain larger tissue samples. Additionally, various biopsy methods have been reported to have a high diagnostic rate for small GISTs. In local gastric SELs, regardless of the tumor size, EUS can be performed first; then, EUS-FNA/B or various biopsy methods can be used to obtain tissue samples for decision-making in relation to therapy and the follow-up period.

Malignant transformation of heterotopic pancreas as middle esophagus adenocarcinoma—A rare case report and comprehensive literature review

Heterotopic pancreas is a rare congenital abnormality that occurs during the growth and development process. It can be found in any part of the digestive tract, but the most common sites are the stomach, duodenum, and jejunum. Malignant transformation especially in the esophagus is rare. Here, we aim to report an unusual case of mid‐esophageal adenocarcinoma that originated from a heterotopic pancreas.

Clinicopathological features of intraductal papillary mucinous neoplasm derived from ectopic pancreas: A systematic review

Background

Methods

Results

Conclusion

•

The ectopic pancreas can be complicated with pancreatitis, pseudocyst formation, cyst formation, insulinoma, adenoma, and malignant transformation. Intraductal papillary mucinous neoplasm (IPMN) derived from the ectopic pancreas is rare and can undergo malignant transformation.

•

It is challenging to diagnose IPMN derived from ectopic pancreas preoperatively using the existing imaging modalities. Moreover, the clinicopathological characteristics of these tumors have not been elucidated.

•

We performed a review of case reports on IPMNs derived from the ectopic pancreas, including intraductal papillary mucinous carcinoma (IPMC) that was treated in our hospital, to determine the clinicopathological features of the tumors.

•

This is the first systematic review of the literature on IPMN derived from the ectopic pancreas. The review revealed that IPMN derived from the ectopic pancreas was diagnosed incidentally in most patients, and some patients were asymptomatic.

•

The existing imaging modalities may not accurately diagnose the condition preoperatively and differentiate between IPMN and IPMC. Risk factors for malignant transformation should be clarified through further research.

Ectopic Pancreatitis in the Gastric Antrum Mimicking Malignancy on FDG PET/CT

ABSTRACT

A 34-year-old man suffered intermittent abdominal pain for 1 month, especially after drinking or eating. Enhancement CT was performed to determine the cause, which detected a soft tissue mass in the gastric antrum, suggestive of possible malignancy. FDG PET/CT scan was undertaken for staging, which showed increased metabolism in the known gastric mass, also suggestive of malignancy. However, this lesion was confirmed as ectopic pancreatitis pathologically.

Ectopic pancreas appearing as a giant gastric cyst mimicking gastric lymphangioma: a case report and a brief review

Background

Ectopic pancreas (EP) is defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. Despite improvements in diagnostic endoscopy and imaging studies, differentiating ectopic pancreatic tissue from gastric submucosal diseases remains a challenge.

Case presentation

Here, we present a case of a 44-year-old woman with severe epigastric pain. Initially, gastric lymphangioma was highly suspected due to a well-demarcated protruding mass with a large size that occurred in the submucosal layer of the gastric antrum and appeared as a cystic lesion. The final correct diagnosis of gastric EP was made during surgery.

Conclusion

Gastric EP with serous oligocystic adenoma appearing as a giant gastric cyst is extremely rare. The difficulty of making an accurate diagnosis and differential diagnosis is highlighted, which may provide additional clinical experience for the diagnosis of EP with serous oligocystic adenoma in the stomach.

Management of gastric ectopic pancreas identified in preoperative evaluation of bariatric surgery - A case report

•

The diagnosis of rare gastric lesions has become more frequent after the increase in bariatric surgery.

•

The preoperative evaluation for bariatric surgery showed two lesions suggestive of Gastric Ectopic Pancreas.

•

The previous identification of these lesions provides better surgical planning.

•

Intraoperative Upper Endoscopy was used to identify the location of these lesions.

•

Simultaneous laparoscopic resection of the lesions associated with Sleeve Gastrectomy was performed.

Background

The diagnosis of gastric lesions, such as the Ectopic Gastric Pancreas (GEP), has become more frequent after the increase in bariatric surgeries. The most frequently used surgical options are: Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB). The scientific papers about GEP in Bariatric Surgery consisted of intraoperative findings, approach the lesion with gastrectomy and the need to change the initial surgical strategy of the Sleeve for others techniques which allow extended gastric resections.

Presentation of case

This is a report on a 21-year-old female patient with class 3 obesity whose preoperative evaluation showed two lesions suggestive of GEP. Simultaneous surgical video-laparoscopic treatment of lesions associated with SG aided by intraoperative Upper Endoscopy (UE) was performed with no perioperative complications.

Conclusion

It is possible to associate the treatment of rare gastric lesions with traditional surgery techniques for obesity.

Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy

INTRODUCTION

Pancreatic rest (PR) is an ectopic pancreatic lesion that is usually found incidentally on endoscopy or surgery. While most lesions do not have clinical significance, some patients are symptomatic and rarely, PR can predispose to malignancy. With the growing popularity of bariatric surgery, it has been unclear how to manage PR found on screening endoscopies, prior to bariatric surgery. Through review of the current literature, we propose an algorithm for clinicians to evaluate and manage PR found on screening endoscopies prior to bariatric surgery.

METHODS

We performed a literature search in PubMed pertaining to PR, clinical characteristics, risk of malignant transformation, endoscopic characteristics, histological descriptions, and resection techniques. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found 33 published articles from 2001 to 2019, including case reports, case series, retrospective cohorts, and a review paper.

RESULTS

PR is commonly found incidentally in the gastric antrum. Larger lesions have a higher risk of being symptomatic or predisposing to malignant transformation. Endoscopic ultrasound (EUS) can assist in the diagnosis of PR and guide resection technique. Certain histological characteristics, such as Heinrich class, grading of neoplasia, and genetic alterations, can determine malignancy risk of PR. Resection technique, either endoscopically or surgically, should be based on lesion size, depth of wall invasion, and the endoscopists' level of skill in endoscopic resection.

CONCLUSIONS

Proper evaluation and treatment of PR should be considered because of the risk for symptoms and malignant transformation. Symptomatic lesions and those at risk for malignant transformation should be considered for resection. EUS can guide the diagnosis and type of resection, either endoscopically through EMR or ESD or surgically through sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB).

Submucosal Tunneling Endoscopic Resection for the Management of Heterotopic Pancreas With Cystic Degeneration

Heterotopic pancreas is pancreatic tissue present outside of the normal location of the pancreas. In the presence of cystic degeneration, heterotopic pancreas is clinically significant because of the symptoms it causes and its physical resemblance to cancerous growth. A diagnosis of heterotopic pancreas is achieved with the aid of various endoscopic techniques for tissue removal. Submucosal tunneling endoscopic resection has proven successful for the resection of gastric subepithelial masses. We present a 53-year-old woman undergoing submucosal tunneling endoscopic resection for the resection of a subepithelial gastric cyst caused by heterotopic pancreas with cystic degeneration.

Pancreatic ductal adenocarcinoma in colonic wall: metastatic disease or cancerized pancreatic ectopic tissue?

We describe two unusual cases of cancerized ectopic pancreatic parenchyma within the wall of the left colon. Although the morphology of the neoplastic cells and their immunoprofile were consistent with pancreatic ductal adenocarcinoma, the detection of small foci of regular ectopic pancreatic tissue close to dysplastic glands at the periphery of the cancerized mass represented the key diagnostic features. A careful histological examination of surgical samples represents the correct approach to the diagnosis of this rare disease, mostly when total-body CT scan evaluation confirms the lack of bilio-pancreatic masses.

Loss of GATA4 causes ectopic pancreas in the stomach

Pancreatic heterotopia is defined as pancreatic tissue outside its normal location in the body and anatomically separated from the pancreas. In this work we have analyzed the stomach glandular epithelium of Gata4 ^flox/flox ; Pdx1-Cre mice (Gata4KO mice). We found that Gata4KO glandular epithelium displays an atypical morphology similar to the cornified squamous epithelium and exhibits upregulation of forestomach markers. The developing gastric units fail to form properly, and the glandular epithelial cells do not express markers of gastric gland in the absence of GATA4. Of interest, the developing glands of the Gata4KO stomach express pancreatic cell markers. Furthermore, a mass of pancreatic tissue located in the subserosa of the Gata4KO stomach is observed at adult stages. Heterotopic pancreas found in Gata4-deficient mice contains all three pancreatic cell lineages: ductal, acinar, and endocrine. Moreover, Gata4 expression is downregulated in ectopic pancreatic tissue of some human biopsy samples. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.