Pancreatic Rest Research Articles

Ectopic jejunal pancreas with pancreatitis mistaken for a post-transplant lymphoproliferative disease in an immunosuppressed kidney transplant patient

An ectopic pancreas, also known as pancreatic rest or heterotopic pancreas, consists of pancreatic tissue found in a location with no continuity with the anatomic pancreas. This lesion can occasionally cause gastrointestinal obstruction, ulceration or become inflamed and cause ectopic pancreatitis. We present the case of a 29-year-old immunocompromised female patient due to a previous kidney transplant. She presented with nausea and vague abdominal discomfort and was admitted for investigation and treatment of an acute kidney injury. A small bowel mass of unknown etiology was incidentally found on abdominal computed tomography imaging. Due to the high suspicion of a post-transplant lymphoproliferative disease, a surgical exploration took place and revealed the presence of a pancreatic rest with chronic pancreatitis. Ectopic pancreas diagnosis is challenging and surgical exploration is warranted when a neoplastic process is suspected.

Characterization of subepithelial lesions of the stomach and esophagus by contrast-enhanced EUS: A retrospective study.

Background and Objectives:Subepithelial lesions (SELs) of the upper part of the digestive tract are rare, and it can be difficult to characterize them. Recently, contrast-enhanced endosonography (EUS) and elastometry have been reported as useful adjuncts to EUS and EUS-guided fine needle aspiration (EUS-FNA) in cases of pancreatic mass and lymph node involvement. The aim of this retrospective analysis was to evaluate whether contrast-enhanced EUS can discriminate benign submucosal lesions from malignant ones. We describe our retrospective experience using the contrast agent SonoVue® (Bracco Imaging, Milan, Italy) in an attempt to increase the diagnostic yield.Patients and Methods:Between May 2011 and September 2014, 14 patients (5 men, 9 women; median age 64 years, range 31–80 years) with SELs of the stomach or esophagus underwent EUS with SonoVue® (low mechanical index). There were 3 esophageal lesions and 11 gastric lesions. Mean size of the lesions was 30 mm (range 11–50 mm). They were discovered after anemia (n = 5), dysphagia (n = 1), and pain (n = 4) and during follow-up for resected gastrointestinal stromal tumors (GISTs) (n = 1) and a standard upper gastrointestinal endoscopy (n = 3). On endoscopic sonograms, 10 of these lesions were hypoechoic and located in the fourth layer (muscularis), and 4 were in the second or third layer (mucosa and submucosa). Contrast enhancement was assessed in the early phase (after several seconds) and late phase (>30 seconds); a final diagnosis was made based on the findings of EUS-FNA using a 19-gauge ProCore (Cook Medical, Bloomington, IN) (n = 9) or 22-gauge FNA system (Cook Medical) (n = 1), the resected specimen (n = 3), or deep biopsy (n = 1). Different immunostaining was used in the pathologic studies (RNA was analyzed later using the C-kit, CD-117, CD-34, desmin, DOG-1, α-smooth actin, caldesmon, PS-100, and Ki-67 antibodies).Results:Final diagnoses were leiomyoma (n = 4), GIST (n = 5), schwannoma (n = 1), inflammatory tumor of Helvig (n = 1), pancreas rest (n = 2), and fibrosis (n = 1). No complications occurred. All 5 GISTs showed enhancement in the early and late phases, whereas the 8 remaining lesions did not show any enhancement. Only 1 leiomyoma showed heterogeneous enhancement.Limitations:The monocentric and retrospective study design and small number of patients.Conclusions:In cases of SELs of the stomach or esophagus, SonoVue® could be a complementary tool to endosonography to differentiate GISTs (early and clear enhancement) from other SELs (few or no enhancement), such as leiomyomas or pancreatic rest. These results are similar to those of the few, small studies published on this topic, but more studies with a larger number of patients are needed to confirm these findings.

Sa1953 NOTES FOR SUBEPITHELIAL TUMORS: EFTR AND STER - A SINGLE CENTER FIVE YEAR PROSPECTIVE SERIES IN THE US

Many guidelines recommend surgery for suspected GISTs ≥2 cm and endoscopic surveillance of those <2cm. This approach, is also applied to other mesenchymal tumors of uncertain behavior (e.g. glomus, granular cell tumors etc.) and creates an inordinate burden of surgery and endoscopy for small SETs the majority of which are low risk. Initial attempts at endoscopic resection, mostly from Asia, using ESD to "excavate" muscularis propria (MP) based SETs may leave microscopic residua and is not applicable to tumors with extraluminal growth. Similarly, device-assisted full thickness resection with devices such as over the scope clips is limited to smaller SETs with intraluminal growth. Recently, Asian pioneers reported 2 endoscopic techniques that achieve R0 en bloc resection of MP-based SETs: Submucosal Tunnel Endoscopic Resection (STER)- an offshoot of POEM utilizing the submucosal tunnel method to ensure secure closure of the full-thickness defect and endoscopic full-thickness resection (EFTR)- direct full thickness resection with closure of the defect with clips or sutures. We present an update of the first large Western series. 107 resections were performed from 9/2012 to 11/2017 by a gastroenterologist with a current experience of >400 POEMs and >500 ESDs. Baseline characteristics (Table 1): 70 female, mean age 58, 23% severely comorbid pts (ASA class 3-4), 78% upper SETs (esophagus, stomach, duodenum). Pathology revealed 77% SETs with malignant potential (45 GISTs, 25 leiomyomas, 1 leiomyosarcoma, 3 granular cell tumor, 1 glomus tumor) Mean size 28mm. Median Procedure 90 min [IQR 56,160]. Complete en bloc resection achieved in 103/107 (96%). Piecemeal/incomplete resection in 4 cases (2 pancreatic rests, one 4 cm granular cell tumor, one 5 cm GIST) and conversion to surgical resection in 3 cases (GIST, carcinoid, endometriosis). Laparoscopic gastrotomy for specimen extraction was performed after completion of the endoscopic resection and closure (11 cases) rather than morcelizing the specimen which would preclude proper margin evaluation. No significant AEs, except 1 pt with infected pleural effusion after STER requiring esophageal stent and IR drain. EFTR and STER achieve en bloc R0 resection of SETs <5 cm. The excellent outcomes probably reflect extensive prior experience with POEM, advanced closure techniques, and ESD for SETs. EFTR and STER represent a NOTES alternative to laparoscopic resection. Advantages include: 1.Incisionless minimal tissue re section 2. Resection of SETs at locations where laparoscopic "wedge" resection is challenging such as the GE junction, esophagus and cardia 3. Definitive diagnosis and complete resection obviating any further endoscopic surveillance for low risk lesions.

Early versus delayed enteral feeding in acute pancreatitis

Background: Early enteral feeding through a nasoenteric feeding tube is often used in patients with acute pancreatitis, as compared to previous notion of pancreatic rest. This study aims to compare various outcomes of early and late enteral feeding in severe acute pancreatitis.Methods: This study was a randomized trial conducted at Victoria hospital, Bengaluru between July 2016 and June 2017. Patients with severe acute pancreatitis were randomized into early enteral feeding and late enteral feeding groups in the ratio of 1:1. Early enteral feeding group were started on oral feeds within 24 hours of admission. Late enteral feeding group were started on oral feeds after 72 hours of admission. Patient demographics, clinical findings, investigations, length of hospital stay, complications were assessed and compared.Results: In 124 out of 132 patients were included who met inclusion criteria. The mean age of patients was 28.6 years. There were 120 males (96.7%) and 4 females (3.2%). There were no significant differences in age, sex ratio and comorbidities between the two groups. Early enteral feeds group showed lesser number of gastrointestinal adverse effects after initiation of enteral feeds, lesser number of days taken to develop full tolerance to enteral feeds, lesser number of days of admission, lesser complications like necrotizing pancreatitis, single or multiple organs failure, lesser number of ICU admissions, requiring mechanical ventilation, including lesser mortality when compared to delayed enteral feeds group.Conclusions: Patients with severe acute pancreatitis can safely be started on early enteral feeds within 24 hours of admission.

Don't Mess With the Pancreas (Wherever It May Be): Acute Pancreatic Rest“itis” Presenting as a Submucosal Mass With Gastric Outlet Obstruction

Don't Mess With the Pancreas (Wherever It May Be): Acute Pancreatic Rest“itis” Presenting as a Submucosal Mass With Gastric Outlet Obstruction

Low Grade Pre-malignant Lesion of Pancreatic Rest in Stomach, Surveillance a Dilemma

INTRODUCTION: Pancreatic intraepithelial lesions (PanIN) are premalignant lesions of pancreatic ductal adenocarcinoma (PDA). PanIN and PDA found in ectopic gastric pancreatic rest tissue are extremely rare, with only two cases of low-grade PanIN in ectopic gastric ectopic pancreatic tissue reported. In this case report, we present a case of PanIN in gastric ectopic pancreatic tissue found after lesion removal by endoscopic mucosal resection (EMR). CASE REPORT: A 47-year-old female with no significant history underwent an upper endoscopy for abdominal pain. Upper endoscopy revealed gastritis in the stomach and a 1 cm subepithelial lesion with central umbilication in the gastric antrum (figure 1). Endoscopic ultrasound examination revealed that the lesion was arising and limited to only the submucosa. EMR was performed to remove the lesion en bloc (figure 1). Pathological examination revealed gastric heterotopic pancreatic tissue and focal pancreatic intraepithelial neoplasia 1A (figure 2). Follow-up surveillance endoscopy performed at 6 months revealed no evidence of recurrence (figure 3).Figure: Endoscopic image showing (Left) A 1 cm submucosal polyp with central umbilication in the antrum. (Middle) Post en-block removal of polyp by endoscopic mucosal resection technique. (Right) Lesion closed with 2 clips.Figure: Histopathologic examination of haematoxylin and eosin stained pancreatic rest tissue specimen under x400 shows that pancreatic duct is lined by a single layer of epithelium with abundant apical mucinous cytoplasm and basal nuclei that lack atypia consistent with Pancreatic Intraepithelial Neoplasia 1A.Figure: Endoscopic image showing a scar tissue in the antrum from prior intervention with no residual pancreatic rest tissue.DISCUSSION: PanIN refers to a small intraductal noninvasive lesion formed by metaplasia and proliferation of ductal epithelium. It is classified by dysplasia severity—PanIN 1 and 2 are low grade, and PanIN 3 is high grade. In orthotopic pancreas, PanIN 3 is known as carcinoma-in-situ. Conversely, PanIN 1 and 2 tumors grow slowly, might take up to 12 years to transition into PanIN 3 and even longer to change to PDA. These results can be extrapolated to pancreatic rest tissue due to similar mutations. Presently, asymptomatic pancreatic rest is monitored, while symptomatic cases—or those suspicious of malignancy on ultrasound—are resected using endoscopic techniques or surgical resection. There are no guidelines for endoscopic surveillance and therapy of these asymptomatic, premalignant and malignant gastric ectopic pancreatic rest lesions. In this case we highlight a very rare incidence of a low-grade premalignant lesion within gastric ectopic pancreatic rest removed by endoscopic resection. Further research is necessary to better define strategies for endoscopic surveillance and therapy of asymptomatic gastric ectopic pancreatic rest given the potentiality of these lesions to be premalignant and transform into malignant lesions that carry a poor prognosis.

A Single Center Experience of Endoscopic Submucosal Dissection

Introduction: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique used for the resection of superficial gastrointestinal tumors with data showing high en bloc and curative resection rates in early gastric cancer. While it has been widely employed in East Asia, its adoption in the West has been slow due to the increased technical difficulty, higher rate of complications, longer procedure times and lower candidate populations. Methods: A retrospective review of the clinical and technical characteristics of ESD for superficial lesions of the gastrointestinal tract treated at Mount Sinai Beth Israel Medical Center, New York between May 2012 and December 2016. Results: We reviewed 59 cases of ESD - 46 gastric, 7 esophageal and 6 colorectal lesions. There were 21 cases of early malignancy, all in the upper GI tract (20 gastric, 1 esophageal). The overall en bloc resection rate was 70% (15/21) and R0 resection rate was 85% (18/21). Among the early gastric cancers, 7 were adenocarcinomas without invasion beyond the submucosa (T1), 3 were intramucosal carcinomas and 10 were cases of high grade dysplasia (HGD). There were 8 cases of low grade dysplasia with endoscopically-visible mucosal abnormalities, all of which were en bloc R0 resections. Eleven of the cases of gastric ESD were for submucosal tumors - 5 GISTs, 3 carcinoid tumors, 1 leiomyoma and 2 pancreatic rests. The seven esophageal lesions were 3 granular cell tumors, 2 dysplastic lesions in the setting of Barrett's esophagus, one case of HGD and one case of lymphoepithelioma-like carcinoma (curative R0 resection). Six of these cases were en bloc resections. Complete resection of 6 colorectal polyps were performed by ESD. Two of these polyps had previously undergone partial mucosal resection limiting en bloc resection. The average procedure time in the esophagus, stomach and colon was 76, 106 and 83 minutes respectively. The average resection sizes were 2, 3 and 2 cm respectively. There was one complication, in a patient who underwent ESD in the proximal stomach for a lesion with LGD, of delayed bleeding requiring hospitalization and endoscopic therapy. Conclusion: In this small single center series, ESD appears to be effective and safe with resection rates comparable to published data. With further experience, specialized training and development of dedicated instruments, ESD should become integrated into specialized endoscopic practice in the West for the treatment of GI tract neoplasms.

Incidence of Sub-epithelial Lesions on Upper Endoscopy: A Single Center 10-Year Experience

Introduction: Historically, incidence of sub-epithelial lesions in the upper GI tract is reported to be around 1%. In addition, changing indications and wider availability of endoscopic ultrasound (EUS) could affect the incidence of sub-epithelial lesions found on routine upper endoscopy. Our aim of the study was to examine the incidence of sub-epithelial lesions found on routine endoscopy (EGD) in an urban university teaching hospital. Methods: We performed a retrospective chart review of all EGDs done between January 2007 and November 2016. ICD-9 and ICD-10 codes were used to identify sub-epithelial lesions and confirmed on review of procedure reports. Pathology and EUS reports where available were reviewed. Multiple EGDs on the same patient were excluded. Overall incidence of sub-epithelial lesions and sub-group incidence in African Americans and women were calculated. The final diagnosis when available was also described. Results: From January 2007 to November 2016, a total of 19,189 EGDs were performed. There were 1061 patients (5.5%) with sub-epithelial lesions. Most of the lesions (85%) were benign such as lipoma, pancreatic rest, leiomyoma etc. Around 5% of the lesions were gastrointestinal stromal tumor (GIST) and carcinoid. No diagnosis was reported in 10% of the lesions. Conclusion: The overall incidence of sub-epithelial lesions on upper endoscopy is higher than previously reported. However, the incidence of GIST and carcinoid lesions was found to be lower.Figure: Subepithelial Lesions by Race and Gender.Figure: Top 4 Total Lesions Found.

Heterotopic Pancreatic Tissue in Gall Bladder: A Rare Entity

Introduction: Pancreatic heterotopia is a rare pathological entity and its localization in gall bladder is extremely rare. It is mostly asymptomatic incidental finding and rarely gives rise to complications. It can be associated with incidental finding or can be symptomatic or may cause complication. Heterotopic pancreas (HP) also referred to as ectopic pancreas, pancreatic choristoma, or pancreatic rest, is defined as the aberrantly located pancreatic tissue in an anomalous location without any anatomic, vascular, or neural continuity with the main body of the normal pancreas. The most common location for HP is the duodenum, upper jejunum and stomach. Case report: A 35 year male was admitted to the Surgical Department of Era’s Lucknow Medical College and Hospital for an elective laparoscopic cholecystectomy. He had complains of sporadic flatulence after meals and belching. His gall bladder was resected post an USG revealing Gall stones and sent for histopathology where he was diagnosed as a case of heterotopic pancreas in the GB neck with chronic cholecystitis. Discussion: Localization of pancreatic heterotopia in gall bladder is the second most prevalent pancreatic anomaly but an extremely rare finding. The incidence in gastrointestinal tract is estimated to be from 0.55% to 13.7% on autopsy, and 0.2% in laparatomy. Most commonly these are incidental findings but some studies have implicated them as causative factors in the genesis of cholecystitis, obstructions etc. Conclusion: HP of the gallbladder may cause clinical symptoms such as cholecystitis as well as complications which can be fatal and hence this condition should be taken into consideration in patients with symptomatic gallbladder disease.

Prediction of esophageal and gastric histology by macroscopic diagnosis during upper endoscopy in pediatric celiac disease.

AIMTo determine the sensitivity of macroscopic appearance for predicting histological diagnosis at sites other than duodenum in pediatric celiac disease (CD).METHODSEndoscopic and histologic findings in pediatric patients undergoing upper endoscopy for first-time diagnosis of CD at Stollery Children’s Hospital from 2010-2012 were retrospectively reviewed.RESULTSClinical charts from 140 patients were reviewed. Esophageal and gastric biopsies were taken in 54.3% and 77.9% of patients, respectively. Endoscopic appearance was normal in the esophagus and stomach in 75% and 86.2%. Endoscopic esophageal diagnoses were eosinophilic esophagitis (EE) (11.8%), esophagitis (7.9%), glycogenic acanthosis (1.3%) and non-specific abnormalities (3.9%). Endoscopic gastric diagnoses were gastritis (8.3%), pancreatic rest (0.9%), and non-specific abnormalities (4.6%). Histology was normal in 76.3% of esophageal and 87.2% of gastric specimens. Abnormal esophageal histology was EE (10.5%), esophagitis (10.5%), glycogenic acanthosis (1.3%) and non-specific (1.3%). Gastritis was reported in 12.8% of specimens. Sensitivity and specificity of normal endoscopy for predicting normal esophageal histology was 86.2% and 61.1%, and for normal gastric histology was 87.4% and 21.4%.CONCLUSIONIn the absence of macroscopic abnormalities, routine esophageal and gastric biopsy during endoscopy for pediatric CD does not identify major pathologies. These findings have cost and time saving implications for clinical practice.

Nutritional Management in Acute Pancreatitis

Acute pancreatitis induce a catabolic stress that increase systemic inflammatory response with worsening nutritional status. Current approach in acute pancreatitis therapy was still symptomatic because of no definitive therapy yet to prevent any inflammatory and proteolytic cascade. One of the most important thing to consider in acute pancreatitis therapy was nutritional management. “Pancreatic rest” concept that formerly used have been known to increase cost, sepsis incidence due to catheter use, and also metabolic and electrolyte disorder. Nowadays, “gut rousing” concept was preferable compared to “pancreatic rest” concept, support that nutritional management was needed to stimulate and generate intestinal function. Enteral nutrition administration have to consider patient’s hemodynamic status. Necrosis incidence, respiratory failure, intensive care, and mortality was found to be lower in patients given enteral nutrition in first 48 hours compared to after 48 hours. Nutrition administration via nasogastric tube or nasojejunal tube was still in doubt while several studies showed that nasogastric tube administration was safe and tolerated, otherwise could be evaluated in larger population sample study. Nutrition and metabolic monitoring was also an important part to reach nutritional goals and reduce complications.

A 20 Year Retrospective Study Assessing the Percentage Distribution of Submucosal Lesions Along the Gastrointestinal Tract

Introduction: We reviewed our experience in the evaluation of submucosal lesions (SML) to better define the incidence of each type of SML based upon their location and endoscopic appearance. Determining the percent of each SML at each section of the gastrointestinal tract may provide valuable information for the practicing endoscopist to enhance pre-test probability prior to referral for endoscopic ultrasound (EUS). Methods: We reviewed all referrals for endoscopic ultrasonographic evaluation for submucosal lesions (SML) from 1993 through 2013 at the University of Louisville. Of the total 4789 cases, 639 (13.3%) were referred for evaluation of SML by EUS. Of these patients referred, 369 (55.1%) were male with an average age of 58.49 (range 18-88 years). SMLs were distributed as follows: 122 Esophageal (18.7%), 353 gastric (54.1%), 105 small intestinal (16.1%), 36 colonic (5.5%), and 35 rectal (5.4%). Data was stratifi ed by location of the SML and by type (table 1/figure 1). Percentages were calculated for each SML at each gastrointestinal location. Hypoechoic lesions included c-kit CD-117 positive GISTs and negative leiomyomas. “Normal” was defined by studies where there was extrinsic compression of the GI tract by a normal organ or structure. “Other” lesions included hypertrophic folds, polyps, involuted appendices, ganglioneuromas, pancreatic rests and abscesses. Paired Pearson correlations were calculated for the different sections of the GI tract, comparing the distribution of types of SML from one section to the next.Figure 1Results: Overall, the incidence of each type of SML at a specific section of the GI tract differed significantly through the GI tract, meaning that contiguous and non-contiguous sections of GI tract had different proportions of each type of SMLs. The incidence of cysts and hypoechoic lesions both decreased when passing distally through the GI tract. In contrast, lipomas increased in incidence distally in passing the GI tract. Extrinsic compression made up a significant portion of cases referred for evaluation of SML (14.7%), with structures varying from one level of the GI tract to another (table 2).Table 1: Percent distribution of SMLs at Different Locations in the GI TractTable 2: Causes of External Compression Throughout the GI TractConclusion: At any level of GI tract, an assortment of other etiologies may create the appearance of true SMLs, such as extrinsic compression of GI tract by normal organs, polyps and hypertrophic mucosal folds. Based on results, location of a SML within the GI tract may help the endoscopist predict etiology of true SMLs prior to referral to EUS.

Heterotopic Pancreas Presenting as Hematemesis

Introduction: Heterotopic pancreas is also known as an aberrant pancreas or accessory pancreas, is a scare congenital abnormality defined as the growth of pancreatic tissue outside of the pancreas with no anatomic or vascular connection with normal pancreatic tissue. Such tissue may occur throughout the Gastrointestinal (GI) tract but has a propensity to affect the stomach and the proximal small intestine. The majority of patients with pancreatic heterotopia are asymptomatic, but when symptoms occur they can present in a variety of ways. We report a case of a patient whose pancreatic rest presented as epigastric pain and was diagnosed by endoscopic biopsy after an episode of hematemesis. Case Presentation: The patient is a forty two year old female patient with a history of an ectopic pregnancy and ovarian cyst removal in 2011. She came to the primary care clinic to establish care in 2012, at which she complained of epigastric pain radiating to the back for years, no relationship to food. She denied any nausea, vomiting, weight loss, changes in appetite, melena or hematochezia. Four months later, she presented to the Emergency Room complaining of two episodes of bloody emesis with epigastric pain. Her vital signs: temperature 98.7F, HR: 85 and BP110/78 mmHg. She was well appearing, no epigastric tenderness, no organomegaly appreciated. Laboratory results were significant for HCT = 10.8/33.3 MCV 81.7. Helicobacter pylori test was negative. Amylase, lipase and hepatic panel were normal. Abdominal Ultrasound was normal. The Patient had an endoscopy that revealed two antral polyps in the stomach that were biopsied. Colonoscopy showed Grade one hemorrhoids. Pathology report revealed Gastric Heterotopic pancreas without inflammation. Three months later, she had a follow up clinic visit and was asymptomatic. Discussion: Heterotopic pancreas can exist at any position in the abdominal cavity. It is usually found in the upper gastrointestinal tract, with >90% of the cases involving the stomach, duodenum or jejunum. The Incidence rate is 0.11% - 0.21%, and a male to female ratio 3:1. Diagnosis is often difficult and symptoms can mimic other GI pathologies and malignancies. The particular symptomatology that manifest is relative to the size and its location within the GI tract. Hematemesis is a rare presentation of heterotopic pancreatic tissue and it is vital that all clinicians be aware of this clinical entity to avoid misdiagnoses.

Heterotopic pancreatic rests: imaging features, complications, and unifying concepts

The spectrum of pancreatic heterotopia will be reviewed, including clinical features, potential complications, and imaging manifestations. This will also include a review of various entities associated with pancreatic heterotopia such as groove pancreatitis and cystic dystrophy of gastroduodenal heterotopic pancreas. These entities were previously thought of as distinct histopathologic entities but now appear to represent manifestations of pancreatic heterotopia. Pancreatic heterotopia and heterotopic pancreatitis can have a wide range of appearances. Several entities, which were previously thought to be distinct, can be considered manifestations of pancreatic heterotopia and heterotopic pancreatitis.

The Role of Endoscopic Ultrasound in the Diagnostic Assessment of Subepithelial Lesions of the Upper Gastrointestinal Tract

IntroductionThe identification of subepithelial lesions is a relatively frequent finding at endoscopy however their natural history is not well known. Our aim was to analyze the role of endoscopic ultrasound (EUS) in the diagnostic approach of subepithelial lesions of the upper gastrointestinal tract. MethodsRetrospective study which included 324 patients undergoing upper radial EUS for evaluation of subepithelial lesions from 2008 to 2014. The EUS features, presumptive diagnosis and management decision were analyzed. Results324 patients included, 60% with gastric subepithelial lesions, 28% oesophageal and 12% from the duodenum. Based on EUS features the presumptive diagnosis was: 25% gastrointestinal stromal tumor, 21% lipoma, 19% leiomyoma, 17% pancreatic rest, 7% submucosa cysts, 1% granular cell tumors, 1% carcinoids, 1% mucosa lesions and 8% not defined. After EUS the suggested approach was no follow-up in 45%, follow-up with re-examination with EUS in 35% and additional tissue sampling or endoscopic/surgical resection in 20%. The latter was based on EUS features of risk at the diagnosis (53%), such as size ≥2cm, hypoechogenicity, heterogeneity, lobulation, calcifications, cystic component and regional adenopathies; impossibility to define a presumptive diagnosis (39%) or EUS features change at follow-up (8%). The combination of multiple features correlated with a higher probability of this recommended strategy (p<0.001), in 100% when 4 or more features were present. Among the 33 patients who underwent fine needle aspiration, in 66% the result was inconclusive. During follow-up, none of the patients who were managed with surveillance radial EUS presented complications. ConclusionEUS is the method of choice in the study of subepithelial lesions of the upper gastrointestinal tract, in most cases defining a diagnosis. The need for a definitive diagnosis or therapeutic approaches can be based on ultrasound risk features, presented, in the majority, at presentation. This study shows that EUS is capable of safely and accurately define those subepithelial lesions that can be managed only with surveillance ultrasound while waiting for better results with fine needle aspiration.

A retrospective study on the safety, diagnostic yield, and therapeutic effects of endoscopic unroofing for small gastric subepithelial tumors.

Accurate diagnosis of small gastric subepithelial tumors (SETs) is essential to assess their malignant potential. Endoscopic unroofing has been reported to yield sufficient tissue samples for histologic evaluation. This study aimed to evaluate the safety, diagnostic yield, and potential therapeutic effects of this technique over time. This retrospective analysis of prospectively collected clinical data identified patients who underwent endoscopic unroofing at the Medical University of Vienna from January 2003 to December 2012. Demographic data, indications for endoscopic unroofing, intraprocedural adverse events, hospital stay, histologic results, and follow-up procedures were reviewed. A total of 14 patients (7 men; 7 women; median age, 70 years; range, 51-95 years) underwent endoscopic unroofing of 14 gastric SETs with a mean diameter of 26 ± 13mm at EUS. In 9 of 14 cases, endoscopic unroofing was done exclusively for diagnostic purposes; in the remaining cases, it was performed with therapeutic intent because of bleeding from the gastric SETs. Unroofing was technically successful in 13 of 14 cases and revealed 8 cases of GI stromal tumor (GIST) and 1 case each of leiomyoma, fibroid polyp, glomus tumor, pancreatic rest, and nondiagnostic material at histology. Intraprocedural bleeding was the only adverse event (4 cases) and could be managed endoscopically. A follow-up EUS was available (median, 8 months) for 10 of the 14 patients. Notably, most patients showed complete regression of their gastric SETs after unroofing (on white light and EUS), including the glomus tumor, the leiomyoma, and 6 of the 8 cases of GIST. Endoscopic unroofing was safe and had a very favorable diagnostic yield in this study. Unexpectedly, it led to complete regression in most gastric SETs. Although it is not an oncologically curative treatment, endoscopic unroofing can be a valuable option to treat local adverse events in patients unfit for surgical therapy. (Clinical trial registration number: NCT02587923.).

Efficiency and safety of endoscopic resection in the management of subepithelial lesions of the stomach.

Gastric subepithelial tumors represent a diagnostic and therapeutic challenge, given their histologic heterogeneity and potential malignant behavior. The objective of this article is to evaluate the interest, efficiency and safety of endoscopic resection for subepithelial gastric lesions of size <20 mm. We conducted a single-center retrospective study in a tertiary care center. A total of 33 lesions (10 malignant/23 benign lesions) were studied. Mean histological size was 14.5 mm. Nine EMR, 18 ESD and six hybrid resections were performed. A total of 93.9% lesions were resected in one piece. At six months' follow-up, complete and definitive resection was obtained in 96.7% of cases. A vertical resection was insufficient in four cases. One GIST needed a complementary surgical resection, one neuroendocrine tumor was successfully treated by a new ESD session and two pancreatic rests were not additionally treated given the benign character and the absence of residual tissue in endoscopic control after six months. There was only one severe adverse event (2.9%); one pneumoperitoneum with ESD, three bleeding with one ESD and two EMR, always treated conservatively or endoscopically. Endoscopic resection is safe and should be the procedure of choice for both diagnosis and definitive resection of subepithelial gastric lesions of size under 20 mm.

The Duplicated Pancreas: Imaging Evaluation of a Rare Anomaly Presenting as Acute Pancreatitis

There are multiple variants of normal anatomy involving multiple organ systems, many of which are well documented throughout the medical community. Specifically, the pancreas can demonstrate a wide range of variants that include divisum, ectopic tissue, annular pancreas, ductal variation, and pancreatic rests. However, upon literature review, a complete duplication of the pancreas resulting in two separate pancreases is rarely documented. This case provides an interesting diagnosis of two individual pancreases in a patient whom initially presented clinically with recurrent bouts of acute pancreatitis and weight loss status post prior cholecystectomy. Dedicated CT, MRI, MRCP, and endoscopic ultrasound were able to delineate pertinent anatomy and acute findings. The resultant patient course is difficult to predict secondary to limited documentation of duplicated pancreases in the medical literature. Additionally, the case helps provide insight into complications that may arise from this embryologic anomaly, the best imaging techniques for evaluation, and future management of this patient.

Bowel Rest

A 70-year old man with a 50-year history of Crohn’s disease developed crampy lower abdominal pain, bloating, and a decreased number of bowel movements. Past medical history was remarkable for hypertension and atrial fibrillation. Abdominal examination was unremarkable. Laboratory testing was normal. Computed tomography of the abdomen showed an ileal stricture, 25 cm in length (Figure A). No other abnormalities were detected. Colonoscopy was performed to the terminal ileum where the stricture was identified. Biopsy specimens confirmed Crohn’s ileitis. Endoscopic dilatation could not be performed because of the length of the stricture and the patient was referred for ileocolonic resection. The sections of the resected small intestine showed a Crohn’s-related stricture. Additional incidental findings included a Meckel’s diverticulum containing 3.5-cm of heterotopic pancreas (Figure B), also known as a pancreatic rest, with an intraductal papillary mucinous neoplasia (IPMN) (Figure C, arrow) with high-grade dysplasia (Figure D, arrow). Subsequent abdominal magnetic resonance imaging and magnetic resonance cholangiopancreatography (Figure E) showed multiple pancreatic cysts that communicated with a normal-caliber main pancreatic duct. These features are consistent with a diagnosis of branch-duct IPMN (BD-IPMN). Heterotopic pancreas is pancreatic tissue found anywhere along the gastrointestinal tract that lacks an anatomic and vascular connection to the normal pancreas. IPMN arising from heterotopic pancreas is rare, with very few cases reported.1Tsapralis D. Charalabopoulos A. Karamitopoulou E. et al.Pancreatic intraductal papillary mucinous neoplasm with concomitant heterotopic pancreatic cystic neoplasia of the stomach: a case report and review of the literature.Diagn Pathol. 2010; 5: 4Google Scholar Furthermore, there have been only 32 reported cases of malignancy arising within the heterotopic pancreatic tissue and the true incidence is unknown.2Song J.Y. Han J.Y. Choi S.K. et al.Adenocarcinoma with intraductal papillary mucinous neoplasm arising in jejunal heterotopic pancreas.Korean J Pathol. 2012; 46: 96-100Google Scholar IPMNs first were reported in 1982 and are defined as intraductal grossly visible epithelial neoplasms of mucin-producing cells arranged in papillary formations, originating in the main pancreatic ducts or its branches.3Tanaka M. Fernandez-del Castillo C. Adsay V. et al.International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.Pancreatology. 2012; 12: 183-197Google Scholar IPMNs can affect the main pancreatic duct (main-duct IPMN), branch ducts (BD-IPMN), or both the main and side branches (mixed-IPMN). Management consists of surveillance, or surgical resection in cysts deemed to be at high risk of malignant transformation. Surgical resection is recommended for most patients with main- or mixed-duct IPMN because high-grade or invasive adenocarcinoma is found in between 58% to 63% of patients who undergo surgical resection.3Tanaka M. Fernandez-del Castillo C. Adsay V. et al.International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.Pancreatology. 2012; 12: 183-197Google Scholar In contrast, BD-IPMNs are associated with a much lower risk of malignant transformation, with 25% of patients who undergo surgical resection found to have high-grade or invasive carcinoma.3Tanaka M. Fernandez-del Castillo C. Adsay V. et al.International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.Pancreatology. 2012; 12: 183-197Google Scholar To determine appropriate management, BD-IPMNs should be characterized in terms of size, presence of enhancing solid component, mural nodule, suspicious cytology, or main duct involvement. Consensus guidelines recommend surgery for symptomatic BD-IPMNs, or those with high-risk features.3Tanaka M. Fernandez-del Castillo C. Adsay V. et al.International consensus guidelines 2012 for the management of IPMN and MCN of the pancreas.Pancreatology. 2012; 12: 183-197Google Scholar Surveillance imaging (computed tomography, magnetic resonance imaging, or endoscopic ultrasound) is recommended for the remainder of BD-IPMNs, with surveillance intervals determined by the size of the cyst.

Robot-Assisted Resection of a Pyloric Pancreatic Rest with Peroral Endoscopic Removal and Reconstruction by Partial Gastroduodenostomy

Background: Gastric pancreatic rests consist of ectopic pancreatic tissue within the stomach wall and exhibit a typical endoscopic appearance. They are frequently asymptomatic, but can cause pain, erosions, and depending on their location, gastric outlet obstruction. Symptomatic pancreatic rests should be resected surgically. Objective: We report the first robot-assisted resection of a pyloric pancreatic rest with endoscopic removal of the tumor through the pharynx and subsequent reconstruction of the gastric outflow tract by partial gastroduodenostomy. Case: A 10-year-old girl presented with several months of worsening abdominal pain and nonbilious emesis. An upper gastrointestinal endoscopy showed a large pancreatic rest adjacent to and obstructing the pylorus, confirmed by endoscopic ultrasound. The patient was scheduled for robot-assisted resection of the tumor. Intraoperatively, resection of the mass with part of the pylorus was performed. To avoid augmenting one of the robotic trocar sites for removal of the tumor, the mass was pushed into the stomach and retrieved endoscopically through the esophagus and pharynx. The pylorus was reconstructed robotically by transverse gastroduodenostomy using interrupted sutures in two layers. The operative time was 320 minutes. Results: The patient tolerated the procedure well, advanced on her diet without difficulties, and discharged home on postoperative day 3. Histopathology confirmed the diagnosis. She remained asymptomatic, and an upper gastrointestinal contrast study 3 months later showed normal passage of contrast from the stomach into the duodenum. She remains asymptomatic at 8 months follow-up. Conclusions: Symptomatic pyloric pancreatic rests require careful excision with precise reconstruction of the gastric outflow tract, and therefore lend themselves to a robot-assisted approach. Endoscopic removal through the mouth as a natural orifice allows for removal without augmenting one of the trocar sites and thereby minimizes visible scars. If careful resection and reconstruction are achieved, the outcome is excellent. No competing financial interests exist. Runtime of video: 4 mins 50 secs This video was presented at the International Pediatric Endosurgery Group's 23rd Annual Congress, July 2014, in Edinburgh, Scotland.