Gastric Antral Pancreatic Rest Resection Using Endoscopic Band Ligation Snare Polypectomy Technique

Abstract

Background: Although gastric antral pancreatic rests (PR) have characteristic endoscopic and EUS features, confirming a histologic diagnosis may be desirable to exclude other significant pathology. Forceps biopsy and snare polypectomy are often unsuccessful due to inadequate depth of sampling. Removal with endoscopic band ligation snare polypectomy technique (EBLSP) may be a safe and effective way of obtaining a tissue diagnosis of PR. Aims: To assess the efficacy and safety of EBLSP in obtaining a tissue diagnosis of PR compared to sampling with biopsy +/- snare polypectomy, and to characterize PR endoscopic appearance. Methods: Retrospective case series in which an electronic GI endoscopic report database was searched for patients who underwent EGD between 1/00 and 10/08 at an academic medical center by a single endoscopist and were found to have gastric antral subepithelial masses. The images were reviewed for endoscopic appearance and tissue sampling technique, and final pathologic results were recorded. EBLSP was performed with rubber band ligation followed by snare polypectomy and clip placement. Results: 61 patients with subepithelial antral masses were identified. 21(34%) were histology proven PR, of which 16(76%) were obtained with EBLSP, 4(19%) with forceps biopsy +/- snare polypectomy, and 1(5%) with cap EMR technique. The median endoscopic size of histology proven PR was 10 mm (range 6-15 mm). The median distance from the pylorus was 35 mm (range 10-60 mm). The median location relative to the pylorus was at the 6 o'clock position (range 3-7 o'clock). 13(62%) displayed central umbilication. EUS was performed on 19(90%) PR with median dimensions being 8.5 by 4 mm. All PR were hypoechoic or heterogenous lesions located in the submucosal layer. Among patients with antral masses that endoscopically appeared to be PR, 16 of 18 (89%) who underwent EBLSP had a histologic diagnosis of PR, compared to 4 of 13 (31%) who had sampling with forceps biopsy +/- snare polypectomy (p=0.007). No complications occurred with any tissue sampling method used. Conclusions: 1) Endoscopic submucosal resection of gastric antral pancreatic rests can be safely and effectively performed with band ligation snare polypectomy for pathologic diagnosis. 2) EBLSP has a significantly higher diagnostic yield for suspected pancreatic rests than forceps biopsy +/- snare polypectomy (89% vs 31%, p=0.007). 3) The endoscopic appearance of histology proven pancreatic rests is a raised, 6-15 mm diameter subepithelial mass with central umbilication that is located 1-6 cm from the pylorus in the 3-7 o'clock position.