Endoscopic Ultrasound Scan Research Articles

Comparison of Endoscopic Ultrasound and CT Scan in the Diagnosis of Esophageal Duplication Cysts

Background and AimEsophageal duplication cysts (EDCs) are rare congenital malformations, often discovered incidentally during endoscopy or on computed tomography (CT) scans. The role of endoscopic ultrasound (EUS) and CT scan in the diagnosis of these lesions and indications for surgical treatment are underreported. The aim of this study was to investigate these topics in a cohort of patients.Materials and MethodsBetween January 2001 and October 2020, 82 patients had a suspicion of esophageal duplication cyst on endoscopic ultrasound. Thirty four of these patients were referred for surgical enucleation of the lesion, but three patients were lost to follow-up. At the end, 31 patients, who underwent surgical treatment for their suspected EDC were included in this study. Clinical features, EUS findings, CT images, surgical treatment, and outcome were collected from hospital health records. CT images were re-evaluated by a chest radiologist. Type of surgery, surgical complications, and final histological diagnosis were reported.Results and ConclusionThe patients referred for surgery were younger (p = 0.0001) and had larger lesions (> 2 cm; p = 0.005) than the patients who had non-operative follow-up. From thirty-one operated patients, eighteen (58%) had post-operative histological diagnosis of duplication cyst. On EUS the final histological diagnosis was correct in 58% (18/31) of all the operated cases and on CT scan 57% (17/30). CT scan misdiagnosed three of the EDCs but found two leiomyomas correctly. None of these patients developed malignancy. According to this study, neither EUS without fine-needle biopsy nor CT scan alone can differentiate EDCs from other mediastinal masses.

EUS-FNA Biopsy for Pancreatic Mass.

To assess both solid and cystic pancreatic lesions using endoscopic ultrasound (EUS), and the effect of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in patient management. Descriptive study. Place and Duration of the Study: Department of Gastroenterology, Division of Internal Diseases, Sivas Cumhuriyet University Hospital, Sivas, Turkiye, from January 2018 to 2022. Patients with pancreatic mass, who underwent EUS-FNA were inducted in the study. EUS-FNA was performed using a 22-gauge needle via both transgastric and transduodenal routes. The size of the pancreatic lesion, its location, and whether there was SMA or CA invasion were evaluated on CT and EUS scans. Biopsy results of 64 patients who received EUS-FNA due to pancreatic lesions were considered. The results were divided into malignancy or benign pathology. A total of 64 cases were compared. Crosstable Chi-square analysis showed a statistically significant difference between CT and EUS (p <0.001). EUS-FNA results revealed that out of the 64 patients with pancreatic mass detected in EUS, 46 had adenocarcinoma, 7 were negative for malignancy, 4 had intraductal papillary mucinous neoplasia (IPMN), 3 had neuroendocrine tumour (NET), 2 had lymphoma, and 2 had solid pseudopapillary neoplasia (SPN). In the 2-year follow-up of the seven patients who were negative for malignancy in EUS-FNA, there were no clinical, laboratory or imaging findings indicating pancreatic malignancy or distant metastasis. Tissue sampling through EUS-FNA has minimal side effects and remains useful in managing preoperative patients with resectable or suspicious pancreatic masses. Pancreatic cancer, Abdominal CT, Endoscopic ultrasound (EUS), Ultrasound-guided fine-needle aspiration (EUS-FNA).

Advancing complex hepato-pancreato-biliary surgery in Uganda: Challenges and outcomes.

Uganda has until recently mostly referred patients for complex hepato-pancreato-biliary (HPB) surgery abroad due to lack of local expertize. We report indications and a spectrum of surgeries performed in the first 4years following the establishment of a routine HPB service at Lubaga Hospital (LH), Kampala, Uganda. We also detailed the challenges encountered in setting up this service. Demographic, clinical parameters, surgery indications, procedures performed, and outcomes of consecutive patients that underwent HPB surgeries at LH from December 2018 to October 2022 were analyzed. Majority were females 72 (57.6%) with a median age of 50 (6-88) years. Forty-one (32.8%) underwent surgery on the pancreas (PS), 34 (27.2%) on the liver (LS), and 50 (40.0%) on the bile ducts (CBS). The most common symptom was abdominal pain. Benign disease was present in 37 patients (29.6%) while 88 (70.4%) had malignancy. A total of 34 patients (27.2%) had unresectable pancreatic head cancer and distal cholangiocarcinoma missed at preoperative imaging and discovered intraoperatively thus underwent palliative hepaticojejunostomy. Only 34 (27.2%) patients received postoperative ICU care. In-hospital mortality for this heterogenous group of patients was 6 (4.8%) for PS, 3 (2.4%) for LS, and 8 (6.4%) for CBS. Despite many challenges like limited access to ERCP accessories, lack of endoscopic ultrasound scans and PET-CT scans in the whole country, late presentation, and low quality imaging especially in preoperative determination of resectability of hepato-pancreato-biliary cancers, we managed to establish a functional HPB service. Patient results achieved were good in spite of these limitations.

Diagnosis by Endoscopic Ultrasonography-Guided Sampling through the Lower Gastrointestinal Tract.

Endoscopic ultrasound-guided fine-needle aspiration/biopsy (EUS-FNA/FNB) is very safe and has a high diagnostic rate for upper gastrointestinal lesions, especially pancreatic lesions, but its application in the lower gastrointestinal tract has rarely been reported. Due to the tortuous course of the colorectum, with the sigmoid colon particularly prone to perforation, most endoscopists are reluctant to perform lateral-sector endoscopic ultrasound scanning without a water-bag protection for the puncture. The ultrasonic endoscopy and flexible puncture needle techniques recently introduced into clinical practice have made ultrasound-guided puncture safer and more convenient. In addition, endoscopists have carefully tested various protective measures to improve the safety of the lower gastrointestinal puncture, substantially increasing its clinical feasibility. In this article, we review the iterations of endoscopic ultrasound equipment introduced in recent years and the many ingenious ideas proposed by endoscopists regarding lower gastrointestinal puncture.

Linear EUS Accuracy in Preoperative Staging of Gastric Cancer: A Retrospective Multicenter Study.

Preoperative gastric cancer (GC) staging is the most reliable prognostic factor that affects therapeutic strategies. Contrast-enhanced computed tomography (CECT) and radial endoscopic ultrasound (R-EUS) scans are the most commonly used staging tools for GC. The accuracy of linear EUS (L-EUS) in this setting is still controversial. The aim of this retrospective multicenter study was to evaluate the accuracy of L-EUS and CECT in preoperative GC staging, with regards to depth of tumor invasion (T staging) and nodal involvement (N staging). 191 consecutive patients who underwent surgical resection for GC were retrospectively enrolled. Preoperative staging had been performed using both L-EUS and CECT, and the results were compared to postoperative staging by histopathologic analysis of surgical specimens. L-EUS diagnostic accuracy for depth of invasion of the GC was 100%, 60%, 74%, and 80% for T1, T2, T3, and T4, respectively. CECT accuracy for T staging was 78%, 55%, 45%, and 10% for T1, T2, T3, and T4, respectively. L-EUS diagnostic accuracy for N staging of GC was 85%, significantly higher than CECT accuracy (61%). Our data suggest that L-EUS has a higher accuracy than CECT in preoperative T and N staging of GC.

OGC P47 The Role of Endoscopic Ultrasound Scan In Staging Patients With Oesophageal Cancer- A Retrospective Single Centre Study

Abstract Background There are conflicting opinions on the role of Endoscopic Ultrasound (EUS) in the staging of oesophageal cancer (OG) patients which can complicate and delay intervention. We aim to audit the use of EUS in the OG cancer staging pathway as well as assess accuracy in selected cases. Methods A retrospective audit of the hospital database of patients diagnosed with oesophageal carcinoma between January 2016 and March 2021.The duration between the first MDT and EUS performed was calculated. Concordance between initial CT and EUS stage as well as histology in patients that were offered direct to surgery were evaluated using Cohen's Weighted Kappa. Results A total of 301 patients were identified. Overall, there was a moderate agreement (K=0.526) between CT and EUS reported T Staging(p&amp;lt;0.001). There was substantial agreement (K=0.798) between CT reporting T2, T3 and EUS(p&amp;lt;0.0005). Twenty-seven patients underwent upfront surgery-11 were T1, 16 were T2 and T3 disease. Comparing to final histology, EUS reported an accurate T1 stage in 36.3% compared with 0% with CT (p=0.018), whereas T2 and T3 disease were accurately reported with EUS and CT in 43.7% and 37.5% respectively (p=0.375). The median number of days between first MDT and EUS was 14 days (8,18) and this was requested after CT and PET CT results were available in 80% of cases. Conclusions This audit demonstrates minor differences between EUS and CT for T2 and T3 disease and therefore unlikely to alter management. However, EUS is superior to CT for staging Tx and T1 disease and is therefore likely to impact on the treatment options. EUS also contributed to prolonged pre-treatment staging time. Adopting a selective approach to EUS could result in overall reduction of waiting times from referral to decision making and increase cost-effectiveness.

344 Interval Ultrasound Scanning in Idiopathic Pancreatitis - Are We Following Up Patients Appropriately?

Abstract Aim Acute pancreatitis of unknown cause requires investigation to identify reversible causes of the disease before classifying it as truly idiopathic. This study reports on the follow-up of patients in a district general hospital (DGH) who were diagnosed with acute pancreatitis of unknown cause compared to the gold standard evaluation of the disease by interval abdominal ultrasound scan (US) or outpatient endoscopic US. Method Inclusion criteria was all patients discharged from the DGH with a diagnosis of acute pancreatitis and no cause described on the discharge summary from 1st January 2021 to 30th June 2021. The primary outcome was outpatient abdominal US follow-up. Secondary outcomes included an endoscopic US booked as an outpatient. Patients with gallstones identified on imaging or with another identified cause of the acute pancreatitis were excluded. Results 50% (12 out of 24) patients did not receive follow-up US or any other imaging. Of the patients who did receive follow-up imaging 50% (6 out of 12) had a magnetic resonance imaging (MRI) abdomen or magnetic resonance cholangiopancreatography (MRCP) and the remainder 50% had an abdominal US. 12.5% of patients (3 out of 24) had an outpatient endoscopic US requested. Conclusions Management of patients with acute pancreatitis is costly at an estimated £303 per night. To reduce likelihood of future unnecessary admissions, patients require appropriate investigation to have any reversible causes identified and managed. In a system which has suffered bed shortages and significant financial restraints we need to ensure these patients are not lost to US follow-up.

Clinical Predictors of Locally Advanced Pathology in Esophageal Adenocarcinoma.

BackgroundIn patients with resectable esophageal adenocarcinoma (EAC), the decision for neoadjuvant treatment depends on clinical staging with endoscopic ultrasound (EUS) and positron-emission tomography (PET) scan. Patients with locally advanced EAC pathology misclassified as early EAC by clinical staging are missing the opportunity to receive neoadjuvant therapy. We aim to identify predictors of locally advanced pathology in EAC to determine more accurately those who benefit from neoadjuvant therapy. MethodsRetrospective study of patients who underwent upfront endoscopic or surgical resection for EAC without neoadjuvant therapy from January 2011 to December 2017 was performed. Clinical characteristics, EUS, PET scan and histologic findings were analyzed. Multivariable analysis of predictors of locally advanced stage was performed and a risk prediction score was developed.ResultsA total of 97 patients were included; 68 patients were staged as early EAC (pT1 or pT2 and pN0) and 29 patients were staged as locally advanced EAC (pT1 or pT2 with pN1 and pT3 or pT4 irrespective of N status). In a predictive model of EAC, patients presenting with dysphagia, tumor size >2 cm, exophytic mass appearance on endoscopy and absence of hiatal hernia were more likely to be have locally advanced pathology with a probability of 70% (C-statistic 0.766).ConclusionsA risk prediction model based on the presence of dysphagia, tumor size >2 cm, exophytic mass appearance and absence of hiatal hernia can be used to identify locally advanced pathology in EAC patients.

Results of DETECTYON study: Diagnostic accuracy of 68GA PET, endoscopic ultrasound (EUS) and CT scan in the assessment of lymph node metastases from non functioning pancreatic neuroendocrine neoplasms

Results of DETECTYON study: Diagnostic accuracy of 68GA PET, endoscopic ultrasound (EUS) and CT scan in the assessment of lymph node metastases from non functioning pancreatic neuroendocrine neoplasms

A novel approach to a rare case of non-islet cell hypoglycaemia.

SummaryInsulin autoimmune syndrome (IAS) is a rare cause of non-islet cell hypoglycaemia. Treatment of this condition is complex and typically involves long-term use of glucocorticoids. Immunotherapy may provide an alternative in the management of this autoimmune condition through the suppression of antibodies production by B-lymphocyte depletion. We present a case of a 62-year-old male, with refractory hypoglycaemia initially presenting with hypoglycaemic seizure during an admission for acute psychosis. Biochemical testing revealed hypoglycaemia with an inappropriately elevated insulin and C-peptide level and no evidence of exogenous use of insulin or sulphonylurea. Polyethylene glycol precipitation demonstrated persistently elevated free insulin levels. This was accompanied by markedly elevated anti-insulin antibody (IA) titres. Imaging included CT with contrast, MRI, pancreatic endoscopic ultrasound and Ga 68-DOTATATE position emission tomography (DOTATATE PET) scan did not reveal islet cell aetiology for hyperinsulinaemia. Maintenance of euglycaemia was dependent on oral steroids and dextrose infusion. Complete resolution of hypoglycaemia and dependence on glucose and steroids was only achieved following treatment with plasma exchange and rituximab.Learning pointsInsulin autoimmune syndrome (IAS) should be considered in patients with recurrent hyperinsulinaemic hypoglycaemia in whom exogenous insulin administration and islet cell pathologies have been excluded.Biochemical techniques play an essential role in establishing high insulin concentration, insulin antibody titres, and eliminating biochemical interference. High insulin antibody concentration can lead to inappropriately elevated serum insulin levels leading to hypoglycaemia.Plasma exchange and B-lymphocyte depletion with rituximab and immunosuppression with high dose glucocorticoids are effective in reducing serum insulin levels and hypoglycaemia in insulin autoimmune syndrome (IAS).Based on our observation, the reduction in serum insulin level may be a better indicator of treatment efficacy compared to anti-insulin antibody (IA) titre as it demonstrated greater correlation to the frequency of hypoglycaemia and to hypoglycaemia resolution.

A Curious Case of Hypoglycemia: A Rare Occurrence of Insulin Autoimmune Syndrome

Background: Hypoglycemia can be challenging, requiring close monitoring and evaluation. Although treating diabetes can cause hypoglycemia, the coexistence of autoimmune syndromes contributes to rare etiologies. They are characterized by elevated insulin levels with either insulin autoantibodies (IAA) or insulin receptor antibodies (IRA). It has been observed commonly in Japan but is scarce among non-Asian groups. We present a unique case of insulin autoimmune syndrome (IAS) that posed a diagnostic challenge in an African American male. Case: A 73-year-old African American male was admitted with altered mental status. Medical history included type 2 diabetes, hypertension, and hyperlipidemia. Home medications were carvedilol and simvastatin. On arrival, vital signs were normal. A fingerstick glucose was 52 mg/dL with a serum level of 68 mg/dL (70–110). Other labs were normal. Given symptomatic hypoglycemia, an IV dextrose infusion was initiated. Once his mentation improved, a diet was started. Despite this, he had recurrent hypoglycemia with glucose levels as low as 22 mg/dL, predominantly in fasting state with sporadic hyperglycemia. On rare occasions, he received correctional insulin for the same. An HbA1c was <4% (4–6). Thyroid function test and AM cortisol were normal. A cosyntropin stimulation test was negative for adrenal insufficiency. A hypoglycemia panel showed inappropriately high levels of insulin, highest at 77.4 μIU/mL(<=29.1), proinsulin of 19.7 pmol/L (<=8), and C-peptide of 5.6 (0.8–3.69 ng/mL) when serum glucose was 25 mg/dL. An MRI abdomen was normal. Octreotide study was negative for insulinoma. He had a normal response to IM glucagon, inferring normal glycogen stores. He was started on Diazoxide 160 mg thrice a day for recurrent hypoglycemia. An endoscopic ultrasound and DOTATATE scan were negative. He had no hypoglycemia for a few days, attributable to lingering effects of diazoxide. Eventually, his serum glucose was 52 mg/dL. Labs prior to glucose correction included an insulin level elevated at 1,000 (normal <3 mcIU/mL), c-peptide at 0.90 ng/mL, and proinsulin of 5.6 pmol/L. Given exceedingly high insulin levels, we measured an IAA level. This was >50 u/mL (normal <0.4 u/mL). With negative imaging and high IAAs, a diagnosis of IAS was made. Discussion: IAS or Hirata disease is a rare condition with hyperinsulinemic hypoglycemia and high titers of antibodies to endogenous insulin. The binding kinetics of endogenous insulin to these antibodies causes physiologically inappropriate levels of bioavailable insulin, causing either hyper- or hypoglycemia. IAA should be measured in patients with high insulin levels that are inconsistent with C peptide levels. We believe this to be the first African American patient to have been diagnosed with Hirata disease. Making a correct diagnosis may spare a hypoglycemic patient from unnecessary pancreatic surgical intervention.

CLINICAL, BIOLOGICAL AND ENDOSCOPIC ULTRASOUND CHARACTERISTICS OF PANCREATIC CANCER IN CHO RAY HOSPITAL

Background: Pancreatic cancer is a common disease of digestive cancers. The tumor progresses rapidly and malignantly, showed a low 5-year survival rate. However, when diagnosed and treated early, the 5-year survival rate of pancreatic cancer improves significantly. Endoscopic ultrasound (EUS) has the advantage that probe can optimal access to the pancreas and surrounding organs, therefore, diagnose pancreatic tumors can be made even when the tumor is small (&lt; 2 cm). Furthermore, Endoscopic Ultrasound- Guided Fine needle aspiration (EUS-FNA) can determine the exact histology of the tumor. Objectives: 1. Investigate some clinical, biological and endoscopic ultrasound characteristics in patients with pancreatic cancer. 2. Evaluate the relationship between endoscopic ultrasound images with clinical and biological characteristics and compare the results between endoscopic ultrasound with computer tomography. Materials and methods: Descriptive cross-sectional studies in 58 patients with pancreatic cancer had endoscopic ultrasound. Results: In 58 patients with pancreatic cancer, we recorded that patients with a history of smoking accounted for 32.8%, and drinking alcohol 31%. Abdominal pain was 89.7%, 44.8% of patients show anorexia, 37.9% have weight loss. 69% of patients had CA 19-9 &gt; 37 UI/ml. EUS found a patient with pancreatic tumor &lt; 2 cm, but CT scan could not detect. Tumors in pancreatic head accounted for 60.3%; in the body 24.1%, 96.6% of pancreatic cancer have a hypoechoic structure, heterogeneous ultrasound. There was a significant relation between pancreatic head tumor and other part with jaundice (p = 0.013). Compatibility in diagnosis of vascular invasion between EUS and CT scan was average (K = 0.483). Conclusion: Smoking and alcohol consumption accounted for the highest proportion, abdominal pain was the most common clinical symptom. Endoscopic ultrasound can diagnose small pancreatic tumors that CT scan can not detect. Key words: Pancreatic cancer, endoscopic ultrasound, clinical characteristics, bio-marker

Clinical Risk Prediction Model for Neoadjuvant Therapy in Resectable Esophageal Adenocarcinoma.

Clinical staging with endoscopic ultrasound (EUS) and positron emission tomography (PET) is used to identify esophageal adenocarcinoma (EAC) patients with locally advanced disease and therefore, benefit from neoadjuvant therapy. However, EUS is operator dependent and subject to interobserver variability. Therefore, we aimed to identify clinical predictors of locally advanced EAC and build a predictive model that can be used as an adjunct to current staging methods. This was a cross-sectional study of patients with EAC who underwent preoperative staging with EUS and PET scan followed by definitive therapy at our institution from January 2011 to December 2017. Demographic data, symptoms, endoscopic findings, EUS, and PET scan findings were obtained. Four hundred and twenty-six patients met the study criteria, of which 86 (20.2%) patients had limited stage EAC and 340 (79.8%) had locally advanced disease. The mean age was 65.4±10.3 years of which 356 (83.6%) were men and 393 (92.3%) were White. On multivariable analysis, age (above 75 or below 65 y), dysphagia [odds ratio (OR): 2.84], weight loss (OR: 2.06), protruding tumor (OR: 2.99), and tumor size >2 cm (OR: 3.3) were predictive of locally advanced disease, while gastrointestinal bleeding (OR: 0.36) and presence of visible Barrett's esophagus (OR: 0.4) were more likely to be associated with limited stage. A nomogram for predicting the risk of locally advanced EAC was constructed and internally validated. We constructed a nomogram to facilitate an individualized prediction of the risk of locally advanced EAC. This model can aid in decision making for neoadjuvant therapy in EAC.

Application and status of digestive endoscopy in the overall management of portal hypertension-related esophagogastric variceal bleeding

Portal hypertension-related esophagogastric variceal bleeding (EVB) is deadly. Therefore, multidisciplinary management involving hepatologists, digestive endoscopy, radiological intervention, and/or surgery is necessary. Digestive endoscopy is the core of the multidisciplinary approach to the overall management of portal hypertension. It plays an important role in the early warning, emergency treatment, and the prevention of the initial and re-bleeding of portal hypertension accompanied by esophagogastric varices. In addition, gastroscopy with endoscopic ultrasound scanning can enhance the management capabilities of ectopic varices.

Subtotal Cholecystectomy: Results of a Single-Centre, Registry-Based Retrospective Cohort Study of 180 Adults in 2011–2018

Background: Data on subtotal cholecystectomy (STC) as an alternative to conventional cholecystectomy in difficult surgical situations are limited. This multi-aspectual report aims to reduce the STC-specific knowledge gap and inform clinical decision-making strategies. Methods: All 180 patients who underwent STC at a single centre between 2011 and 2017 were assessed in this retrospective cohort study. Their outcomes were followed up until March 23, 2018. Six subgroups stratified by surgical setting (elective/non-elective), surgical approach used (open/laparoscopic), and type of procedure (reconstituting/fenestrating) were compared. Findings: The ratio of conventional to STC procedures during the study period was 13:1. Of the 180 patients, 150 (83%) had a history of hospitalisation for acute biliary disease. The proportion of all cholecystectomies that were STC ranged from 1% to 71% between individual surgeons; similarly, laparoscopic STC comprised 0%–97% of all STCs. STC was associated with high intraoperative and short-term postoperative complication rates (10·6% and 88·0%, respectively). There were three intraoperative complications, comprising one case each of bile duct injury (3·9%), significant bleeding from hepatic vessels (3·3%), and intestinal injury requiring repair (2·2%). The most common postoperative surgical site complications were external bile leak (21%), wound infection (17%), and biloma (10%). Strong associations between fenestrating STC and the rates of postoperative bile leak and retained gallstones, mainly in the main bile duct, were observed. A total of 532 targeted non-invasive and invasive investigations (304 computed tomography scans, 153 endoscopic retrograde cholangiopancreatography scans, 50 magnetic resonance cholangiopancreatography scans, and 25 endoscopic ultrasound scans) were performed. Interpretation: STC is associated with significant intraoperative and postoperative complication rates and a high investigation burden. Injury can be avoided when conversion to STC is timely and its technical variant is correctly selected. The STC rate could be introduced as a quality indicator for gallbladder surgery. Funding: Neither author received specific funding for this work. Declaration of Interests: The authors declare no competing financial interests. Ethics Approval Statement: The institutional clinical audit management board reviewed, approved, and registered the project as a no-risk observational cohort study. Hence, acquisition of informed consent from patients was not required for this study, as it does not include personal information about individual patients.

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Case Presentation: A 55-year-old man presented in 1998 to the emergency department with hematemesis, and multiple ulcers were noted in esophagogastro-duodenoscopy. Subsequently, he was initiated on a proton pump inhibitor (PPI) initially with lanzoprazole and then esomeprazole 40 mg twice daily. He continued to have symptoms of epigastric pain, vomiting, and diarrhea. Elevated fasting gastrin levels of 111 and 130 pmol/L (normal, 0 to 40 pmol/L) off PPI were noted in 2005 and 2011, respectively. Endoscopic ultrasound, computed tomography (CT) and octreotide scans remained nonlocalizing for gastrinoma in these same years. A CT scan showed generalized gastric fold hypertrophy (Fig. 1 A). What is the diagnosis?

2002 Oh My Lipoma: An Unexpected Cause of a Gastrointestinal Hemorrhage

INTRODUCTION: Gastrointestinal (GI) lipomas are benign tumors made of adipose tissue that are usually asymptomatic and slow-growing. Lipomas of the GI tract are uncommon, and even less common to find in the gastric region. Around 220 cases of gastric lipomas are reported in the literature. Of these cases, very few have shown a gastric lipoma that leads to symptomatic anemia and hemorrhage. CASE DESCRIPTION/METHODS: A 48-year-old man with a history of hypertension presented to the emergency room with shortness of breath and was found to have a hemoglobin of 6.0 g/dl, with a baseline of 15 g/dl. Gastroenterology was consulted, and the patient had an esophagogastroduodenoscopy (EGD) performed. The EGD showed a large, 4 cm, polypoid, submucosal, ulcerated mass with active oozing of blood on the lesser curvature of the gastric body. Biopsies were taken, and computed tomography (CT) imaging was performed as there was concern this was a malignant mass. Pathology showed the mass to be a gastric lipoma, and the patient was taken for a partial gastrectomy to remove the lipoma due to risk for bleeding. The surgery was performed without complications. DISCUSSION: Interestingly, gastric lipomas account for less than 1% of tumors in the stomach. This case displays a rare finding of a large gastric lipoma that led to symptomatic anemia and gastrointestinal hemorrhage. Most gastric lipomas are asymptomatic, but can ulcerate depending on the size and location. Ulceration can occur as a result of pressure necrosis of overlying mucosa, causing large volume bleeding. Lipomas can be diagnosed with endoscopic ultrasound, EGD, and CT scan. Treatment modalities include aspiration lumpectomy, strip biopsy, endoscopic unroofing technique, or surgical removal with partial gastrectomy. Rarely are gastric lipomas removed surgically, but in the case of large volume blood loss or active bleeding, they are removed surgically rather than endoscopically. Of note, it is important to rule out any evidence of malignancy or metastatic disease with imaging prior to surgical removal of a lipoma. If malignancy is ruled out, oftentimes endoscopic removal of the lipoma can be performed rather than undergoing a large surgical resection.

Outcomes of endoscopic submucosal dissection in esophageal adenocarcinoma staged T1bN0 by endoscopic ultrasound in non-surgical patients.

Patients with esophageal adenocarcinoma (EAC) invading submucosa (T1b) are traditionally treated with esophagectomy and with chemoradiotherapy in poor surgical patients. Endoscopic submucosal dissection (ESD) has emerged as an alternative treatment in these patients. In this case series, we analyzed the outcomes of ESD in EAC staged T1bN0 by endoscopic ultrasound (EUS). Patients with EAC staged T1bN0M0 by EUS and PET scan who underwent ESD by a single operator (MS) between 2014 and 2017 at our institution were included. They were deemed as poor surgical candidates and ESD was considered as the most appropriate treatment option after a multi-disciplinary evaluation. There were 8 patients (male =5; female =3) with average age of 70.5 years old (range, 53-84 years old). ESD was completed in 7 and aborted in 1 patient due to tumor invasion into muscularis propria. En bloc, R0 and curative resection rates were 86% (6/7), 86% (6/7) and 71% (5/7) respectively. Final histology was intramucosal (T1a) in 4 and submucosal (T1b) in 3. One patient (14%) developed stricture requiring balloon dilation. Mean follow-up duration was 10 months (range, 3-15 months) and 71% (5/7) remain in clinical remission. Two patients required CRT, one with T1a who developed recurrence and another with T1b with lymphovascular invasion. In poor surgical candidates, ESD was associated with accurate staging and favorable outcomes in EAC staged T1bN0 by EUS. We suggest considering ESD in EAC staged T1bN0 for accurate histological staging, curative potential and also to help determine further course of treatment.

Insulinoma presenting with post-prandial hypoglycaemia following fundoplication.

SummaryInsulinomas are rare neuroendocrine tumours that classically present with fasting hypoglycaemia. This case report discusses an uncommon and challenging case of insulinoma soon after upper gastrointestinal surgery. A 63-year-old man presented with 6 months of post-prandial hypoglycaemia beginning after a laparoscopic revision of Toupet fundoplication. Hyperinsulinaemic hypoglycaemia was confirmed during a spontaneous episode and in a mixed-meal test. Localisation studies including magnetic resonance imaging (MRI), endoscopic ultrasound (EUS) and gallium dotatate positron emission tomography (68Ga Dotatate PET) were consistent with a small insulinoma in the mid-body of the pancreas. The lesion was excised and histopathology was confirmed a localised well-differentiated neuroendocrine pancreatic neoplasm. There have been no significant episodes of hypoglycaemia since. This case highlights several key points. Insulinoma should be sought in proven post-prandial hyperinsulinaemic hypoglycaemia – even in the absence of fasting hypoglycaemia. The use of nuclear imaging targeting somatostatin and GLP1 receptors has improved accuracy of localisation. Despite these advances, accurate surgical resection can remain challenging.Learning points:Hypoglycaemia is defined by Whipple’s triad and can be provoked by fasting or mixed-meal tests.Although uncommon, insulinomas can present with post-prandial hypoglycaemia.In hypoglycaemia following gastrointestinal surgery (i.e. bariatric surgery or less commonly Nissen fundoplication) dumping syndrome or non-insulinoma pancreatogenous hypoglycaemia syndrome (NIPHS) should be considered.Improved imaging techniques including MRI, endoscopic ultrasound and functional nuclear medicine scans aid localisation of insulinomas.Despite advances in imaging and surgical techniques, accurate resection of insulinomas remains challenging.

Laparoscopic surgery for solitary insulinoma in the absence of IOUS.

Background:Insulinomas are the most common pancreatic neuroendocrine neoplasms. In spite of adequate pre-operative localisation, conventional surgical methods rely on intraoperative palpation. Intraoperative ultrasonography (IOUS) is said to aid in accurate localisation, decreases morbidity. Laparoscopic removal of pancreatic endocrine neoplasms is beneficial due to magnification and minimal invasion; however, in the absence of IOUS, error of judgement may lead to conversion to open surgery, thereby relying on ‘palpation method’ to localise the tumour. We combined laparoscopic surgical removal of insulinomas using an innovative method of ‘laparoscopic finger palpation’ with intraoperative blood glucose monitoring and frozen section for surgical cure.Materials and Methods:Patients were evaluated and investigated by the department of endocrinology and referred for surgical management of insulinoma. Pre-operative localisation of insulinoma was done by either contrast-enhanced computerised tomography angiogram – arterial and venous phase, or endoscopic ultrasound (EUS) or DOTATATE scan. Intraoperative localisation was done by laparoscopic dissection and ‘laparoscopic finger palpation’. After enucleation, the specimen was sent for frozen section, and in the interim period, serial monitoring of blood glucose was done by the anaesthetist. Maintenance of glucose levels for more than 45 min after enucleation and confirmation of neuroendocrine tumour on frozen section was the end point of surgical procedure.Results:A total of 19 patients were subjected to laparoscopic removal of solitary insulinomas. Enucleation was performed in 16 patients successfully. In three patients, laparoscopic distal pancreatectomy was performed. Three patients had pancreatic duct leak, of which two patients responded to conservative approach and the third patient required drainage by USG-guided pigtail catheter. All patients are cured of their disease and no patient has had recurrence so far.Conclusion:Multidisciplinary approach involving laparoscopic palpation, frozen sections and intraoperative blood sugar monitoring helps laparoscopic management of solitary insulinomas without IOUS.