Clinical analysis of ectopic pancreas with endoscopic ultrasonography: an experience in a medical center

Laparoscopic resection and endoscopic submucosal dissection for treating gastric ectopic pancreas

BACKGROUND

Gastric ectopic pancreas (GEP) is a rare developmental abnormality that refers to the existence of pancreatic tissue in the stomach with no anatomical relationship with the main pancreas. It is usually difficult to diagnose through histological examination, and the choice of treatment method is crucial.

AIM

To describe the endoscopic ultrasound characteristics of GEP and evaluate the value of laparoscopic resection (LR) and endoscopic submucosal dissection (ESD).

METHODS

Forty-nine patients with GEP who underwent ESD and LR in the Second Affiliated Hospital of Fujian Medical University from May 2018 to July 2023 were retrospectively included. Data on clinical characteristics, endoscopic ultrasonography (EUS), ESD, and LR were collected and analyzed. The characteristics of EUS and the efficacy of the two treatments were analyzed.

RESULTS

The average age of the patients was 43.31 ± 13.50 years, and the average maximum diameter of the lesions was 1.55 ± 0.70 cm. The lesion originated from the mucosa in one patient (2.04%), from the submucosa in 42 patients (85.71%), and from the muscularis propria in 6 patients (12.25%). Twenty-nine patients (59.20%) with GEP showed umbilical depression on endoscopy. The most common initial symptom of GEP was abdominal pain (40.82%). Tumor markers, including carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA-19-9), were generally within the normal range. One patient (2.04%) with GEP had increased CEA and CA-19-9 levels. However, no cancer tissue was found on postoperative pathological examination, and tumor markers returned to normal levels after resecting the lesion. There was no significant difference in surgery duration (72.42 ± 23.84 vs 74.17 ± 12.81 min) or hospital stay (3.70 ± 0.91 vs 3.83 ± 0.75 d) between the two methods. LR was more often used for patients with larger tumors and deeper origins. The amount of bleeding was significantly higher in LR than in ESD (11.28 ± 16.87 vs 16.67 ± 8.76 mL, P < 0.05). Surgery was associated with complete resection of the lesion without any serious complications; there were no cases of recurrence during the follow-up period.

CONCLUSION

GEP has unique characteristics in EUS. LR and ESD seem to be good choices for treating GEP. LR is better for large GEP with a deep origin. However, due to the rarity of GEP, multicenter large-scale studies are needed to describe its characteristics and evaluate the safety of LR and ESD.

Clinical classification of symptomatic heterotopic pancreas of the stomach and duodenum: A case series and systematic literature review

BACKGROUND

Heterotopic pancreas (HP) is an aberrant anatomic malformation that occurs most commonly in the upper gastrointestinal tract. While the majority of heterotopic pancreatic lesions are asymptomatic, many manifest severe clinical symptoms which require surgical or endoscopic intervention. Understanding of the clinical manifestations and symptoms of HP is limited due to the lack of large volume studies in the literature. The purpose of this study is to review symptomatic cases at a single center and compare these to a systematic review of the literature in order to characterize common clinical manifestations and treatment of this disease.

AIM

To classify the common clinical manifestations of heterotopic pancreas.

METHODS

A retrospective review was conducted of pathologic samples containing heterotopic pancreas from 2000-2018. Review was limited to HP of the upper gastrointestinal tract due to the frequency of presentation in this location. Symptomatic patients were identified from review of the medical records and clinical symptoms were tabulated. These were compared to a systematic review of the literature utilizing PubMed and Embase searches for papers pertaining to heterotopic pancreas. Publications describing symptomatic presentation of HP were selected for review. Information including demographics, symptoms, presentation and treatment were compiled and analyzed.

RESULTS

Twenty-nine patient were identified with HP at a single center, with six of these identified has having clinical symptoms. Clinical manifestations included, gastrointestinal bleeding, gastric ulceration with/without perforation, pancreatitis, and gastric outlet obstruction. Systemic review of the literature yielded 232 publications detailing symptomatic cases with only 20 studies describing ten or more patients. Single and multi-patient studies were combined to form a cohort of 934 symptomatic patients. The majority of patients presented with abdominal pain (67%) combined with one of the following clinical categories: (1) Dyspepsia, (n = 445, 48%); (2) Pancreatitis (n = 260, 28%); (3) Gastrointestinal bleeding (n = 80, 9%); and (4) Gastric outlet obstruction (n = 80, 9%). The majority of cases (n = 832, 90%) underwent surgical or endoscopic resection with 85% reporting resolution or improvement in their symptoms.

CONCLUSION

Heterotopic pancreas can cause significant clinical symptoms in the upper gastrointestinal tract. Better understanding and classification of this disease may result in more accurate identification and treatment of this malformation.

Role of endoscopic ultrasonography for differential diagnosis of upper gastrointestinal submucosal lesions

OBJECTIVE

To determine the accuracy of endoscopic ultrasonography (EUS) in the diagnosis of upper gastrointestinal submucosal lesions (SMLs).

METHODS

This was a retrospective study involving patients diagnosed with SMLs using EUS and confirmed by histopathology from November 2014 to December 2020 at The Third Xiangya Hospital of Central South University.

RESULTS

A total of 231 patients with SMLs were examined by EUS. Histologically, 107 lesions were stromal tumors, and 75 lesions were leiomyomas. Stromal tumors were mainly located in the stomach (89.7%), and leiomyomas were predominantly seen in the esophagus (69.3%). The diagnostic accuracy of EUS for stromal tumors and leiomyomas was 80.4% and 68.0%, respectively. The diagnostic accuracy was highest for lesions located in the muscularis mucosa. The mean diameter of stromal tumors measured using EUS was significantly larger than that of leiomyomas (21.89 mm vs. 12.35 mm, p < 0.001). Stromal tumors and leiomyomas originated mainly from the muscularis propria (94.4%) and the muscularis mucosa (56.0%), respectively. Compared with the very low-risk and low-risk groups of stromal tumors according to the National Institute of Health guidelines, the intermediate-risk and high-risk groups were more likely to have a lesion > 3 cm (p < 0.001) and a surface ulcer (p < 0.01) identified by EUS.

CONCLUSIONS

EUS has good diagnostic value for the diagnosis of upper gastrointestinal SMLs based on the lesion size and the muscle layer of origin. The diagnostic accuracy of EUS lesions is related to the origin, and the diagnostic accuracy is greatest in the mucosal muscularis layer. Stromal tumors > 3 cm and a surface ulcer on EUS are likely to be intermediate or high risk for invasion.

Diagnostic yields of endoscopic ultrasound-guided fine-needle tissue acquisition according to the gastric location

The diagnostic accuracy of endoscopic ultrasound-guided fine-needle tissue acquisition (EUS-FNTA) according to the gastric location of subepithelial tumors (SETs) has not been well established. We aimed to evaluate the efficacy of EUS-FNTA for the diagnosis of gastric SETs according to tumor location.Thirty-three patients diagnosed with gastric SETs via EUS-FNTA from January 2016 to May 2018 were analyzed retrospectively. Patient demographics, diagnostic yields, and complications were evaluated.Nineteen patients (57.6%) were female, with a mean age of 57.7 years. Endoscopic ultrasound revealed a mean longitudinal diameter of 25.6 mm. The most common location of SETs was in the gastric body (n = 18, 54.5%), followed by cardia and fundus (n = 10, 30.3%), and antrum (n = 5, 15.2%). A 20-gauge biopsy needle was most frequently used (90.9%). The diagnostic yield was obtained in 23 patients (69.7%). The most common diagnosis was gastrointestinal stromal tumor (73.9%), followed by leiomyoma (17.4%). The diagnostic yield of SETs in gastric antrum (0/5, 0%) was significantly lower than that in the gastric body and cardia (23/28, 82.1%, P = .001). A case of immediate bleeding after EUS-FNTA occurred in 1 patient (3.0%) who recovered uneventfully. According to related literature, the overall diagnostic yield of SETs in gastric antrum was significantly lower than that in the gastric body, fundus, and cardia (29.7% vs 71.4%, P < .001, n = 191).EUS-FNTA is ineffective in the diagnosis of SETs in the gastric antrum. Although EUS-FNTA is an advanced diagnostic tool for gastric SETs, it is essential to develop more effective methods for the diagnosis of antral SETs.

Endoscopic submucosal dissection as alternative to surgery for complicated gastric heterotopic pancreas

BACKGROUND

Gastric heterotopic pancreas (GHP) is generally asymptomatic and rarely features complications such as pancreatitis, pseudocysts, gastric outlet obstruction, bleeding, obstructive jaundice, or intussusception. However, the treatment of complicated GHP is challenging and often requires surgical resection.

AIM

To investigate the clinical outcomes of endoscopic submucosal dissection (ESD) as alternative to surgical resection for complicated GHP.

METHODS

This is a single-center, retrospective study. Between January 2013 and December 2017, a total of 5 patients underwent ESD for complicated GHP at Asan Medical Center. Patients who were diagnosed with complicated GHP were treated conservatively as with general practice for acute pancreatitis. After conservative management for resolving the acute phase of pancreatitis, ESD was performed as definitive treatment for complicated GHP. ESD was performed using the conventional method under conscious sedation. The clinical features of patients and tumors, procedure-related characteristics, and long-term outcomes were investigated.

RESULTS

The age of the 5 patients ranged from 28-43 years. Two of the patients were males. All lesions were located in the greater curvature of the antrum. On endoscopic ultrasonography during the pain episode, all lesions were located across the muscularis mucosa, submucosa, and proper muscle layers. The median lesion size was 20 [interquartile range (IQR), 18-35] during the pain episode at the time of the diagnosis of complicated GHP, and 15 mm (IQR, 9-33) at the time of ESD after conservative treatment. The procedure time ranged from 15-120 min. There were no procedure-related adverse events such as perforation or bleeding. The length of hospital stay after the procedure ranged from 2-4 d. All patients were symptom free during the median follow-up period of 46.0 mo (IQR, 39-60).

CONCLUSION

ESD appears to be a feasible and effective treatment option for complicated GHP based on the favorable clinical outcomes.

Endoscopic submucosal dissection as alternative to surgery for complicated gastric heterotopic pancreas

BACKGROUND

Gastric heterotopic pancreas (GHP) is generally asymptomatic and rarely features complications such as pancreatitis, pseudocysts, gastric outlet obstruction, bleeding, obstructive jaundice, or intussusception. However, the treatment of complicated GHP is challenging and often requires surgical resection.

AIM

To investigate the clinical outcomes of endoscopic submucosal dissection (ESD) as alternative to surgical resection for complicated GHP.

METHODS

This is a single-center, retrospective study. Between January 2013 and December 2017, a total of 5 patients underwent ESD for complicated GHP at Asan Medical Center. Patients who were diagnosed with complicated GHP were treated conservatively as with general practice for acute pancreatitis. After conservative management for resolving the acute phase of pancreatitis, ESD was performed as definitive treatment for complicated GHP. ESD was performed using the conventional method under conscious sedation. The clinical features of patients and tumors, procedure-related characteristics, and long-term outcomes were investigated.

RESULTS

The age of the 5 patients ranged from 28-43 years. Two of the patients were males. All lesions were located in the greater curvature of the antrum. On endoscopic ultrasonography during the pain episode, all lesions were located across the muscularis mucosa, submucosa, and proper muscle layers. The median lesion size was 20 [interquartile range (IQR), 18-35] during the pain episode at the time of the diagnosis of complicated GHP, and 15 mm (IQR, 9-33) at the time of ESD after conservative treatment. The procedure time ranged from 15-120 min. There were no procedure-related adverse events such as perforation or bleeding. The length of hospital stay after the procedure ranged from 2-4 d. All patients were symptom free during the median follow-up period of 46.0 mo (IQR, 39-60).

CONCLUSION

ESD appears to be a feasible and effective treatment option for complicated GHP based on the favorable clinical outcomes.

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).

Endoscopic submucosal dissection for gastric ectopic pancreas: a single-center experience

BACKGROUND AND OBJECTIVE

Endoscopic submucosal dissection (ESD) is a minimal invasive technology and could allow "en bloc" resection for superficial gastric tumors. The aim of this study is to evaluate the safety and feasibility of ESD for gastric ectopic pancreas (EP).

METHODS

A total of 93 patients diagnosed with ectopic pancreas who underwent ESD between January 2011 and June 2017 were enrolled. The demographic, clinical, and endoscopic data were collected and analyzed.

RESULTS

The average maximal diameter of lesions was 1.01 (range 0.4-3.0) cm with mean age of patients which was 39.75 (range 15-66) years. Overall, all of procedures en bloc was successful. The median operative time was 76.87 (range 30-160) min. A total of 12 patients experienced complications. In seven patients, bleeding occurred during the operation and was treated using hot biopsy forceps or metal clip. Five cases suffered from pneumoperitoneum which was managed well. The mean length of postoperative hospital stay was 5.7 (range 2-17) days. There was no relapse in any cases during the follow-up.

CONCLUSION

ESD appears to be a safe and feasible approach for curative treatment in gastric ectopic pancreas. Larger studies are needed to identify the role and the outcomes of ESD in another center.

Magnifying endoscopy with narrow-band imaging for gastric heterotopic pancreas

BACKGROUND AND STUDY AIMS

 Heterotopic pancreas is a common subepithelial lesion in the stomach. However, its histological diagnosis is difficult when tissue samples are obtained with a conventional biopsy forceps. This study aimed to describe the magnifying endoscopy with narrow-band imaging (ME-NBI) features of gastric heterotopic pancreas.

PATIENTS AND METHODS

 We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from January 2010 to December 2010. Thirty-six patients with endosonographically diagnosed heterotopic pancreas who underwent ME-NBI and endoscopic ultrasonography (EUS) simultaneously were studied. The ME-NBI features of their lesions were analyzed.

RESULTS

 Thirty lesions were located in the antrum and six in the body. Six lesions (17 %) showed umbilication or central dimpling on the surface, and nine (25 %) had a macroscopic opening on the surface. On ME-NBI, a microscopic opening was identified in 22 (81 %) of 27 lesions wherein a macroscopic opening was not observed during conventional endoscopy. Macroscopic or microscopic opening was observed in 31 lesions (86 %). The frequency of macroscopic or microscopic opening was higher in lesions with anechoic duct-like structures than in lesions without such structures on EUS (91 % [29/32] vs 50 % [2/4], P  = 0.027). Focal loss of microsurface structure and presence of a thickened submucosal vessel were observed in 6 (17 %) and 5 lesions (14 %), respectively.

CONCLUSIONS

The characteristic ME-NBI feature of heterotopic pancreas is presence of a microscopic opening on its surface. This ME-NBI feature is potentially useful for differentiating heterotopic pancreas from other gastric subepithelial tumors.

Ectopic pancreas in the upper gastrointestinal tract: Is endosonographic diagnosis reliable? Data from the German Endoscopic Ultrasound Registry and review of the literature

Background:

Ectopic pancreas (EP) belongs to the most frequent subepithelial lesions (SELs) of the upper gastrointestinal (GI) tract. In the majority of cases, it is detected incidentally. Differential diagnosis from mesenchymal subepithelial tumors may be difficult.

Methods:

Among 24,308 endosonographic examinations and interventions, which were prospectively enrolled in the database of the German Endoscopic Ultrasound (EUS) Registry from January 2009 to August 2013, 575 were performed for suspected SELs of the upper GI tract. Sixty three cases of EP of the upper GI tract (stomach, n = 53; duodenum, n = 10; esophagus, n = 0) were extracted and retrospectively reviewed.

Results:

In 65.1% of cases, radial echoendoscopes or radial miniprobes were used for examination. Nearly 84% of EP was found in the stomach, 16% in the duodenum, none in the esophagus. In 88.9% of cases, the EUS examination discerned the layer of origin. In 59% of cases EP was described as a heterogeneous, in 28.6% as a homogeneous-hypoechoic and in 7.9% as a homogeneous-echogenic subepithelial mass lesion. Mean diameter was 13.0 mm × 8.1 mm, the mean ratio between long and short axis diameter was 1.75. EUS-guided fine needle aspiration (EUS-FNA) was used to accomplish cytological or histological diagnosis in only 6.3% of cases.

Conclusions:

EP accounts for 11% of all EUS examinations performed for subepithelial lesions of the upper GI tract and prospectively enrolled in the German EUS registry. Rather than being an eyecatcher, EP is a chameleon with numerous differential diagnoses. In selected cases, EUS-FNA may help clarifying the diagnosis.

Gastric Heterotopic Pancreas: Computed Tomography With Clinicopathologic Correlation

Asymptomatic heterotopic pancreas (HP) is benign and can be monitored long term without further intervention. Heterotopic pancreas is sometimes surgically resected because it can be difficult to distinguish HP from neoplastic submucosal masses such as gastrointestinal stromal tumors. Although it is not very common, HP should be considered in the differential diagnosis when diagnosing extramucosal gastric masses to avoid unnecessary intervention. We review gastric HP with pathologic correlation to help with diagnosing HP on computed tomography.

Endosonogragphic features of lesions suggesting gastricectopic pancreas: experience of a single tertiary center

BACKGROUND/AIM

We aimed to present the endoscopic ultrasound (EUS) features of gastric lesions suggesting gastric ectopic pancreas during upper gastrointestinal endoscopy that were diagnosed in our gastroenterology unit, which is a tertiary center for endoscopic procedures in Turkey.

MATERIALS AND METHODS

The data of patients who underwent upper gastrointestinal EUS in our center between April 2012 and July 2014 were retrospectively analyzed.

RESULTS

All of the lesions suggesting gastric ectopic pancreas were localized in the gastric antrum. Thirty-six of 44 lesions (81.1%) showed central dimpling. Lesion borders were shown to be definite in 10 (22.7%) lesions, whereas the borders of 34 lesions (77.3%) were indefinite. Thirty-nine lesions (88.6%) had heterogeneous and 5 lesions (11.4%) had homogeneous echo patterns; whereas 29 lesions (65.9%) were hypoechoic, 9 lesions (20.5%) were hyperechoic and 6 lesions (13.6%) had mixed echogenicity. Forty-two lesions (95.5%) were shown to affect only a single sonographic layer of the gastric wall.

CONCLUSION

EUS features of lesions that strongly suggest gastric ectopic pancreas endoscopically, without any histopathological evidence and without either endoscopic or surgical resection, are as follows: indefinite border appearance, minimal heterogeneous hypoisoechoic echo pattern, existence of anechoic duct-like structures inside the lesion, common localization in the submucosal layer, and existence of umbilication.

Gastric heterotopic pancreas masquerading as a stromal tumor: A case report

Heterotopic pancreas (HP), a rare condition that is generally asymptomatic, is an aberration in the developmental profile of the pancreas. While it can occur in any location in the gastrointestinal tract, it is most typically found in the antrum of the stomach and is usually wrongly considered to be a submucosal tumor (SMT). Despite advances in diagnostic modalities, a HP still poses a diagnostic dilemma to clinicians. Invasive surgery or endoscopic resection have often been inappropriately applied in cases of an ectopic pancreas due to the difficulty in distinguishing it from neoplastic SMTs, such as gastrointestinal stromal tumors (GISTs). The present study reports the unusual case of a middle-aged female with an SMT at the lesser curve of the mid-body of the stomach, which was initially diagnosed as a GIST through endoscopic ultrasonography and computed tomography. However, following removal by endoscopic submucosal dissection, this lesion was finally histopathologically confirmed as an HP. Therefore, although it is rare, the possibility of an HP should always be considered when diagnosing an extramucosal gastric mass. The precise pre-operative diagnosis of this entity may avoid unnecessary extensive treatment intervention.

Diagnosis of ectopic pancreas by endoscopic ultrasound with fine-needle aspiration

AIM: To study the clinical, endoscopic, sonographic, and cytologic features of ectopic pancreas (EP).

METHODS: This was a retrospective study performed at an academic referral center including two hospitals. Institutional review board approval was obtained. Patients referred to the University Hospital or Denver Health Medical Center Gastrointestinal Endoscopy Lab for gastroduodenal subepithelial lesions (SEL) with a final diagnosis of EP between January 2009 and December 2013 were identified. Patients in this group were selected for the study if they underwent endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) or deep biopsy. A review of the medical record was performed specifically to review the following information: presenting symptoms, endoscopic and EUS findings, computed tomography or magnetic resonance imaging findings, pathology results, procedure-related adverse events, and subsequent treatments after EUS-FNA. EUS with FNA or deep submucosal biopsy was performed in all patients on an outpatient basais by one of two physicians (Attwell A, Fukami N). Review of all subsequent clinic notes and operative reports was performed in order to determine follow-up and final diagnoses.

RESULTS: Between July 2009 and December 2013, 10 patients [3 males, 7 females, median age 52 (26-64) years] underwent EUS for a gastroduodenal SEL and were diagnosed with EP. One patient was symptomatic. Six (60%) lesions were in the antrum, 3 (30%) in the body, and 1 (10%) in the duodenum. A mucosal dimple was noted in 6 (60%). Mean lesion size was 17 (8-25) mm. Gastrointestinal wall involvement: muscularis mucosae, 10%; submucosa, 70%; muscularis propria, 60%; and serosa, 10%. Nine (90%) lesions were hypoechoic and 5 (50%) were homogenous. A duct was seen in 5 (50%). FNA was attempted in 9 (90%) and successful in 8 (80%) patients after 4 (2-6) passes. Cytology showed acini or ducts in 7 of 8 (88%). Superficial biopsies in 7 patients (70%) showed normal gastric mucosa. Deep endoscopic biopsies were taken in 2 patients and diagnostic in one. One patient (10%) developed pancreatitis after EUS-FNA. Two patients (20%) underwent surgery to relieve symptoms or confirm the diagnosis. The main limitation of the study was the fact that it was retrospective and performed at a single medical center.

CONCLUSION: EUS features of EP include antral location, mucosal dimple, location in layers 3-4, and lesional duct, and FNA or biopsy is accurate and effective.

Endosonographic features of histologically proven gastric ectopic pancreas

Gastric ectopic pancreas is an uncommon developmental anomaly and its histological diagnosis is usually difficult by using a conventional biopsy forceps. In the literature, most cases of gastric ectopic pancreas were usually diagnosed by gross pattern during endoscopic examination or features of endoscopic ultrasound. In contrast, this disease was seldom diagnosed by histology in clinical practice. Although the typical endoscopic ultrasonographic features of ectopic pancreas include heterogeneous echogenicity, indistinct borders, and a location within 2 or more layers, it can also exhibit hypoechoic homogeneous echogenicity and a distinct border within the fourth sonographic layer (muscularis propria) similar to the endoscopic ultrasonographic features of gastrointestinal stromal tumors. In our study, we found that 53% of gastric ectopic pancreas originated within the fourth sonographic layer, demonstrating hypoechoic, homogeneous echogenicity, and distinct borders. Therefore, recognizing endoscopic ultrasonographic features, combining with deep biopsy, endoscopic ultrasound-guided fine needle aspiration/core needle biopsy can prevent conducting unnecessary resection. Surgical resection is the mainstay treatment for symptomatic gastric ectopic pancreas, but endoscopic resection using endoscopic mucosal resection or endoscopic submucosal dissection technique provides an alternative method of removing superficial-type and deep-type gastric ectopic pancreas.

Acute ectopic pancreatitis occurring after endoscopic biopsy in a gastric ectopic pancreas

Ectopic pancreas is a congenital anomaly and the most common type of ectopic tissue in the gastrointestinal tract. Most patients with an ectopic pancreas are asymptomatic and rarely have complications. Ectopic pancreatitis after an endoscopic biopsy has not been reported. We report a patient who developed acute ectopic pancreatitis in the stomach after an endoscopic biopsy. A 71-year-old male patient presented with a subepithelial tumor (SET) in the stomach and had no symptoms. Endoscopic ultrasonography demonstrated a 30-mm hypoechoic mural mass, lobulated margins, and anechoic duct-like lesions. To obtain proper tissue specimen, endoscopic biopsy was performed through the opening on the surface of the mass. The pathologic results confirmed an ectopic pancreas. One day after the endoscopic biopsy, he developed persistent epigastric pain. His serum amylase and lipase elevated. Computed tomography of the abdomen showed swelling of the SET and diffuse edema of the gastric wall. His condition was diagnosed as acute ectopic pancreatitis occurring after endoscopic biopsy.

Gastroscopy and endoscopic ultrasonograhpy for diagnosis of heterotopic pancreas in the stomach

AIM: To investigate the value of gastroscopy, endoscopic ultrasonography (EUS) and multi-slice spiral computed tomography (MSCT) in the diagnosis of heterotopic pancreas (HP) in the stomach.

METHODS: Clinical data (including endoscopic manifestations and pathological findings) of 268 patients diagnosed with HP by gastroscopy, biopsy, EUS or MCST at our hospital from January 2005 to September 2013 were retrospectively analyzed.

RESULTS: Of all the patients, 84 were diagnosed with HP by gastroscopy and 26 of them were pathologically confirmed (26/84, 31.0%); 7 were diagnosed by both biopsy and pathology (7/7, 100%); 174 were diagnosed by EUS and 151 of them were confirmed by pathology (151/174, 86.8%); 3 were diagnosed by MSCT, but only 1 was confirmed by pathology (1/3, 33.3%).

CONCLUSION: EUS is a useful technique for diagnosing HP in the stomach and it is the first choice for diagnosis of HP.

Endoscopic removal of symptomatic gastric heterotopic pancreas: a report of nine cases

AIMS

The aim of this study was to evaluate the efficacy and safety of endoscopic removal of symptomatic gastric heterotopic pancreas (HP).

PATIENTS AND METHODS

From January 2010 to December 2011, 9 patients with suspected symptomatic HP were enrolled in the study. Endoscopic ultrasonography was performed to clarify the HP tissue location and to choose the endoscopic resection method. Endoscopic mucosal resection or endoscopic submucosal dissection was performed to remove the HP tissue. Symptoms in the enrolled patients were assessed before and after endoscopic removal of the HP tissue. Tumor pathology and complications were recorded after the treatment. A standard follow-up was scheduled at 1 week and 2 months after treatment.

RESULTS

Removal of suspected HP with endoscopic mucosal resection or endoscopic submucosal dissection was successful in all 9 cases. Abdominal pain, leukocytosis, and bleeding occurred in 6 patients, 2 patients, and 1 patient, respectively, after treatment and were relieved by symptomatic treatment. There were no other unpredictable complications. The symptoms related to HP, including epigastric pain, bloating, and postprandial fullness, were relieved significantly after the treatment. During follow-up, there was no recurrence of HP in any patient.

CONCLUSIONS

Endoscopic removal appears to be a safe and effective method to treat gastric lesions suspected to be HP with symptoms. The symptoms, such as epigastric pain, bloating, and postprandial fullness were well resolved after endoscopic treatment.

Technique of endoscopic biopsy of islet allografts transplanted into the gastric submucosal space in pigs

Currently, islet cells are transplanted into the liver via portal vein infusion. One disadvantage of this approach is that it is not possible to adequately biopsy the islets in the liver to assess for rejection. Islet transplantation (Tx) into the gastric submucosal space (GSMS) can be performed endoscopically and has the potential advantage of histological evaluation by endoscopic biopsy. The aim of this study was to determine whether a representative allograft sample could be obtained endoscopically. We performed islet Tx into the GSMS in nonimmunosuppressed pigs using simple endoscopic submucosal injection. Islets were transplanted at four sites. Endoscopic ultrasonography and biopsy of the transplanted islets at two sites by modified endoscopic submucosal dissection were carried out successfully in all pigs 5 days after islet Tx. Tissue obtained at both biopsy and necropsy (including full-thickness sections of the gastric wall around the sites of the remaining islets and biopsies) were examined by histology and immunohistochemistry to confirm the presence of the islet grafts and any features of rejection. Representative allograft sampling was successfully obtained from all biopsy sites. All biopsies included islets with insulin-positive staining. There was significant CD3(+) and CD68(+) cell infiltration in the islet masses obtained at biopsy and from sections taken at necropsy, with similar histopathological features. Endoscopic biopsy of islet allografts in the GSMS is feasible, provides accurate histopathological data, and would provide a significant advance if translated into clinical practice.

Gastric subepithelial masses: evaluation of multidetector CT (multiplanar reconstruction and virtual gastroscopy) versus endoscopic ultrasonography

OBJECTIVES

To assess the role of multidetector computed tomography (MDCT) with multiplanar reconstruction (MPR) and virtual gastroscopy (VG) for detection and differentiation of gastric subepithelial masses (SEMs) by comparison with endoscopic ultrasonography (EUS).

METHODS

Forty-one patients with a suspected SEM were evaluated using EUS and MDCT. MDCT findings were analyzed based on the consensus of two radiologists who were blinded to the EUS findings. The analysis of the CT features included the location, size, and contours of the tumor, the presence of central dimpling, as well as the growth pattern, enhancement pattern, and enhancement degree. The long diameter (LD) and the short diameter (SD) of each lesion were measured and the LD/SD ratios were calculated. EUS and MDCT results were compared with histopathology for the pathologically proven lesions. For the non-pathologically proven lesions, MDCT results were compared with EUS.

RESULTS

Among the 41 patients, 34 SEMs were detected using EUS. For the detection of SEMs with MDCT, a sensitivity of 85.3%, a specificity of 85.7%, a positive predictive value of 96.7%, and a negative predictive value of 54.5% were calculated. The overall accuracy of MDCT for detecting and classifying the SEMs was 85.3 and 78.8%, respectively.

CONCLUSIONS

MDCT with MPR and VG is a valuable method for the evaluation of SEMs. Specific MDCT criteria for various SEMs may be helpful in making an accurate diagnosis.

Endoscopic ultrasonography-guided diagnosis of subepithelial tumors

Subepithelial lesions are frequently discovered during routine endoscopic examinations. These lesions represent a wide spectrum of heterogeneous benign to malignant conditions. Most of these lesions are asymptomatic. There is no consensus regarding how to manage these lesions. Over the last 2 decades, the approach to these lesions has significantly improved owing to the introduction of endoscopic ultrasonography, fine-needle aspiration, immunohistochemical staining methods, and different treatment options. This article discusses the nature of subepithelial lesions, focusing on the most recent developments that use endoscopic ultrasonography to diagnose and manage these lesions.

Pancreatic rest resection using band ligation snare polypectomy

BACKGROUND

Although pancreatic rests have characteristic endoscopic features, confirming a histological diagnosis may be desirable to exclude other significant pathology.

AIMS

The aim of this study was to assess the efficacy and safety of endoscopic band ligation snare polypectomy (EBLSP) for removal of suspected pancreatic rests and to compare the diagnostic yield to other endoscopic tissue sampling methods.

METHODS

An electronic endoscopic report database was searched for patients referred for evaluation of incidentally found gastric antral subepithelial lesions. Tissue sampling technique, pathology, and complications were recorded.

RESULTS

Removal of suspected pancreatic rests with EBLSP was successful in all 21 cases without complications. Nineteen of 21 (90%) who underwent EBLSP had a histological diagnosis of heterotopic pancreas compared with 5 of 14 (36%) who underwent tissue sampling with biopsy and/or snare (P = 0.001). The endoscopic characteristics of the histology proven pancreatic rests were an antral subepithelial mass with central umbilication measuring 6-10 mm in diameter and located 2-6 cm from the pylorus in the 3-7 o'clock position.

CONCLUSIONS

Endoscopic band ligation snare polypectomy resection of gastric antral lesions suspected to be pancreatic rests had a diagnostic yield superior to standard biopsy forceps and snare polypectomy techniques. However, because all pathologically confirmed pancreatic rests had typical endoscopic appearances of pancreatic rests, it may not be necessary to obtain histologic diagnosis for every suspected gastric antral heterotopic pancreas.

Endoscopic removal of gastric ectopic pancreas: An initial experience with endoscopic submucosal dissection

AIM: To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas.

METHODS: A total of eight patients with ectopic pancreas were included. All of them underwent endoscopic ultrasonography before endoscopic resection. Endoscopic resection was performed by two methods: endoscopic mucosal resection (EMR) by the injection-and-cut technique or endoscopic mucosal dissection (ESD).

RESULTS: We planned to perform EMR in all eight cases but EMR was successful in only four cases. In the other four cases, saline spread into surrounding normal tissues and the lesions became flattened, which made it impossible to remove them by EMR. In those four cases, we performed ESD and removed the lesions without any complications.

CONCLUSION: If conventional EMR is difficult to remove gastric ectopic pancreas, ESD is a feasible alternative method for successful removal.

Heterotopic Pancreas within Meckel's Diverticulum with Obscure then Massive Gastrointestinal Bleeding in a 12-year-old Child: Case Report and Review of the Literature

We report a case of a 12-year-old boy with heterotopic pancreas (HP) located in a Meckel's diverticulum (MD) and presenting as obscure gastrointestinal (GI) bleeding. Upper GI endoscopy and colonoscopy did not reveal the source of the bleeding, however, capsule endoscopy revealed a space-occupying lesion in the ileum. The patient developed massive bleeding and an emergency exploratory laparotomy was performed. A congested MD was discovered 100 cm from the ileocaecal valve using intra-operative endoscopy; the ulcerated tip of the diverticulum appeared to be the source of the bleeding. The MD and adjacent ileal segment were resected and an end-to-end anastomosis performed. Subsequent pathological examination revealed an ileal MD with HP tissue within the submucosa. The patient remains well, 12 months after the operation, with no evidence of recurrent bleeding. This case suggests that HP should be considered as one possible cause of obscure GI bleeding in children and capsule endoscopy is a valuable adjuvant tool in the diagnosis of HP in children.