Submucosal Lesions Research Articles

Transbronchial Needle Aspiration

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Conventional transbronchial needle aspiration in community practice.

Conventional transbronchial needle aspiration (C-TBNA) provides an opportunity to diagnose mediastinal lesions and stage bronchogenic carcinoma in a minimally invasive fashion. The procedure is easy to learn and requires zero upfront cost. Any community pulmonologist can acquire and maintain the skills of C-TBNA without undergoing formal interventional pulmonary fellowship training. Besides being used for the diagnosis and staging of lung cancer, C-TBNA can be used in patients suspected to have benign conditions such as sarcoidosis and tuberculosis. It also contributes in improving the diagnostic yield of flexible bronchoscopy while dealing with endobronchial, submucosal, peribronchial, or peripheral lesions. C-TBNA may be the only diagnostic modality that can be performed in patients in whom mediastinoscopy is contraindicated due to a bleeding diathesis. The procedure is safe and has great potential to augment the welfare of patients with pulmonary ailments. The learning curve of the procedure is short and steep. Every community pulmonologist should be able to perform C-TBNA.

Computed tomography findings for a gastric lymphoepithelioma-like carcinoma: How often does it present as a submucosal mass?

To describe the anatomical location, size, tumour characteristics and morphology on CT of gastric lymphoepithelioma-like carcinoma (LELC) in order to determine the proportion of lesions that present as submucosal masses, and to review the clinicopathological findings. This retrospective study reviewed CT images of 186 lesions from 178 patients with LELC. CT morphologies and other findings were also analyzed. Pathology and medical records were reviewed. A pathology slide review of the lesions that presented with submucosal masses was performed. Gastric LELC presenting as a submucosal mass was found in 9.1%. The most common CT morphology was eccentric wall thickening (67.7%). On the pathology review, 14/17 submucosal mass lesions (82.4%) had a central ulceration. 105 lesions were T1/T2 stage (94.1%), and N0 stage was diagnosed in 66.1%. Fifty-six of 63 metastatic lymph nodes (LNs) (88.9%) demonstrated homogeneous enhancement, regardless of size. Male predominance (85.4%), upper stomach location (45.7%) and multiplicity (4.5%) were found. Gastric LELC presenting as a submucosal mass is only detected in a small portion of all patients, and the most common finding is eccentric wall thickening. Central ulceration and enlarged LNs with homogeneous enhancement are occasionally other features on CT. • LELCs as submucosal masses on CT were detected in only 9.1 %. • The most common CT finding was eccentric wall thickening (67.7 %). • Central ulceration and enlarged LNs with homogeneous enhancement might be seen.

A rare presentation of colonic polyp

Fig. 1 – Colonoscopy showing a large submucosal polypoidal growth in descending colon. A 60-year-old female, a known diabetic presented with complaints of crampy intermittent pain in left lower abdomen for 15 days associated with one episode of passage of blood stained stools. Colonoscopy revealed a large submucosal polypoidal lesion in the transverse colon [Fig. 1]. CECT abdomen was suggestive of a descending colon lipoma causing proximal colo-colic intussusception [Figs. 2A, B and 3 respectively]. Her serum CEA levels were within normal limits. Intraoperatively, a large 6 cm 4 cm pedunculated polypoidal growth was seen arising from splenic flexure of colon [Fig. 4]. There were no palpable lymph nodes in mesocolon and no evidence of metastasis to liver. She underwent Left Hemicolectomy with colo-colic anastomosis using GIA 80 mm green staplers (Covidien, USA). Postoperative stay in hospital was uneventful. Histopathological examination revealed colonic lipoma. Adult intussusception represents 1% of all bowel obstructions and 5% of all bowel intussusceptions. In contrast to pediatric intussusceptions, which is idiopathic in 90% of cases, 70–90% of adult intussusceptions have an organic cause, 60% developing due to neoplasms (60% malignant and 24–40% benign). Adult colonic intussusceptions are caused by a Article history: Received 14 November 2015 Accepted 16 November 2015 Available online 3 December 2015

Mucocele of the Appendix: A Rare Disease

Introduction: Mucocele of the appendix is caused by a retention cyst, mucosal hyperplasia, mucinous cystadenoma or mucinous cystadenocarcinoma. It is extremely rare, found in 0.2-0.3% of resected appendices in the United States. Early diagnosis is rare due to absent or nonspecific symptoms like right lower quadrant abdominal pain, gastrointestinal bleeding, intestinal obstruction, genitourinary symptoms or acute abdomen. Early diagnosis and resection are important since some appendiceal mucoceles are malignant and may lead to peritoneal dissemination and the clinical syndrome of pseudomyxoma peritonei. Case report: A 74-year-old male presented with intermittent right lower quadrant abdominal pain and hematochezia for 4-6 weeks. He had no pertinent abdominal symptoms including nausea, vomiting, bloating, diarrhea or constipation or weight loss. Routine laboratory testing showed microcytic anemia. He had a colonoscopy 5 years ago which was normal. Repeat colonoscopy showed a protuberant mass at appendiceal orifice which was firm on palpation with biopsy forceps. Biopsy of the lesion showed mild inflammatory changes. With the above described endoscopic appearance of the lesion, clinical suspicion for mucocele was high, hence CT scan was obtained. CT scan showed low attenuation, well-defined 2.5-cm mass, with no signs of inflammation suggestive of mucocele of the appendix. Patient underwent surgery for ileo-caecal resection. Histopathology of the surgical specimen was reported as mucinous cystadenoma of appendix. On 3-month follow-up, patient is doing well and his anemia is resolving. Discussion: Appendiceal mucoceles may be recognized at colonoscopy as an extrinsic or submucosal lesion with smooth indentation into the caecal lumen. Appearance of the appendiceal orifice in the center of the mound has been labeled as the “volcano sign.” Highly suggestive endoscopic finding is that of a glossy, rounded, balloon-shaped mass protruding from the appendiceal orifice and moving in and out with respiration. This case highlights the importance of endoscopic appearance of appendiceal mucocele which can be missed on a biopsy. Further imaging is warranted when mucocele of appendix is suspected on colonoscopy. Recognition at colonoscopy is important as it enables accurate diagnosis of this rare clinical entity. Surgical excision of the tumor without rupture is of paramount importance because rupture of the lesion causes pseudomyxoma peritonei. Survival is excellent after standard appendectomy of retention cysts, mucosal hyperplasia, or cystadenoma.

All That Glitters Is Not Gold: Gastric Adenocarcinoma With Medullary Pattern Presenting as Submucosal Lesion

All That Glitters Is Not Gold: Gastric Adenocarcinoma With Medullary Pattern Presenting as Submucosal Lesion

Carcinoid of the Duodenal Bulb: A Rare Occurrence

Introduction: The incidence of neuroendocrine tumors has increased significantly in the last few decades. Carcinoid tumor, a subtype of neuroendocrine tumors, arises from the enterochromaffin cells of the epithelial lining of the gastrointestinal tract, retroperitoneum and large bronchi. Duodenal carcinoids are extremely rare and can present with a variety of symptoms including epigastric pain, vomiting, anemia, and weight loss. We report a rare case of a patient who presented with iron deficiency anemia and was found to have multiple carcinoids of the duodenal bulb. Case: 60 year-old male presented to his primary care physician's office to establish care and reported a history of GERD for which he was taking Omeprazole 20 mg daily in the morning. He underwent routine laboratory investigations revealing iron deficiency anemia which prompted the need for an endoscopy. His initial EGD showed a 5 mm duodenal bulb polyp with biopsies showing changes suggestive of a hyperplastic polyp. Given his persistent anemia and an inconclusive workup otherwise including a colonoscopy, he underwent a second-look EGD after six months which showed two submucosal duodenal bulb lesions, 15 mm and 5 mm, both of which were biopsied with cold biopsy forceps and showed a neoplasm formed by nests of cells with moderately clear-to-pale eosinophilic cytoplasm and nuclei with finely stippled chromatin. A chromogranin stain was performed and was positive, thereby rendering a diagnosis of a carcinoid tumor. He underwent an octreoscan and a CT scan which showed no metastatic disease. The patient underwent a Billroth procedure. Intra-operatively, no evidence of diffuse peritoneal disease or metastases to the intra-abdominal viscera was observed. The liver did not have any palpable masses. He tolerated the procedure well and was discharged home with a surveillance EGD showing no evidence of recurrence. Discussion: Duodenal carcinoids, although rare, should be kept in the differential diagnosis of the polypoid lesions of the duodenum and may occasionally cause anemia. Two duodenal carcinoids occurring concomitantly and presenting as iron deficiency anemia is extremely rare. These lesions typically have a low metastatic potential and have a good curative rate if localized and diagnosed early.

Endoscopic Resection of a Bleeding Brunnerʼs Glands Hamartoma

Brunner's glands hamartoma is a rare and benign lesion arising from the brunner's glands of the duodenum. This proliferation can be symptomatic with bleeding or obstruction, rarely with chronic pancreatitis. Around 200 cases have been reported and tumors are rarely more than 5 cm. A 81 years-old lady known for gastroeosophageal reflux on proton pump inhibitor and a 28x18 mm pedunculated submucosal lesion (hyper echoic with small hypo echoic foci) of the duodenum which was stable in appearance and size in 2009 presented with a 5 days history of melena with abdominal discomfort. Her blood work was remarkable for haemoglobin of 64 g/L (127 g/L previously).Figure 1The upper endoscopy showed a more than 5 cm duodenal polyp with multiples ulcerations and friability without active bleeding. Placement of a ligating device to prevent the rebleeding, polyloop 30mm (Olympus: HX-400U-30), was impossible due to the size and position of the lesion. A CT-scan confirmed a polypoïd lesion anchored in the duodenal bulb without extra digestive extension of suspicious ganglion. An endoscopic ultrasonography showed a more than 4x3 cm lesion of the duodenal bulb with a relatively short and thick peduncle originating from the mucosa with complete sub mucosa infiltration. This lesion was diffusely homogenous with a hyper echoic pattern. There was no muscular layer infiltration. Considering the advanced age of the patient an endoscopic resection was considered acceptable. A second endoscopy was performed. An « en bloc » resection with a 3x6 cm Acusnare polypectomy snare (Cook Medical: ASJ-1-S: G22630) at the base of the peduncle. The polyp was displaced in the stomach with some resistance and an arterial bleeding from the base of the polypectomy was control with a Resolution Clip (Boston Scientific: 2261). Two other clips were installed and a polyloop 30 mm surrounding the clips closed the mucosal defect. The polyp was then grabbed with the snare but was too big to pass the gastro oesophageal junction. We unsuccessfully tried to cut the polyp in two pieces. A 16.7 mm inner diameter 50 cm length Guardus gastric overtube (USEndoscopy: BX00711149) was placed in the stomach. The polyp was grabbed again with the snare and impacted 50% of its length in the distal portion of the overtube. All items (polyp, scope, overtube) were removed « en bloc » without much resistance. Pathology showed a 5.5x4x2.2 cm lesion with a 1.2x2 cm insertion site considered a brunner's glands hamartoma without dysplasia with multiple superficial ulcers. The resection was incomplete with lesion at the insertion site. The patient had no complication or further bleeding and was discharged home. A six months follow-up upper endoscopy is pending.

Cross-sectional GI Imaging Should Precede Capsule Endoscopy in Evaluation of Overt-Obscure GI Bleeding With Negative Endoscopic Work-up

A 54 year old female with GERD on daily omeprazole presented with 2 days of maroon stools which progressed to melena. She denied abdominal pain, hematemesis, or NSAID use. Physical exam was notable for stable vital signs, benign abdomen, and rectal exam with black stool positive for occult blood. Her hemoglobin was 8.2g/dL, decreased from 12 a week earlier, and BUN was 21mg/dL. She was started on IV pantoprazole and EGD revealed a few small fundic gland polyps, but no blood or ulcers. Colonoscopy revealed hematin scattered throughout the entire colon and distal terminal ileum. The patient continued to have melena and was referred for CT enterography (CTE). A 4.1 x 4.8 x 4.7 cm hypervascular mass was seen arising from the wall of the terminal ileum with large feeding vessels from the superior mesenteric artery. She underwent exploratory laparotomy with excision of an isolated mass and resection of 14cm small bowel. Pathology demonstrated a submucosal lesion without hemorrhage or necrosis with normal overlying mucosa; high-power exam showed bland spindle shaped cells with varying degrees of eosinophilic cytoplasm arranged in fascicles. Mitoses numbered < 2 per 50 high power fields. A c-kit (CD117) stain was positive, confirming the diagnosis of low-grade GIST. This case illustrates an example of active, overt-obscure GI bleeding (OGIB) diagnosed by CTE following negative colonoscopy and EGD. In this setting, guidelines favor proceeding to capsule endoscopy (CE) as a first-line diagnostic tool for evaluation of the small bowel. The few prospective studies directly comparing diagnostic yield of CTE vs CE for OGIB are conflicting, as sensitivity is influenced by lesioncharacteristics and timing of exam, among other factors. In this patient who was unable to receive a CE in the hospital, CTE presented a safe, noninvasive initial step towards an expedient diagnosis. Most guidelines incorporate both CE and CTE after negative colonoscopy and endoscopy. With overt-obscure bleeding, we believe CTE may be superior given its widespread availability and ability to detect masses and bleeding lesions. Further prospective studies are needed to elucidate the optimal approach. In the meantime, we as endoscopists evaluating GI bleeding should think beyond just endoscopic approaches and consider CTE in the appropriate setting.Figure 1

An Incidental Finding of Rectal Carcinoid Tumor

Adenocarcinoma is the most common malignancy found in the rectum. However, the incidence of rectal carcinoid has been rising after implementation of screening colonoscopy. The rectum is the second most common anatomic site for carcinoid tumor. Embryologically, rectal carcinoids are hindgut tumors which are non secretory. Hence, they rarely present with carcinoid syndrome even in patients with metastatic disease. A recent systematic review of rectal carcinoid by McDermott et.al was unable to perform a metaanalysis on optimal treatment strategies for localized and widespread disease due to the wide variety of data recorded from various sources. Our aim is to make physicians aware that the rectal carcinoid is becoming a common diagnosis thus clinicians should have current knowledge of classification, management and treatment options available. A 62-year-old African American male with a significant past medical history of hypertension and tobacco abuse presented to the gastrointestinal (GI) lab for colorectal cancer screening colonoscopy. Patient had no specific GI complaints and a 10-point review of symptoms was unremarkable except for decreased exercise tolerance. Physical examination was unremarkable including digital rectal exam. During colonoscopy, a 7-10 mm firm polypoid submucosal lesion was noted in distal rectum and was resected using an electrocautery snare and ERBE endocut current. Histologic evaluation of the resected polyp demonstrated a well-differentiated neuroendocrine neoplasm that stained positive for chromogramin, synaptophysin, and Ki-67 proliferation marker. Patient underwent repeat colonoscopy about a month later. Biopsy obtained from previous polypectomy site was negative for carcinoid tumor cells. The rectal carcinoid classification, management and treatment options have been defined based on the size and aggressiveness of the lesion. As there is no defined TNM system classification, there is no homogenous data available yet on how to manage rectal carcinoid. Treatment strategy is based on tumor size, radiologic testing and surveillance examination including use of rectal EUS.Figure 1

Going All the Way: Endoscopic Full-thickness Resection (EFTR) of a Rectal Mass

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal lesions, such as early cancer or submucosal tumor. We present a case of young female with early rectal cancer treated successfully with EFTR of a rectal mass with clear margins on pathologic review. A 46-year-old female presents for initial screening colonoscopy. The patient had no GI complaints, and but her family history was significant for colorectal cancer in her father prior to the age of 50, but she had been delayed in obtaining a colonoscopy. An index screening colonoscopy was performed which a 3 cm semi-sessile mass was seen in the rectum about 1.5 cm from the anal verge. The mass was non circumferential and located at the posterior bowel wall. Biopsies of the rectal polyp revealed adenocarcinoma without lympho-vascular invasion. The large rectal mass was referred to our institution for resection, as the patient did not wish to undergo surgery. The periphery of the mass was injected submucosally with a solution of hyaluronic acid, hypertonic saline and methylene blue in order to raise the lesion and obtain an appropriate resection cushion. After a proper lift had been obtained, submucosal dissection was started. The dissection of the lesion began in the periphery moving towards the center. The 1.5 dual knife was used to create the initial mucosal incision and then dissect the submucosa with swift coagulation and endocut modes as deemed necessary. After the periphery of the lesion had been dissected, the center of the lesion was injected further with hyaluronic acid, hypertonic saline and methylene blue in order to raise the lesion. However, the center of the lesion did not raise well and it was difficult to separate the lesion from the muscularis. It was necessary to dissect through the muscularis to remove the lesion. The dissection was carried on until the whole lesion was resected completely. There was a 2 cm defect in the rectal wall afterwards. Apollo overstitch was used to close the defect using 4 running sutures. Pathology revealed moderately differentiated adenocarcinoma with clear mucosal margins. The patient did well after the procedure and has had no further complications. EFTR as a technique can achieve a full-thickness tumor resection with reliable closure of the bowel wall, but further refinements of the technique and device are necessary in order to reliably resect submucosal lesions, especially larger ones.

Laparoscopic-Assisted Surgery for Malignant Fibrous Histiocytoma Originating from the Descending Colon: A Case Report and Literature Review

Primary malignant fibrous histiocytoma (MFH) localized in the large intestine is extremely rare. We report a first case of MFH in colon that underwent a laparoscopy-assisted colectomy. A 74-year-old female had a 3-month history of blood stool. Barium enema study showed protrusion in the descending colon. Colonoscopy revealed submucosal tumor-like lesion with central ulceration.

Post-treatment Evaluation of Paranasal Sinuses After Treatment of Sinonasal Neoplasms.

The aim of imaging in the follow-up of asymptomatic patients treated for sinonasal neoplasms is to detect submucosal relapsing lesions. The challenge is to discriminate recurrent tissue within the changes resulting from unpredictable healing of tissue after surgery and radiotherapy. Scar, inflammation, and recurrence can be better separated with a multisequence MR imaging approach. The choice of the field of view should take into account the risk of in-field intracranial recurrences, craniofacial bone metastases, and perineural spread. Fluorodeoxyglucose-PET has a role in assessing distant metastasis. Its usefulness in local and regional surveillance has yet to be established.

The new concept of ureteral access sheath with guidewire disengagement: One wire does it all.

To prospectively evaluate the new Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) access sheath (UAS) which allows the use of a single wire to serve as both safety and working guide. Between June and September 2014, adult patients from five European centers who underwent flexible ureteroscopy (fURS) for therapeutic and diagnostic purposes were included. The 12/14Fr Flexor©Parallel™ UAS was evaluated. Data were collected and examined by both univariate and multivariate analyses. The UAS material and usage characteristics were rated per case by the surgeons on a scale from very bad to very good. In total, 134 UASs were used in 67 male and 67 female patients. Fifty percent of ureters (67 patients) were pre-stented. Ninety percent of the procedures were therapeutic. The overall successful insertion rate was 94 %. Pre-stenting status was the only independent factor for a successful access sheath insertion: 98.5 % of the pre-stented patients had a successful UAS placement vs. 82 % of non-pre-stented (p = 0.001, C.I. 95 %: 1.2). Evaluation of the material and radiopacity was considered very good in over 90 % of cases. Release of the guidewire, hydrophilic coating, gliding of the endoscope and repeatability were considered very good in over 80 %. There were two (1.4 %) UAS malfunctions and one submucosal lesion reported. The use of the Flexor©Parallel™ Rapid Release™ (Cook(®), Bloomington, IN, USA) with usage of a single guidewire in a prospective multicentric scenario was clinically applicable in the majority of cases. Pre-stenting increased the chance of a successful insertion from 82 to 98.5 %.

Disección endoscópica submucosa: curva de aprendizaje en modelos porcinos

IntroductionGastric cancer remains the second leading cause of cancer-related death worldwide. The technique of endoscopic submucosal dissection (ESD) for “en bloc” removal of early gastric lesions has become the treatment of choice in eastern countries. ObjectiveTo evaluate the learning curve of the ESD technique in ex vivo and in vivo porcine models according to international recommendations (30 cases). Material and MethodsTwo ESD techniques per session of simulated gastric lesions were performed, initially in 10 ex vivo models using porcine viscera. These were followed by in vivo porcine models, with 2 ESD performed in each porcine stomach. Raised, flat and depressed mucosal lesions were simulated, as well as submucosal lesions. Statistical analysisThree groups of 10 cases each were established and their dissection speed (area/time), success rate and complications were compared by ANOVA. Parametric tests were expressed as mean ± standard deviation using the Student t-test. Nominal categorical or qualitative variables were analysed and proportions compared by X2. Differences were considered significant at a value of p<.05 with a β power of .80. Resultsa total of 30 dissections of simulated gastric lesions were performed. The first 20 (67%) were performed in ex vivo models and the rest (33%) in live pigs. Of these, 21 cases (70%) were performed on mucosal lesions, most of them elevated (Paris 0-Ip) and 9 (30%) on submucosal lesions (Paris 0-IIa). In total, 57% were located in the posterior wall of the stomach, 23% in the antrum and 20% in the greater curvature. The area and speed of the dissection were calculated using the following formulae: area=(π D2/4) and speed=(area/time). The procedure was successful in 93% (28/30) of cases after “en bloc” tissue resection. The complication rate was 7% (2 perforations). All pigs remained alive for the 72hours of monitoring time. The size of the resected lesions varied significantly between the 3 groups (p<.001), with no change in the time of dissection (p=.429). Dissection speed was significantly higher in groups 2 and 3 compared to the first group (p<.001). ConclusionThe dissection program in biological models contributes to the learning curve of the technique with a clear and progressive improvement in the level of skill and success rate, as well as a complication rate similar to those described in the literature. Porcine ex vivo and in vivo models are very useful in the learning curve of this modality. Once this knowledge has been acquired, the technique can be applied in humans.

Primary gastric tuberculosis mimicking a submucosal tumor

AbstractGastric tuberculosis is very rare and is usually associated with pulmonary tuberculosis. Endoscopically, it usually resembles peptic ulcer disease or malignancy. We present a 28-year-old female who had a submucosal lesion in the body of the stomach that mimicked a submucosal tumor. Endoscopic ultrasound guided fine needle aspiration yielded caseous material, and the cytological examination confirmed the diagnosis of tuberculosis.

PTU-007 Needle knife mucosal incision to obtain deep biopsies of submucosal lesions along the gi tract – efficacy and safety

<h3>Introduction</h3> Submucosal lesions in the GI (gastro-intestinal) tract are difficult to diagnose. The diagnostic yield from mucosal biopsies using standard endoscopic forceps (bite-on-bite technique) and from EUS guided FNA is limited. Endoscopic submucosal dissection and surgery are high risk methods of tissue acquisition as the majority of these lesions are benign. Early diagnosis of a benign lesion will reduce the need for regular surveillance. In some instances, the diagnosis will also help in the endoscopic treatment of symptomatic benign lesions. We therefore evaluated the diagnostic yield achieved from mucosal incision-assisted biopsies of various submucosal lesions in a series of 10 patients. <h3>Method</h3> A 20 month retrospective study of all patients who had mucosal incision-assisted biopsy of submucosal GI lesions. In case of upper GI lesions, EUS assessment preceded the needle knife mucosal incision. In lesions with a higher risk of bleeding, the defect was closed with clips. For all patients, we recorded the size, site and histopathological findings of the lesions and any procedure-related complications. <h3>Results</h3> 10 submucosal lesions (size varying from 10–30 mm) were biopsied using prior mucosal incision between May 2013 and Dec 2014. Two were colonic, 3 duodenal, 2 in the stomach and 3 in the oesophagus. Adequate tissue for diagnosis was obtained in all except one small oesophageal lesion. Histological diagnosis and site is shown in the Table 1. One patient had delayed bleeding which settled following endoscopic treatment. There were no other complications, immediate or late. <h3>Conclusion</h3> Mucosal incision-assisted biopsy is effective in the diagnosis of submucosal GI lesions with a high yield. It also appears safe. Although significant bleeding and perforation are possible complications, only one case of delayed bleeding, endoscopically treated, occurred in this series. Patients with asymptomatic benign lesions can be therefore be reassured with no need for further surveillance whilst appropriate treatment (endoscopic or surgical) can be rapidly arranged for malignant or symptomatic benign lesions. <h3>Disclosure of interest</h3> None Declared.

PTH-040 Laparoscopic-assisted colonoscopic polypectomy is a safe and effective option for difficult polyps: a single tertiary referral centre experience

<h3>Introduction</h3> Colonic polyps deemed difficult to access or resect at endoscopy are often referred for surgical resection. We report our experience using laparoscopic assisted colonoscopic polyp resection at a single tertiary referral centre. <h3>Method</h3> Combined procedures from 2012 to 2014 for patients referred for resection of colonic polypsons deemed not amenable for safe endoscopic resection or where access was difficult, and therefore planned for laparoscopic assistance, were analysed. Clinical data regarding primary lesion, reason for referral for laparoscopic assistance, and outcomes were recorded. <h3>Results</h3> 15 patients have so far been planned for laparo-endoscopic procedures following multidisciplinary meetings, of whom 1 patient proceeded with surgery alone. 14 patients, with median age 73.0 years (range 35.7–85.1 years) were studied. The main reasons for laparoscopic assistance were: large high risk polyps, unfavourable location and the presence of diverticular disease. The median size of the polyps was 5 cm (range 2.3–15 cm). All procedures were performed under general anaesthetic. Completion of colonoscopic resection was performed with surgical presence without laparoscopic assistance in one. Laparoscopic adhesiolysis was performed in 5 patients to facilitate access. Seven patients required surgical resection (laparoscopic right hemicolectomy in 6 and sigmoid resection in 1). A cancer was confirmed histologically in 3 of these patients, with the other four being adenomas with high-grade dysplasia (HGD, 1) or low grade dysplasia (LGD, 3). In the remaining 7 patients, complete polypectomy was achieved, with histopathology showing adenomas with HGD (2), LGD (1), and lipomas in 3 patients with submucosal lesions, and non-diagnostic material in one patient. Median post-operative length of stay was 2 days (range 1 to 5 days) following colonoscopic resection, and uncomplicated except for post-polypectomy syndrome in one patient. Three of these patients have been followed-up to 6 months, with no recurrence of the lesion seen. Amongst patients requiring surgical resection, length of stay was longer (median 6 days [range 3–21 days], p = 0.002, Mann Whitney), with one patient suffering from anastomotic leak and another from an intra-abdominal fluid collection managed conservatively. <h3>Conclusion</h3> Attempted laparoscopic-assisted colonoscopic polypectomy is an effective strategy in a selected patients, enabling safe and complete polypectomy for lesions that are difficult to resect at primary colonoscopy. This approach may help to reduce surgical morbidity and reduce length of hospital stay. <h3>Disclosure of interest</h3> None Declared.

Neurothekeoma of the tongue in a 9-year-old child: Case report and literature review

Abstract Neurothekeoma is a rare oral tumor. This tumor is usually asymptomatic and grows slowly. Only 42 cases have been reported in this localization and 95% occur in adults. We report a case of cellular neurothekeomas of the tongue in a 9-year-old female child. A contrast-enhanced magnetic resonance showed a submucosal lesion in the posterior third of the tongue that stretched deep into the intrinsic muscles. On immunohistochemical staining the lesion was negative for S-100 protein emphasizing their lack of relationship to nerve sheath myxoma and other nerve sheath tumors. Surgical treatment was successful without recurrences. Additionally, a literature review is done.

The examination of gastric submucosal protruding lesions with endoscopic ultrasound (EUS)

Introduction: The submucosal lesions of the gastrointestinal tract are often discovered during gastroscopy as intact epithelium-covered or exulcerated alterations. They are detected either incidentally or as the cause of gastrointestinal bleeding. Biopsies taken from the surface of the mucosa do not provide meaningful assistance in the characterization of the lesions. Endoscopic ultrasonography (EUS)-guided fine needle aspiration cytology (FNA) has a key role in the diagnosis of theise tumors. Results: In 2013 and 2014, during the EUS examinations of the esophagus, stomach and duodenum, submucosal protruding lesions were described in 19 cases. The average age of the patients was 66.46 years. Gender distribution: female: 5 (26%), male: 14 (74%). The number of gastric lesions was 13 (68%). In the group of gastric lesions, due to histologically confirmed adenocarcinoma of the stomach FNA was not performed in two cases (15.3%). FNA was performed on 11 patients (84.6%). The overall results of the EUS-FNA were diagnostic, suggestive, and nondiagnostic in 6 (54.5%), 4 (36.4%), and 1 (9%) cases respectively. Distribution of cytological results: C1: 1 (9%), C2: 8 (72.7%), C3: 1 (9%) C5: 1 (9%). Gastrointestinal stromal tumor (GIST) had the greatest proportion of the diagnoses: 4 cases (36.4%). Each of the cases listed below had a single occurence (9% of the total): lipoma, pancreatic cyst, abscess, leiomyogen tumor, low-differentiated adenocarcinoma, lymphoma, metastasis in lymph node of ductal, and tubular adenocarcinoma. Conclusion: Our results correlate with the data we have found in the international literature. The endoscopic ultrasound is of paramount importance in the diagnosis of gastric submucosal lesions. We suggest that into the diagnostical algorithm of gastric submucosal lesions detected during routine gastroscopy, EUS should be introduced as the second step, with FNA (when necessary).