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 ¤  Abstract
 ¤ Introduction
 ¤ Case Report
 ¤ Discussion
 ¤ Conclusion
 ¤  References
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 Table of Contents     
UNUSUAL CASE
Year : 2020  |  Volume : 16  |  Issue : 2  |  Page : 179-181
 

Ectopic pancreas mimicking gastric submucosal tumour treated using robotic surgery


1 Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
2 Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Department of Surgery, Faculty of Medicine; Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
3 Department of Surgery, Division of Colorectal Surgery; Department of Surgery, Division of General and Digestive Surgery, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
4 Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital; Graduate Institute of Clinical Medicine; Department of Surgery, Faculty of Medicine; Graduate Institute of Medicine; Center for Biomarkers and Biotech Drugs, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan

Date of Submission01-Jan-2019
Date of Acceptance03-Jan-2019
Date of Web Publication11-Mar-2020

Correspondence Address:
Prof. Jaw-Yuan Wang
Department of Surgery, Division of Colorectal Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung 807
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_1_19

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 ¤ Abstract 

Gastric ectopic pancreas presenting as a submucosal tumour accounts for approximately 11% of all endoscopic ultrasonography (EUS) examinations. Definitive diagnosis through endoscopy is difficult, even with EUS-guided fine-needle aspiration biopsy for histological examination. For symptomatic patients or those with uncertain diagnosis, complete surgical resection is the primary strategy for treatment and diagnosis. Herein, we report a case of gastric ectopic pancreas treated using robotic surgery.


Keywords: Ectopic pancreas, gastric submucosal tumour, robotic surgery


How to cite this article:
Chang TK, Huang CW, Ma CJ, Su WC, Tsai HL, Wang JY. Ectopic pancreas mimicking gastric submucosal tumour treated using robotic surgery. J Min Access Surg 2020;16:179-81

How to cite this URL:
Chang TK, Huang CW, Ma CJ, Su WC, Tsai HL, Wang JY. Ectopic pancreas mimicking gastric submucosal tumour treated using robotic surgery. J Min Access Surg [serial online] 2020 [cited 2020 Apr 4];16:179-81. Available from: http://www.journalofmas.com/text.asp?2020/16/2/179/252457



 ¤ Introduction Top


Gastric submucosal tumours (SMTs) are usually incidental endoscopic presentations. Obtaining accurate preoperative diagnoses of SMTs through grasp or needle biopsy is difficult. SMTs may originate from mesenchymal tumours, lymphomas, epithelial tumours or congenital abnormalities. Ectopic pancreas is a congenital abnormality that can cause gastric SMTs. Herein, we report a patient with gastric SMT who was treated successfully through robotic surgery. The final pathology report confirmed gastric ectopic pancreas.


 ¤ Case Report Top


A 55-year-old man had a medical history of hypertension, type 2 diabetes mellitus, peptic ulcer disease and gastroesophageal reflux disease as well as a surgical history of appendectomy. He was completely independent in his daily activities. He was referred to our hospital for management of an incidental gastric SMT diagnosed during a health examination. He denied any gastrointestinal symptoms and associated family history of malignancy. No obvious abnormalities were detected during physical examination except for the appendectomy scar. Routine laboratory investigations did not reveal any specific abnormalities. Serum tumour markers, including chromogranin A (63.5 ng/mL), carcinoembryonic antigen (2.89 ng/mL) and carbohydrate antigen 19-9 (<13.4 U/mL) were all within the normal limits. Esophagogastroduodenoscopy revealed a polypoid tumour with intact overlying mucosa and central umbilication on the posterior wall of the antrum [Figure 1]a and [Figure 1]b. During endoscopic ultrasonography (EUS) examination, the tumour exhibited homogeneous iso/hypoechoic density, arose from the muscularis mucosa layer and exhibited a preserved muscularis proper layer [Figure 1]c. The fine-needle aspiration biopsy revealed only chronic gastritis. An abdominal computed tomography revealed a focal enhancing submucosal thickening at the gastric antrum [Figure 1]d. After receiving robotic partial gastrectomy, he recovered satisfactorily and was discharged uneventfully with a post-operative hospital stay of 6 days. The pathology report of the tissue specimen indicated ectopic pancreatic tissue [15 mm × 11 mm × 7 mm, [Figure 1]e. He still regularly visits our outpatient department for follow-up.
Figure 1: (a) Gross view of tumour during EGD examination: polypoid tumour with intact overlying mucosa and central umbilication. (b) Gross view of tumour on EGD with NBI. (c) EUS: Iso/hypoechoic homogeneous tumour arising from the MM layer with a preserved PM layer on the posterior wall of the antrum (17.4 mm × 5.1 mm). Some hyperechoic foci (green arrow) were observed inside the tumour, and no obvious ductal structure was observed. (d) CT: Focal enhancing mucosal or submucosal thickening (red circle). (e) Gross view of the specimen. EGD: Esophagogastroduodenoscopy, NBI: Narrow-band imaging, EUS: Endoscopic ultrasonography, CT: Computed tomography, MM: muscularis mucosa, PM: muscularis proper

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Surgical procedure

Before surgery, endoscopic tattooing for tumour localisation was performed. Under endotracheal general anaesthesia, the patient was placed in the supine position. The trocars were inserted and positioned as shown in [Figure 2]. Subsequently, the patient was placed in the 30° reverse Trendelenburg position, and the Da Vinci robotic (Intuitive Surgical, Inc., Sunnyvale, CA, USA) system was docked above the patient's head. A Harmonic scalpel (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) and ProGrasp (Intuitive Surgical, Inc., Sunnyvale, CA, USA) were used as robotic instruments. We used the harmonic scalpel to perform a full-thickness, circumferential and wedge resection with a margin of approximately 1 cm along the tattooed area. The gastrectomy wound was closed intracorporeally in the fashion of two-layered Albert–Lembert continuous sutures using with 3-0 V-Loc barbed sutures (Medtronic, Minneapolis, Minnesota, USA). The negative suction drain was placed around the anastomosis, and the trocar wound was closed.
Figure 2: After a small subumbilical incision through the Hasson method, a 12-mm camera port was inserted through it, and three 8-mm trocars were inserted and positioned under direct laparoscopic visualisation. Trocar disposition. 'C' is a 12-mm camera port; '1'–'3' are 8-mm trocars for the robotic arm; and 'A' is a 5- or 12-mm trocar functioning as an assistant port

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 ¤ Discussion Top


The incidence of ectopic pancreas was reported to be 0.6%–13.7% in an autopsy series.[1] Gottschalk et al. reported that ectopic pancreas accounts for 11% of all SMTs receiving EUS examination.[2] It may arise from anywhere along the primitive foregut but is most commonly observed in the stomach (26%–38%) and duodenum (28%–36%).[1],[3] Usually, ectopic pancreas does not cause symptoms; if it does, symptoms may result from stenosis, ulceration, bleeding, inflammation or tumour formation.

Symptomatic gastric ectopic pancreas or tumours with uncertain histological representation in which the possibility of malignancy cannot be discounted may need further intervention. Therefore, excision of the entire tumour with a safe margin remains a curative and definitive treatment. The two major excision methods are surgical excision and endoscopic submucosal dissection (ESD).[4],[5] In addition, the three surgical approaches for excision are classic laparotomy, laparoscopic surgery [6] and robotic surgery.[7],[8] ESD is less invasive than surgery but requires a high level of skill. Furthermore, the consequences, such as the involvement of the resection margin or ESD-related complication, should be considered. Both laparoscopic surgery and robotic surgery are less invasive approaches than classic laparotomy and require lower levels of skill than ESD. The robotic surgery system provides a magnified three-dimensional high-definition vision system and tiny wristed instruments to enable surgeons to perform complex operations with dexterity and precision in a more ergonomic position compared with standard laparoscopic surgery. Thus far, no consensus or guideline exists for the management of patients with gastric ectopic pancreas. The case in our study was suitable for minimally invasive surgery, and robotic surgery was selected because he exhibited a posterior gastric SMT. Considering the high cost of robotic surgery, robotic surgery may have to be reserved for patients with posterior gastric wall SMTs or those who require intracorporeal reconstruction and anastomosis.[7],[8]


 ¤ Conclusion Top


Gastric ectopic pancreas is a rare gastric SMT. Surgical excision is suitable for symptomatic patients or those with uncertain tumour histology. In some patients, robotic surgery may be a safe and feasible approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgements

This work was supported by grants through funding from the Ministry of Science and Technology (MOST107-2321-B-037-003, MOST107-2314-B-037-116, MOST107-2314-B-037-022-MY2, and MOST107-2314-B-037-023-MY2), the Ministry of Health and Welfare (MOHW106-TDU-B-212-113006, MOHW107-TDU-B-212-123006, and MOHW107-TDU-B-212-114026B funded by Health and Welfare Surcharge of Tobacco Products), Kaohsiung Medical University Hospital (KMUH106-6R32, KMUH106-6M28, KMUH106-6M29, KMUH106-6M30, KMUH106-6M31, KMUHS10701, KMUHS10712), and Kaohsiung Municipal Ta-Tung Hospital (KMTTH104-023). In addition, this study was supported by the Grant of Biosignature in Colorectal Cancers, Academia Sinica, Taiwan, R.O.C. and a grant from Kaohsiung Medical University (KMU-S105011 and KMU-PT10616). This manuscript was edited by Wallace Academic Editing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 ¤ References Top

1.
Mortelé KJ, Rocha TC, Streeter JL, Taylor AJ. Multimodality imaging of pancreatic and biliary congenital anomalies. Radiographics 2006;26:715-31.  Back to cited text no. 1
    
2.
Gottschalk U, Dietrich CF, Jenssen C. Ectopic pancreas in the upper gastrointestinal tract: Is endosonographic diagnosis reliable? Data from the German endoscopic ultrasound registry and review of the literature. Endosc Ultrasound 2018;7:270-8.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Nishida T, Kawai N, Yamaguchi S, Nishida Y. Submucosal tumors: Comprehensive guide for the diagnosis and therapy of gastrointestinal submucosal tumors. Dig Endosc 2013;25:479-89.  Back to cited text no. 3
    
4.
Khashab MA, Cummings OW, DeWitt JM. Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas. World J Gastroenterol 2009;15:2805-8.  Back to cited text no. 4
    
5.
Faigel DO, Gopal D, Weeks DA, Corless C. Cap-assisted endoscopic submucosal resection of a pancreatic rest. Gastrointest Endosc 2001;54:782-4.  Back to cited text no. 5
    
6.
Paolucci P, Brasesco OE, Rosin D, Saber AA, Avital S, Berho M, et al. Laparoscopic resection of ectopic pancreas in the gastric antrum: Case report and literature review. J Laparoendosc Adv Surg Tech A 2002;12:139-41.  Back to cited text no. 6
    
7.
Hsu SD, Wu HS, Kuo CL, Lee YT. Robotic-assisted laparoscopic resection of ectopic pancreas in the posterior wall of gastric high body: Case report and review of the literature. World J Gastroenterol 2005;11:7694-6.  Back to cited text no. 7
    
8.
Langone A, Gasloli G, Caristo I, Monteleone L, Griseri G, Bianchi M, et al. Robotic antrum-pyloric resection with intracorporeal anastomosis in a young woman with ectopic pancreas pyloric stenosis. J Robot Surg 2012;6:167-70.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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