Minimally Invasive Management of Ectopic Pancreas

Various Phenotypes of Ectopic Pancreatic Tissue in Children: Case Series and Literature Review

Background and Clinical Significance: Ectopic pancreatic tissue (EPT), an infrequently documented condition within the pediatric population, is often asymptomatic. When clinical manifestations do occur, their severity is contingent upon the location, size, and involvement of the adjacent mucosa. Case presentation: This is a case series study, involving six children aged 15 days-13 years diagnosed with EPT from a single institution. Five of the six cases presented with both EPT and ectopic gastric tissue, located at the site of Meckel's diverticulum, while one case presented EPT exclusively, which was localized in the duodenum I. A case of Littre's hernia was identified in a newborn. Two of the six cases experienced gastrointestinal bleeding. Due to limited data on EPT in children, a comprehensive review of the literature was conducted to integrate the findings of the case series. The review synthesized evidence on clinical manifestations, diagnostic approaches, phenotypic classifications, and management strategies. Articles were identified through searches on PubMed and publisher platforms such as Elsevier and Wiley Online Library, using keywords like "ectopic pancreatic tissue", "heterotopic pancreas", and "pediatric ectopic pancreas". Conclusions: The identification of EPT continues to pose a diagnostic challenge, as the symptoms are nonspecific and can sometimes be life-threatening. Additionally, there are currently no specific paraclinical investigations available for this purpose. Histopathological evaluation remains crucial for establishing the diagnosis, which is often confirmed only after complications have arisen.

Ileal intussusception due to heterotopic pancreas in the ileum: a case report

Heterotopic pancreas (HP) is a rare condition where pancreatic tissue is found outside its usual location, usually within the gastrointestinal tract. While typically asymptomatic, HP can cause complications like gastrointestinal bleeding and intussusception, especially in adults, posing diagnostic and therapeutic challenges. A 31-year-old male presented with severe abdominal pain, nausea, and vomiting. Initial imaging revealed significant ileal and cecal wall thickening. Despite antibiotic therapy, his condition worsened, necessitating exploratory laparotomy. Intraoperative findings showed ileal intussusception near the cecum, leading to ileocecal resection and ileo-colic anastomosis. Pathological examination confirmed HP as the cause of intussusception. This case underscores the importance of considering HP in adult intussusception. Timely surgical intervention is critical to prevent severe complications. At a two-year follow-up, he remained symptom-free, highlighting the necessity for prompt diagnosis and management.

Esophageal Atresia and Gastric Ectopic Pancreas: Is There a Real Association?

OBJECTIVE

 Heterotopic pancreas (HP) is a condition in which there is well-differentiated pancreatic tissue that lacks any anatomic or vascular contact with the pancreatic gland. It normally arises from the stomach but can be found in other locations. Although it is usually asymptomatic, obstructive symptoms, bleeding, or malignant degeneration can occur. The incidence is very low, but it is significantly more common in patients with esophageal atresia (EA). The aim of this study is to evaluate the incidence of HP in patients with and without EA and to compare the results in both groups.

MATERIAL AND METHODS

 We conducted a 2-year prospective study in pediatric patients who benefited from an upper gastrointestinal endoscopy. Patients were divided into two groups: group "A" comprised patients with EA and group "B" those without EA. The variables analyzed were the clinical presentation, presence of HP, location, associated malformations, genetic disorders, and management.

RESULTS

 A total of 192 consecutive patients were included in the study: 51 (26.6%) in group A and 141 (73.4%) in group B. Indications for endoscopy in group B were eosinophilic esophagitis in 37 (19.2%) patients, celiac disease in 23 (11.95%) patients, and other disorders in 81 (42.2%) patients. Gastric HP was found in seven patients, all of them in group A. All lesions were hosted in the prepyloric antrum. The prevalence of HP in groups A and B was 13.7 and 0%, respectively (p < 0.05). Female gender was predominant in patients with AE and HP, this result being statistically significant (p = 0.044). No other associated malformation or genetic syndrome studied showed association with HP. Only one patient debuted with upper gastrointestinal (GI) bleeding and required excision, while six patients were asymptomatic. The mean follow-up was 54 months (range: 45-78 months).

CONCLUSION

 The incidence of gastric HP is more common in patients with EA, with the female gender being a risk factor for their association. Active search and follow-up is recommended as it may become symptomatic anytime and need resection.

Clinical features and treatment of heterotopic pancreas in children: a multi-center retrospective study

OBJECTIVE

Heterotopic pancreas, an uncommon condition in children, can present with diagnostic and treatment challenges. This study aimed to evaluate the clinical features and treatment options for this disorder in pediatric patients.

METHODS

We conducted a retrospective analysis, including patients diagnosed with heterotopic pancreas at four tertiary hospitals between January 2000 and June 2022. Patients were categorized into symptomatic and asymptomatic groups based on clinical presentation. Clinical parameters, including age at surgery, lesion size and site, surgical or endoscopic approach, pathological findings, and outcome, were statistically analyzed.

RESULTS

The study included 88 patients with heterotopic pancreas. Among them, 22 were symptomatic, and 41 were aged one year or younger. The heterotopic pancreas was commonly located in Meckel's diverticulum (46.59%), jejunum (20.45%), umbilicus (10.23%),ileum (7.95%), and stomach (6.82%). Sixty-six patients had concomitant diseases. Thirty-three patients had heterotopic pancreas located in the Meckel's diverticulum, with 80.49% of cases accompanied by gastric mucosa heterotopia (GMH). Patients without accompanying GMH had a higher prevalence of heterotopic pancreas-related symptoms (75%). Treatment modalities included removal of the lesions by open surgery, laparoscopic or laparoscopic assisted surgery, or endoscopic surgery based on patient's age, the lesion site and size, and coexisting diseases.

CONCLUSIONS

Only one-fourth of the patients with heterotopic pancreas presented with symptoms. Those located in the Meckel's diverticulum have commonly accompanying GMH. Open surgical, laparoscopic surgical or endoscopic resection of the heterotopic pancreas is recommended due to potential complications. Future prospective multicenter studies are warranted to establish rational treatment options.

Overview of ectopic pancreas

This editorial discusses the article written by Zheng et al that was published in the latest edition of the World Journal of Gastrointestinal Surgery. Our primary focus is on the causes, location, diagnosis, histological classification, and therapy of ectopic pancreas. Ectopic pancreas refers to the presence of pancreatic tissue that is situated in a location outside its usual anatomical placement, and is not connected to the normal pancreas in terms of blood supply or anatomical structure. Currently, the embryological origin of ectopic pancreas remains uncertain. The most prevalent form of ectopic pancreatic is gastric ectopic pancreas. Endoscopic ultrasonography examination can visualize the morphological characteristics of the ectopic pancreatic lesion and pinpoint its anatomical location. The histological categorization of ectopic pancreas evolves. Endoscopic treatment has been widely advocated in ectopic pancreas.

Expression and clinicopathological characteristics of PDX1, PTF1A, and SALL4 in large and small ducts of ectopic pancreas located in gastro-duodenum and jejunum

An ectopic pancreas is defined as pancreatic tissue outside its normal location, anatomically separated from the pancreas. The transcription factor pancreas/duodenum homeobox protein 1 (PDX1) is involved in maintaining the pancreas and functions in early pancreatic development, beta cell differentiation, and endocrine non beta cells. Pancreatic transcription factor 1 subunit alpha (PTF1A) affects exocrine cell formation and regulation of acinar cell identity, and is expressed in exocrine cells as a transcription factor. The depletion of SALL4 disrupts self-renewal and induces differentiation. To clarify which of PDX1, PTF1A, or SALL4 determines the difference in Heinrich's classification, we examined the localization and number of positive cells. We analyzed the differential expression of PDX1, PTF1A, and SALL4 in large and small ducts in ectopic pancreas by immunohistochemistry. Results showed that the number of PTF1A-positive cells in large ducts was more widespread in type I than in type II in the gastro-duodenum, and more SALL4-positive cells were noticed in large ducts than in small ducts in the gastro-duodenum of type II. Our results revealed that PTF1A might promote exocrine differentiation in developing the pancreatic tissues, and that those with widespread expression differentiate into exocrine cells.

Pancreatic Heterotopia in the Small Bowel: A Case Report and Literature Review

ABSTRACT

Diagnosing pancreatic heterotopia (PH) is challenging, because it is a rare congenital anomaly. We report the case of a 66-year-old man who presented with ileus and jejunal PH diagnosed using single-balloon enteroscopy. Reviewing 178 cases of small intestinal PH in the literature showed that (1) PH mostly occurred at the duodenum (61.8%), followed by the jejunum (22.5%) and ileum (14.6%); (2) patients with ileal PH were younger (mean, 40.7 vs 54.6 years; P < 0.001), while those with jejunal PH were older (mean, 59.5 vs 51.7 years; P = 0.006); (3) most patients with jejunal PH were females, while those with duodenal or ileal PH were predominantly males (M:F = 0.8:1 vs 2.5:1; P = 0.003); (4) asymptomatic cases were rare (15.2% vs 83.4% in small and nonsmall bowel, respectively); (5) most patients with ileal PH presented with bleeding (61.5%), while the remaining had abdominal pain (42.8%); (6) emergent operation was performed in 11 cases (6.2%), mainly at the jejunum (12.5%) and Meckel's diverticulum (25%); and (7) Heinrich's classification may be inconclusive. Enteroscopy was performed in only 6 cases (3.4%), and earlier diagnosis and further minimally invasive procedures could have been achieved with enteroscopy.

Jejunal Ectopic Pancreas: A Rare Cause of Small Intestinal Mass

Ectopic pancreas (EP) is defined as the presence of pancreatic tissue outside the pancreas with no anatomical connection to the pancreas. It is also known as pancreatic heterotopia, accessory pancreas, aberrant pancreas, or pancreatic rest. The first case of EP was described in 1727 when pancreatic tissue was identified in the ileal diverticulum. Abdominal pain and lower gastrointestinal bleeding are the most common symptoms. On histopathological examination, EP can be classified into four subtypes. Once identified and diagnosed, the treatment is surgical resection and the post-operative course is asymptomatic in most cases. We describe a rare case of EP, which was discovered on the CT scan of the abdomen as a jejunal mass and successfully treated with surgical resection. We have also described the possible role of chromogranin A for diagnosing EP cases and for post-operative follow-up.

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).

Endoscopic submucosal dissection for gastric ectopic pancreas: a single-center experience

BACKGROUND AND OBJECTIVE

Endoscopic submucosal dissection (ESD) is a minimal invasive technology and could allow "en bloc" resection for superficial gastric tumors. The aim of this study is to evaluate the safety and feasibility of ESD for gastric ectopic pancreas (EP).

METHODS

A total of 93 patients diagnosed with ectopic pancreas who underwent ESD between January 2011 and June 2017 were enrolled. The demographic, clinical, and endoscopic data were collected and analyzed.

RESULTS

The average maximal diameter of lesions was 1.01 (range 0.4-3.0) cm with mean age of patients which was 39.75 (range 15-66) years. Overall, all of procedures en bloc was successful. The median operative time was 76.87 (range 30-160) min. A total of 12 patients experienced complications. In seven patients, bleeding occurred during the operation and was treated using hot biopsy forceps or metal clip. Five cases suffered from pneumoperitoneum which was managed well. The mean length of postoperative hospital stay was 5.7 (range 2-17) days. There was no relapse in any cases during the follow-up.

CONCLUSION

ESD appears to be a safe and feasible approach for curative treatment in gastric ectopic pancreas. Larger studies are needed to identify the role and the outcomes of ESD in another center.