Unexpected Ectopic Pancreatic tissue during laparoscopic bariatric surgery. Case report and literature review

Ectopic pancreas in a 16-year-old male during bariatric surgery: A rare case in the medical literature

INTRODUCTION AND IMPORTANCE

Obesity is a global epidemic, and bariatric surgery is an effective treatment. During this surgery, rare abnormalities in the small intestine, like ectopic pancreas (EP), can be found.

CASE PRESENTATION

A 16-year-old male presented at the surgical clinic with a complaint of morbid obesity, weighing 140 KG. Since he was unable to commit to a diet, bariatric surgery was performed. During the surgery, the gastrointestinal tract was examined, and an incidental finding was noted in the wall of the proximal jejunum. The histopathology report revealed that the excisional biopsy was a complete EP in the proximal jejunum. The patient was discharged from the hospital on the first postoperative day, and his condition remained stable.

CLINICAL DISCUSSION

Our case of EP stood out due to its larger size, measuring 3.5 cm in diameter, while EP lesions are typically smaller, despite its size, the patient did not experience any symptoms. EP is more commonly found in individuals between 40 and 50 years old, with a higher incidence in males. However, our patient is only 16 years old.

CONCLUSION

Surgical resection is the most effective treatment, preventing malignant transformation and future complications. To the best of our knowledge, this is the first documented case of incidentally detected heterotopic pancreatic tissue in jejunum during a bariatric procedure in Syria, and it is also the fourth case in the medical literature.

Incidental Jejunal Lesion Necessitating Intraoperative Change of Plan During Bariatric Surgery: a Video Case Report

Incidental gastric and small bowel lesions are commonly encountered during bariatric surgery. Resection of these lesions with negative margins in the same sitting is curative; however, this may necessitate intraoperative change of plan. We present a 44-year-old super obese lady in whom an exophytic jejunal mass was found at 80 cm from the ligament of Treitz, which necessitated a change of procedure from one anastomosis gastric bypass (OAGB) to Roux-en-Y gastric bypass (RYGB). The final pathology was ectopic pancreatic tissue. Running the small bowel during initial diagnostic laparoscopy should be a routine step before division of stomach, to avoid technical complexities when operative plan is changed in order to resect an incidentaloma. Bariatric surgeons should be well versed with all the standard bariatric procedures.

Management of gastric ectopic pancreas identified in preoperative evaluation of bariatric surgery - A case report

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The diagnosis of rare gastric lesions has become more frequent after the increase in bariatric surgery.

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The preoperative evaluation for bariatric surgery showed two lesions suggestive of Gastric Ectopic Pancreas.

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The previous identification of these lesions provides better surgical planning.

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Intraoperative Upper Endoscopy was used to identify the location of these lesions.

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Simultaneous laparoscopic resection of the lesions associated with Sleeve Gastrectomy was performed.

Background

The diagnosis of gastric lesions, such as the Ectopic Gastric Pancreas (GEP), has become more frequent after the increase in bariatric surgeries. The most frequently used surgical options are: Sleeve Gastrectomy (SG) and Roux-en-Y Gastric Bypass (RYGB). The scientific papers about GEP in Bariatric Surgery consisted of intraoperative findings, approach the lesion with gastrectomy and the need to change the initial surgical strategy of the Sleeve for others techniques which allow extended gastric resections.

Presentation of case

This is a report on a 21-year-old female patient with class 3 obesity whose preoperative evaluation showed two lesions suggestive of GEP. Simultaneous surgical video-laparoscopic treatment of lesions associated with SG aided by intraoperative Upper Endoscopy (UE) was performed with no perioperative complications.

Conclusion

It is possible to associate the treatment of rare gastric lesions with traditional surgery techniques for obesity.

Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy

INTRODUCTION

Pancreatic rest (PR) is an ectopic pancreatic lesion that is usually found incidentally on endoscopy or surgery. While most lesions do not have clinical significance, some patients are symptomatic and rarely, PR can predispose to malignancy. With the growing popularity of bariatric surgery, it has been unclear how to manage PR found on screening endoscopies, prior to bariatric surgery. Through review of the current literature, we propose an algorithm for clinicians to evaluate and manage PR found on screening endoscopies prior to bariatric surgery.

METHODS

We performed a literature search in PubMed pertaining to PR, clinical characteristics, risk of malignant transformation, endoscopic characteristics, histological descriptions, and resection techniques. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found 33 published articles from 2001 to 2019, including case reports, case series, retrospective cohorts, and a review paper.

RESULTS

PR is commonly found incidentally in the gastric antrum. Larger lesions have a higher risk of being symptomatic or predisposing to malignant transformation. Endoscopic ultrasound (EUS) can assist in the diagnosis of PR and guide resection technique. Certain histological characteristics, such as Heinrich class, grading of neoplasia, and genetic alterations, can determine malignancy risk of PR. Resection technique, either endoscopically or surgically, should be based on lesion size, depth of wall invasion, and the endoscopists' level of skill in endoscopic resection.

CONCLUSIONS

Proper evaluation and treatment of PR should be considered because of the risk for symptoms and malignant transformation. Symptomatic lesions and those at risk for malignant transformation should be considered for resection. EUS can guide the diagnosis and type of resection, either endoscopically through EMR or ESD or surgically through sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB).

Intraoperative decision making in bariatric surgery

BACKGROUND

Surgeons may encounter unexpected anatomical or pathological findings during various bariatric surgical procedures for which they must make prompt and critical decisions that had not been planned prior to the operation. In this practice review, we present our experiences with unexpected challenges and on-table decision making in bariatric surgery to share our knowledge with colleagues who may encounter the same challenges during bariatric surgery. This paper's content is of applied learning and practical value focusing on challenging intraoperative decision making; however, it does not discuss the details of the various techniques used during surgery.

METHODS

This work is a single-center retrospective review of operations carried out on patients who had unexpected intraoperative findings during bariatric surgery despite the implementation of detailed preoperative evaluations that would have otherwise suggested standard procedures. These findings resulted in abandoned surgery or laparoscopic sleeve gastrectomy instead of the intended Roux-en-Y gastric bypass.

RESULTS

A total of 449 patients had received various bariatric interventions in our unit between 2012 and 2016. Eleven patients, representing approximately 2.4% of the total number of patients surveyed had met the inclusion criteria and were added to the final list for analysis. The mean age of the included patients was 40.82 years (range: 30-51 years), and seven of the patients, representing approximately 63.6% of the included cases, were female. The mean body mass index of the 11 cases was 40.8 (range: 38-48). Only two cases (18.9%) had had their surgery abandoned; the rest (81.1%) had received laparoscopic sleeve gastrectomy instead of Roux-en-Y gastric bypass. None of the 11 patients had perioperative morbidity or mortality.

CONCLUSION

Intraoperative decision making for unexpected findings in bariatric surgery is challenging. In these circumstances, surgeons must make prompt and critical decisions, including abandoning the operation. The available literature on this subject is unsurprisingly limited because of the rarity of such findings.

Unexpected Gastric Ectopic Pancreas During Sleeve Gastrectomy: A Case Report

Patient: Female, 30-year-old

Final Diagnosis: Gastric ectopic pancreas

Symptoms: —

Medication: —

Clinical Procedure: Laparscopic sleeve gastrectomy

Specialty: Surgery