Endoscopic resection of a complex gastric duplication cyst using a submucosal tunneling technique

A 48-year-old woman was incidentally found to have a submucosal lesion (~3 cm) in the antrum, while being evaluated for dyspeptic symptoms ([Fig. 1]). Imaging including endoscopic ultrasound and computed tomography suggested a cystic lesion in the antrum ([Fig. 2]).

Fig. 1 Endoscopic view showing a submucosal bulge along the greater curvature in the antrum.

Fig. 2 Endoscopic ultrasound view showing the cystic lesion in the antrum.

She underwent endoscopic resection of the cystic submucosal lesion using a tunneling technique ([Video 1]). Marks were made around the lesion using a closed triangular knife in soft coagulation mode (effect 4, 80 W). A submucosal lifting injection was performed with diluted indigo carmine dye at the proximal edge of the lesion using a sclerotherapy needle. Subsequently, a longitudinal incision measuring about 2 cm was made. The submucosal fibers along the incision were cleared and the gastroscope was passed into the tunnel. After performing submucosal dissection for about 1 cm, it was possible to visualize the submucosal cystic lesion. The surrounding attachments were systematically cleared using triangular and insulated-tip knives; care was taken to avoid injury to the cyst wall. After dissection had been completed, the lesion was sucked into the cap and brought out via the oral cavity ([Fig. 3]).

Video 1 Technique of submucosal tunneling endoscopic resection (STER) in a patient with a gastric duplication cyst.

Fig. 3 Macroscopic appearance of the resection specimen following en bloc removal of the cyst.

Histopathological examination revealed a large cyst consisting of multiple smaller cysts. Each cyst wall consisted of mucosa, submucosa, and muscularis propria, suggesting a diagnosis of gastric duplication cyst ([Fig. 4 a]). In addition, a focal island of pancreatic acini lined by pyramidal cells could be seen, signifying pancreatic heterotopia ([Fig. 4 b]).

Fig. 4 Histopathology of the resected specimen showing: a a cyst composed of a trilayer structure (mucosa, submucosa, and muscularis propria) consistent with a gastric duplication cyst; b ectopic pancreatic tissue within the gastric duplication cyst.

Gastric duplication cysts are extremely rare and account for about 4 % of all gastrointestinal duplication cysts [1]. Although, the majority of the cases are incidentally diagnosed, bleeding, pain, gastric outlet obstruction, and rarely malignant transformation have been reported [2]. The diagnosis is usually suspected on imaging, especially endoscopic ultrasound [3]. Traditionally, surgery has been used for the management of these lesions. With recent advancements in therapeutic endoscopy, a substantial proportion of these lesions can be resected using submucosal endoscopy techniques [4].

Endoscopy_UCTN_Code_CPL_1AN_2AD

Publication History

Article published online:
28 April 2021

• References

• 1 Kim SM, Ha MH, Seo JE. et al. Gastric duplication cysts in adults: a report of three cases. J Gastric Cancer 2015; 15: 58-63
• 2 Kuraoka K, Nakayama H, Kagawa T. et al. Adenocarcinoma arising from a gastric duplication cyst with invasion to the stomach: a case report with literature review. J Clin Pathol 2004; 57: 428-431
• 3 Hlouschek V, Domagk D, Naehrig J. et al. Gastric duplication cyst: a rare endosonographic finding in an adult. Scand J Gastroenterol 2005; 40: 1129-1131
• 4 Kim GH, Lee MW, Lee BE. et al. Endoscopic submucosal dissection for gastric duplication cyst with heterotopic pancreas. Endoscopy 2021; 53: E19-E20