Endoscopic submucosal dissection of pancreatic heterotopia in children

Aberrant pancreatic tissue is mostly found in the submucosal layer of the upper gastrointestinal tract, occurring in 1.7 % of the population according to summarized post-mortem studies [1]. Gastric pancreatic heterotopia was first recognized by Klob in 1859 [2].

Herein we describe the resection of gastric pancreatic heterotopic lesions in children by endoscopic submucosal dissection (ESD). After the lesion has been localized endoscopically (GIF-HG 290; Olympus Medical, Tokyo, Japan), its extent within the stomach wall is clarified by ultrasound (UM-2R; Olympus Medical) ([Fig. 1]). A solution is circumferentially injected into the submucosa of the lesion ([Fig. 2]). This solution consists of 2.5 mL 1 % sodium hyaluronate (Hyruan; LG Life Sciences) and 7.5 mL of a mixture that is made up of 5 mL adrenalin (1 : 10 000; DBC Adrenaline Injection) and 1 – 2 mL of 8 % indigo carmine (Indigocarmin Amino) diluted in 100 mL normal saline. An electrosurgical knife (DualKnife, KD-650L; Olympus Medical) is used for the mucosal incision and submucosal dissection of the lesion ([Fig. 3]).

Fig. 1 Endoscopic ultrasound showing the extent of the submucosal lesion, which has a maximal diameter of 7.8 mm (arrow).

Fig. 2 A solution of sodium hyaluronate, adrenalin, indigo carmine, and normal saline is circumferentially injected into the submucosa of the lesion: a the start of the injection; b completion of the injection.

Fig. 3 View during endoscopic submucosal dissection showing: a the incision being made with an electrosurgical knife; b the antrum after completion of the resection.

A 12-year-old girl with known hemoglobin H disease presented with intermittent epigastric pain. She was diagnosed with gallstones and a polypoid lesion in the antrum of the stomach ([Fig. 4]). She underwent a laparoscopic cholecystectomy and the gastric lesion was removed by ESD ([Video 1]; [Fig. 3]). At follow-up, she continued to complain of mild abdominal pain when eating oily foods.

Fig. 4 Endoscopic view of a polypoid tumor (pancreatic heterotopia) in the antrum with indentation.

Endoscopic submucosal dissection of gastric pancreatic heterotopia in a 12-year-old girl.

Another antral lesion was identified in a 14-year-old girl with epigastric pain. After the resection of her 10-mm submucosal tumor by ESD, she returned with similar complaints at her follow-up.

The histology of both of these lesions showed pancreatic lobules with islet cells representing type 1 pancreatic heterotopia, according to the classification by von Heinrich [3]. Whilst the alleviation of symptoms is questionable in both patients, the timely removal of these lesions should prevent long-term risks such as gastric outlet obstruction through enlargement, blood loss through ulceration, and neoplastic transformation [4] [5]. In both cases the ESD technique was performed without complications. There have been no late sequelae or evidence of local recurrence after a mean follow-up of 3 years.

ESD currently offers the most elegant method to resect aberrant pancreatic tissue, with perforation being the only significant risk factor [6].

Endoscopy_UCTN_Code_TTT_1AO_2AG

• References

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• 2 Klob J. Pancreas-Anomalien (Anomalies of the pancreas). Zschr Gesellsch Ärzte Wien 1859; 15: 732-734
• 3 von Heinrich H. Ein Beitrag zur Histology des sogenannten akzessorischen Pancreas (A contribution to the histology of the accessory pancreas). Virchows Arch Path Anat 1909; 198: 392-401
• 4 Martinez NS, Morlock CG, Dockerty MB et al. Heterotopic tissue involving the stomach. Annals Surg 1958; 147: 1-12
• 5 Fukumori D, Matsuhisa T, Taguchi K et al. Ectopic gastric pancreatic cancer: report of a case. Hepatogastroenterology 2011; 58: 740-744
• 6 Zhong Y-S, Shi Q, Yao L-Q et al. Endoscopic mucosal resection/endoscopic submucosal dissection for gastric heterotopic pancreas. Turk J Gastroenterol 2013; 24: 322-329