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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 43-45

Incidental heterotopic pancreas on the corpus of stomach during sleeve gastrectomy


1 Department of General Surgery, İstanbul Obesity Surgery(IOC), Kurtköy Ersoy Hospital, İstanbul, Türkiye
2 Department of General Surgery, Sözen Surgery Clinic, Kurtköy Ersoy Hospital, İstanbul, Türkiye

Date of Submission11-Feb-2020
Date of Acceptance25-Apr-2020
Date of Web Publication08-Aug-2020

Correspondence Address:
Dr. Selim Sözen
Department of General Surgery, Sözen Surgery Clinic, Istanbul
Türkiye
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ais.ais_7_20

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  Abstract 


Heterotopic pancreas (HP), also known as ectopic or aberrant pancreas, is a congenital disorder with an occurrence rate of 0.5%–13% in the general population. In this report, a 26-year-old obese female patient with a body mass index of 39.49 kg/m2, with an unremarkable medical and surgical history, was admitted electively for laparoscopic sleeve gastrectomy (LSG). Abdominal ultrasound and esophagogastroduodenoscopy findings were normal. During the operation, a 3 cm subserosal mass was found on the greater curvature in the corpus of the stomach. Following complete exploration of the stomach and regional lymph nodes the surgical technique was not altered because the lesion would remain in the specimen during the procedure. HP can be seen atypically as submucosal tumor but in some instances; it can be found in the muscularis or serosa. Surgical resection is the mainstay treatment if the HP in symptomatic or when the lesion is found incidentally during surgery.

Keywords: Ectopic pancreas, sleeve gastrectomy, submucosal gastric tumor


How to cite this article:
Gencturk M, Erdem H, Bayil S, Sözen S. Incidental heterotopic pancreas on the corpus of stomach during sleeve gastrectomy. Arch Int Surg 2019;9:43-5

How to cite this URL:
Gencturk M, Erdem H, Bayil S, Sözen S. Incidental heterotopic pancreas on the corpus of stomach during sleeve gastrectomy. Arch Int Surg [serial online] 2019 [cited 2020 Sep 21];9:43-5. Available from: http://www.archintsurg.org/text.asp?2019/9/2/43/291750




  Introductıon Top


Heterotopic pancreas (HP), also known as ectopic or aberrant pancreas, is a congenital disorder with an occurrence rate of 0.5%–13% in the general population.[1] It is the second most common submucosal lesion in stomach after gastrointestinal stromal tumor (GIST).[2] Ectopic pancreas can be more common at the age of 30–50 years with a male predominance.[3] HP is usually found incidentally and is generally asymptomatic, but it may become clinically evident depending on its size, anatomical location and the pathological changes similar to orthotopic pancreas, particularly cystic degeneration, ectopic pancreatitis, and even malignant degeneration.[4] In this study, we are reporting a case of gastric HP, which was found incidentally during a bariatric surgery procedure.


  Case Report Top


A 26-year-old obese female patient with a body mass index of 39.49 kg/m2, with an unremarkable medical and surgical history, was admitted electively for laparoscopic sleeve gastrectomy (LSG). Complete blood count and biochemical parameters were in normal ranges. Esophagogastroduodenoscopy findings were normal. This patient had both normal abdominal ultrasound and gastroduodenoscopy before sleeve gastrectomy.

During the operation, approximately 3 cm subserosal mass was found on the greater curvature in the corpus of the stomach. Surgical technique was not changed because the lesion would remain in the specimen during the routine sleeve gastrectomy procedure. The surgical procedure was performed with the help of five trocars. The gastrocolic ligament was cut through the angle of His with an energy device, and the diaphragmatic crura were exposed. A laparoscopic stapler was introduced and fired consecutively along the length of the endoscope against the greater curve. The gastric pouch was created by using a linear stapler, with 2 sequential 4.8/60-mm green load firings for the antrum, followed by 3 sequential 4.8/60-mm purple cartridges for the remaining gastric corpus and fundus. The lesion was taken out of the abdomen; the lesion was marked and was sent to the pathology [Figure 1] and [Figure 2]. The pathology report of the tissue specimen indicated ectopic pancreatic tissue (30 mm × 25 mm × 11 mm) [Figure 3]a and [Figure 3]b. It constituted of pancreatic tissue with acinar cells, duct cells, and islets of Langerhans. Other part of the specimen revealed normal gastric mucosa. The patient was discharged on the fifth postoperative day, without any complications during and after the surgery. At 3-month follow-up, the body mass index (BMI) was 28 kg/m2 and there were no complications during this period.
Figure 1: Macroscopic sleeve gastrectomy specimen

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Figure 2: Gross view of the specimen

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Figure 3: (a) Microscopic view of specimen showing normal well-recognized pancreatic tissue including islets of Langerhans. Histology hematoxylin and eosin staining × 100 magnification. (b) Normal exocrine pancreas and Langerhans islets, with normal distribution of neuroendocrine cells

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  Dıscussıon Top


Most heterotopic pancreatic tissue is discovered in the stomach (particularly antrum), duodenum, jejunum, or a Meckel diverticulum. Other locations include the ileum, liver, spleen, biliary tract, mesentery, fallopian tubes, or umbilicus.[5],[6] HP is usually found incidentally and is generally asymptomatic.[4] Rarely, gastrointestinal bleeding, gastric ulcer, stenosis of the stomach, pancreatitis and malignant transformation can be observed due to this lesion.[7] The most common symptom is epigastric pain. Symptoms can include nausea, vomiting, epigastric pain, dyspepsia, abdominal fullness, and melena.[5] Usually, they are small formations. HP is easily recognized as an incidental finding with its appearance in the form of a small crater close to pylorus in endoscopy.[2] The larger ones are seen as broad-based subepithelial umbilical lesions in endoscopy,[7],[8] which was not featured in the present case. However, in more than half of recorded cases, the endoscopic view is not that specific, for example, the central dimpling is missing.[9] Rarely, large GISTs, schwannomas, and very rarely leiomyomas have a similar central depression caused by necrosis due to poor blood supply.[10] Therefore, the differential diagnosis includes GIST, gastrointestinal autonomic nerve tumor (GANT), carcinoid, lymphoma or gastric carcinoma.[11],[12] It is not difficult to diagnose when pancreatic acini, channels, and Langerhans islands are found histologically. There are four types of pancreatic heterotopia, and they are as follows.[13],[14]

Type I (total heterotopia): typical pancreatic tissue with acini, ducts, and islet cells similar to the normal pancreas.

Type II (canalicular heterotopia): pancreatic ducts only.

Type III (exocrine heterotopia): acinar tissue only.

Type IV (endocrine heterotopia): islet cells only.

The patient in our case report was a type I, with all components of the organ.

HP of the stomach has characteristic computerized tomography (CT) findings that differ from those of gastric submucosal tumors such as GIST and leiomyoma. These criteria are as follows: pre-pyloric antrum or duodenum in location, an ill-defined border, an endoluminal growth pattern, a long-diameter/short-diameter ratio of greater than 1.4, and prominent mucosal enhancement.[9],[15]

HP can be seen atypically as submucosal tumor but in some instances; it can be found in the muscularis or serosa,[16] which was featured in the present case. Surgical resection is the mainstay treatment if the HP in symptomatic or when the lesion is found incidentally during surgery.[5]


  Conclusıon Top


HP is a rare condition. HP should always be considered when diagnosing extramucosal gastric masses. Surgical resection is the mainstay treatment if the HP in symptomatic or when the lesion is found incidentally during surgery.

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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
DeBord JR, Majarakis JD, Nyhus LM. An unusual case of heterotopic pancreas of the stomach. Am J Surg 1981;141:269-73.  Back to cited text no. 1
    
2.
Cengiz C, Oǧuz D, Yuyucu Y, Savaş B, Alaçayir I. Gastrointestinal stromal tümörü taklit eden sıradışı bir gastrik ektopik pankreas olgusu. Endoskopi 2010;18:41-3.  Back to cited text no. 2
    
3.
Mulholland KC, Wallace WD, Epanomeritakis E, Hall SR. Pseudocyst formation in gastric ectopic pancreas. JOP 2004;5:498-501.  Back to cited text no. 3
    
4.
Beger HG, Warshaw AL, Büchler MW, KozarekRA, Lerch MM, Neoptolemos JP, et al. The Pancreas: An Integrated Textbook of Basic Science, Medicine, and Surgery. Wiley-Blackwell 2nd ed. 2009. ISBN: 978-1-444-30013-0.  Back to cited text no. 4
    
5.
Alqahtani A, Aljohani E, Almadi F, Billa S, Alqahtani M, Alkhaldi H. Heterotopic pancreatic tissue in the gastric antrum an incidental finding during bariatric surgery: A case report and literature review. Int J Surg Case Rep 2020;67:39-41.  Back to cited text no. 5
    
6.
Alavinejad P, Sina AH, Dehnavi D, Nayebi M. Esophageal ulcer due to ectopic pancreatic tissue: A case report. Middle East J Dig Dis 2020;12:45-7.  Back to cited text no. 6
    
7.
Hsia CY, Wu CW, Lui WY. Heterotopic pancreas: A difficult diagnosis. J Clin Gastroenterol 1999;28:144-7.  Back to cited text no. 7
    
8.
Biswas A, Husain EA, Feakins RM, Abraham AT: Heterotopic pancreas mimicking cholangiocarcinoma. Case report and literature review. JOP 2007;8:28-34.  Back to cited text no. 8
    
9.
Kim JY, Lee JM, Kim KW, Park HS, Choi JY, Kim SH, et al. Ectopic pancreas: CT findings with emphasis on differentiation from small gastrointestinal stromal tumor and leiyomyoma. Radiology 2009;252:92-100.  Back to cited text no. 9
    
10.
Eckardt AJ, Jenssen C. Current endoscopic ultrasound-guided approach to incidental subepithelial lesions: Optimal or optional? Ann Gastroenterol 2015;28:160-72.  Back to cited text no. 10
    
11.
Christodoulidis G, Zacharoulis D, Barbanis S, Katsogridakis E, Hatzitheofilou K. Heterotopic pancreas in the stomach: a case report and literature review. World J Gastroenterol 2007;13:6098-100.  Back to cited text no. 11
    
12.
O'Reilly DJ, Craig RM, Lorenzo G, Yokoo H. Heterotopic pancreas mimicking carcinoma of the head of the pancreas: A rare cause of obstructive jaundice. J Clin Gastroenterol 1983;5:165-8.  Back to cited text no. 12
    
13.
Gaspar Fuentes A, Campos Tarrech JM, Fernández Burgui JL, Castells Tejón E, Ruíz Rossello J, Gómez Pérez J, et al. [Pancreatic ectopias]. Rev Esp Enferm Apar Dig 1973;39:255-68.  Back to cited text no. 13
    
14.
Chandan VS, Wang W. Pancreatic heterotopia in the gastric antrum. Arch Pathol Lab Med 2004;128:111-2.  Back to cited text no. 14
    
15.
Kim JH, Lim JS, Lee YC, Hyung WJ, Lee JH, Kim MJ, et al. Endosonographic features of gastric ectopic pancreases distinguishable from mesenchymal tumors. J Gastroenterol Hepatol 2008;23:e301-7.  Back to cited text no. 15
    
16.
Agha RA, Borrelli MR, Farwana R, Koshy K, Fowler A, Orgill DP, et al. The SCARE 2018 statement: Updating consensus surgical CAse REport (SCARE) guidelines. Int J Surg 2018;60:132-6.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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