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

New frontiers in ectopic pancreatic tissue management

The pancreatic development variations are relatively frequent but are often overlooked in clinical practice. This is due to the fact that they do not present with a distinct clinical picture and are usually asymptomatic. It also refers to the ectopic pancreatic tissue in the stomach. This anomaly can be diagnosed in any part of the digestive system, but it is mostly seen in the upper gastrointestinal tract, especially in the stomach, duodenum and jejunum. The management of this condition has evolved due to the development of minimally invasive procedures.

Overview of ectopic pancreas

This editorial discusses the article written by Zheng et al that was published in the latest edition of the World Journal of Gastrointestinal Surgery. Our primary focus is on the causes, location, diagnosis, histological classification, and therapy of ectopic pancreas. Ectopic pancreas refers to the presence of pancreatic tissue that is situated in a location outside its usual anatomical placement, and is not connected to the normal pancreas in terms of blood supply or anatomical structure. Currently, the embryological origin of ectopic pancreas remains uncertain. The most prevalent form of ectopic pancreatic is gastric ectopic pancreas. Endoscopic ultrasonography examination can visualize the morphological characteristics of the ectopic pancreatic lesion and pinpoint its anatomical location. The histological categorization of ectopic pancreas evolves. Endoscopic treatment has been widely advocated in ectopic pancreas.

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.

Gastric duplication cysts: literature review and a case report of rare multiple gastric duplication cysts treated by endoscopic submucosal dissection

Gastric duplication cysts (GDCs) are rare structural abnormalities, especially in adults. We first report a rare case of small multiple GDCs in a woman, which presents as a submucosal tumor (SMT) at the gastric antrum. In consideration of the patient's request for surgical treatment and minimally invasive resection, endoscopic submucosal dissection (ESD) was performed to remove the cyst. The case provides a reference for ESD surgery to remove small GDCs. So far, there is no consensus or practice guidelines for the diagnosis and management of GDCs. Herein we perform a comprehensive literature review and discussion on GDCs. GDCs are 'repetitive' cystic or tubular structures of gastric mucosa and muscularis mucosae, and share the muscularis propria and serous layer with the normal gastric wall. GDCs protruding into the stomach cavity can be diagnosed by endoscopic ultrasound (EUS), which has higher specificity and accuracy than CT and MRI. Some GDCs may cause complications, even cancerization. Therefore, we suggest that once found, the GDCs could be completely resected. For GDCs protruding into the stomach cavity, endoscopic surgery such as ESD can be adopted to remove the lesion. Endoscopic full-thickness resection (EFTR) may become an option for larger GDCs in the future. For extraluminal GDC, laparoscopic surgery is currently preferred. In this review, we summarized the structural and histopathological characteristics of GDCs and various treatment therapies, in order to provide experience and reference for the diagnosis and treatment of GDCs in the future.

Gastric duplication cyst with ectopic pancreas in a teenager successfully resected by endoscopic submucosal dissection

BACKGROUND

Gastric duplication cyst associated with ectopic pancreas is rare and we aimed to alert clinician to this congenital anomaly.

CASE PRESENTATION

A 15-year-old girl presented with intermittent vomiting. Gastroscopy showed a submucosal tumor with an approximate diameter of 40 mm in the anterior wall of the gastric antrum. The lesion had a central umbilication and was diagnosed preliminarily as gastric ectopic pancreas with pseudocyst formation on the basis of its appearance. However, computed tomographic scan showed a thick-walled cystic lesion with an enhanced outline of the cystic wall in the antrum of stomach, suggestive of duplication cyst. Serum amylase was normal. Endoscopic ultrasonography revealed a solid-cystic lesion; the solid portion were inhomogeneously mixed with echoes, and had indistinct border to muscularis propria; the cystic portion had echogenic internal mucosal layer and distinct border to muscularis propria. Endoscopic submucosal dissection (ESD) was suggested for the patient to relieve symptoms and diagnose the lesion definitely. The operation procedure was uneventful and the solid-cystic lesion was resected completely. Histopathologic examination revealed that the solid portion was ectopic pancreas, and the cystic portion was gastric duplication cyst. After resection, the patient discharged successfully and neither symptoms nor tumors recurred during the 9 months follow-up period.

CONCLUSIONS

This is the first case of a solid-cystic lesion with central umbilication in the stomach diagnosed as gastric duplication cyst associated with ectopic pancreas. ESD could be an optional treatment to provide a definitive diagnosis.

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.

Proposed Models for Prediction of Mortality in Stage-I and Stage-II Gastric Cancer and 5 Years after Radical Gastrectomy

The current American Joint Committee on Cancer (AJCC) staging system provides limited information for patients with early death from stage-I and stage-II gastric cancer (GC) and death at >5 years after radical gastrectomy. The aim of this study was to construct nomogram models to predict the mortality risk of these patients. In this study, clinical and pathological data on patients who underwent curative gastrectomy at Harbin Medical University Cancer Hospital between 2000 and 2014 were retrospectively collected. Receiver operating characteristic analysis was used to screen for sensitive serum immune biomarkers to predict the risk of mortality death >5 years after radical gastrectomy (Group A) and risk of early death in stage-I and stage-II GC (Group B). The prediction model was constructed by combining serum immune markers with clinicopathological features by R Studio. We found that serum fibrinogen (F), systemic immune inflammation (SII), and pTNM stage were independent risk factors for prognosis in Group A (P < 0.05). F, SII, age, Borrmann type, and scope of gastrectomy were independent risk factors for prognosis in Group B (P < 0.05). The area under the curve of the predictive model in Groups A and B was 0.726 and 0.848, respectively. In conclusion, the predictive models of F and SII combined with clinicopathological features can predict high mortality risk in patients with stage-I and stage-II GC and >5 years after radical gastrectomy, which will contribute to the supplement of the traditional AJCC system and to individual survival prediction.

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.