Digestive Endoscopy 2016; 28: 220–223
Letters, Techniques and Images
223
Gastric Duplication Cyst with Heterotopic Pancreas and Ectopic Submucosal Gland on Submucosal Endoscopy The diagnostic yield of gastrointestinal submucosal tumor (SMT) requires further development. Current sampling methods based on endoscopic submucosal dissection (ESD) technique1,2 have been developed in addition to standard endoscopic ultrasoundguided fine-needle aspiration (EUS-FNA).3 Success of these ESD-related methods relies on identification of the tumor within the submucosa. Random biopsies lead to tissue sampling errors. Consequently, endoscopically visualized features through a dissected submucosa can be helpful for secure sampling.4 The present report describes the first gastric duplication cyst with heterotopic pancreas to be identified through the submucosa. A 41-year-old man presented with a SMT (diameter, 27 × 21 mm) in the middle stomach (Fig. 1A). EUS showed an anechoic mass that exhibited wall thickness of the cyst and internal mosaic-like components, originating in the submucosal layer. Enhanced computed tomography revealed an intraluminally enhanced growing mass (Fig. 1B). Our method1 using submucosal endoscopy with a mucosal flap (SEMF)5 was applied under informed consent. While creating a submucosal tunnel toward the tumor using a 10-mm opening flap, a whitish object was seen in the submucosa (Fig. 2A). After cutting the object, a cavity appeared (Fig. 2B), into which the endoscope was inserted. A soft lesion with a yellowish, multinodular appearance was suspected of being a heterotopic pancreas (Fig. 2C).4 Subsequently, an epithelium-like pyloric gland was identified by magnifying endoscopy with narrow band imaging (Fig. 2D). Tissues were sampled with biopsy forceps, respectively. The opening flap was completely closed with hemoclips and no adverse events occurred. Histological examination of the samples confirmed that one was a heterotopic pancreas and the other an ectopic submucosal gland, resulting in a final diagnosis of a duplication cyst. This case demonstrates that
Figure 2 (a) A whitish object in the submucosa seen during tissue sampling. (b) A cavity after the whitish object was cut. (c) A soft lesion with a yellowish, multinodular appearance (yellow arrows) similar to pancreatic tissue. (d) Magnifying endoscopy with narrow band imaging showing a gastric epithelium-like pyloric gland.
endoscopically visualized features on submucosal endoscopy are key for accurate sampling of indefinite SMT, providing an update on contemporary concepts. Hideki Kobara, Hirohito Mori and Tsutomu Masaki Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan doi: 10.1111/den.12595
REFERENCES 1 Kobara H, Mori H, Fujihara S et al. Bloc biopsy by using submucosal endoscopy with a mucosal flap method for gastric subepithelial tumor tissue sampling (with video). Gastrointest. Endosc. 2013; 77: 141–5. 2 Kataoka M, Kawai T, Yagi K et al. Mucosal cutting biopsy technique for histological diagnosis of suspected gastrointestinal stromal tumors of the stomach. Dig. Endosc. 2013; 25: 274–80. 3 Fernandez-Esparrach G, Sendino O, Sole M et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010; 42: 292–9. 4 Kobara H, Mori H, Fujihara S et al. Endoscopically visualized features of gastric submucosal tumors on submucosal endoscopy. Endoscopy 2014; 46: E660–1. 5 Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Marler RJ. Submucosal endoscopy with mucosal flap safety valve. Gastrointest. Endosc. 2007; 65: 688–94.
SUPPORTING INFORMATION
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Figure 1 (a) A gastric submucosal tumor. (b) Enhanced computed tomography showing a growing, intraluminal mass with internal enhancement (white arrows).
A
DDITIONAL SUPPORTING INFORMATION may be found in the online version of this article at the publisher’s web site. Video S1 Method used to sample lesions in a patient with a gastric SMT.
© 2015 Japan Gastroenterological Endoscopy Society
Letters, Techniques and Images
223
Gastric Duplication Cyst with Heterotopic Pancreas and Ectopic Submucosal Gland on Submucosal Endoscopy The diagnostic yield of gastrointestinal submucosal tumor (SMT) requires further development. Current sampling methods based on endoscopic submucosal dissection (ESD) technique1,2 have been developed in addition to standard endoscopic ultrasoundguided fine-needle aspiration (EUS-FNA).3 Success of these ESD-related methods relies on identification of the tumor within the submucosa. Random biopsies lead to tissue sampling errors. Consequently, endoscopically visualized features through a dissected submucosa can be helpful for secure sampling.4 The present report describes the first gastric duplication cyst with heterotopic pancreas to be identified through the submucosa. A 41-year-old man presented with a SMT (diameter, 27 × 21 mm) in the middle stomach (Fig. 1A). EUS showed an anechoic mass that exhibited wall thickness of the cyst and internal mosaic-like components, originating in the submucosal layer. Enhanced computed tomography revealed an intraluminally enhanced growing mass (Fig. 1B). Our method1 using submucosal endoscopy with a mucosal flap (SEMF)5 was applied under informed consent. While creating a submucosal tunnel toward the tumor using a 10-mm opening flap, a whitish object was seen in the submucosa (Fig. 2A). After cutting the object, a cavity appeared (Fig. 2B), into which the endoscope was inserted. A soft lesion with a yellowish, multinodular appearance was suspected of being a heterotopic pancreas (Fig. 2C).4 Subsequently, an epithelium-like pyloric gland was identified by magnifying endoscopy with narrow band imaging (Fig. 2D). Tissues were sampled with biopsy forceps, respectively. The opening flap was completely closed with hemoclips and no adverse events occurred. Histological examination of the samples confirmed that one was a heterotopic pancreas and the other an ectopic submucosal gland, resulting in a final diagnosis of a duplication cyst. This case demonstrates that
Figure 2 (a) A whitish object in the submucosa seen during tissue sampling. (b) A cavity after the whitish object was cut. (c) A soft lesion with a yellowish, multinodular appearance (yellow arrows) similar to pancreatic tissue. (d) Magnifying endoscopy with narrow band imaging showing a gastric epithelium-like pyloric gland.
endoscopically visualized features on submucosal endoscopy are key for accurate sampling of indefinite SMT, providing an update on contemporary concepts. Hideki Kobara, Hirohito Mori and Tsutomu Masaki Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa, Japan doi: 10.1111/den.12595
REFERENCES 1 Kobara H, Mori H, Fujihara S et al. Bloc biopsy by using submucosal endoscopy with a mucosal flap method for gastric subepithelial tumor tissue sampling (with video). Gastrointest. Endosc. 2013; 77: 141–5. 2 Kataoka M, Kawai T, Yagi K et al. Mucosal cutting biopsy technique for histological diagnosis of suspected gastrointestinal stromal tumors of the stomach. Dig. Endosc. 2013; 25: 274–80. 3 Fernandez-Esparrach G, Sendino O, Sole M et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010; 42: 292–9. 4 Kobara H, Mori H, Fujihara S et al. Endoscopically visualized features of gastric submucosal tumors on submucosal endoscopy. Endoscopy 2014; 46: E660–1. 5 Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Marler RJ. Submucosal endoscopy with mucosal flap safety valve. Gastrointest. Endosc. 2007; 65: 688–94.
SUPPORTING INFORMATION
bs_bs_banner
Figure 1 (a) A gastric submucosal tumor. (b) Enhanced computed tomography showing a growing, intraluminal mass with internal enhancement (white arrows).
A
DDITIONAL SUPPORTING INFORMATION may be found in the online version of this article at the publisher’s web site. Video S1 Method used to sample lesions in a patient with a gastric SMT.
© 2015 Japan Gastroenterological Endoscopy Society
