Endoscopic submucosal dissection as alternative to surgery for complicated gastric heterotopic pancreas

Figure 1 Endoscopic submucosal dissection of complicated gastric heterotopic pancreas (patient 5). A: Endoscopic ultrasonography image showing a homogeneous hypoechoic lesion with cystic (hypoechoic) foci that was located within the 2^nd, 3^rd, and 4^th layers; B: A 1.5 cm subepithelial tumor with umbilication was observed on the greater curvature of the antrum; C: The lesion borders were marked; D: Saline with epinephrine was submucosally injected, and a circumferential mucosal incision was made; E: The submucosal connective tissue and part of the muscularis propria were dissected; F: The resected specimen was fixed; G: Heterotopic pancreas is located in the submucosa underlying intact gastric mucosa (hematoxylin-eosin; original magnification, × 40); H: Normal pancreatic acini with ducts are noted (× 200).

Figure 2 Computed tomography and endoscopic ultrasonography images of each patient at the time of diagnosis of complicated gastric heterotopic pancreas. A-E: Correspond to patient 1, 2, 3, 4, and 5, respectively. The computed tomography and endoscopic ultrasonography findings of each patient are summarized in Table 1.

Figure 3 The clinical course of lesion size according to abdominal pain are summarized. A: Patient 1; B: Patient 3; C: Patient 4; D: Patient 5.

Figure 4 Representative histologic images of gastric heterotopic pancreas. A: Patient 1: Pancreatic tissue is in proper muscle with involvement of resection margin (arrow) (hematoxylin-eosin; original magnification, × 40); B: Patient 3: There is focal nest of cells and bluish material with fibrosis and severe cautery artifact (× 100); C: Patient 4: Submucosal fibrosis with foreign body reaction and dystrophic calcification (arrow) was noted (× 40); D: Patient 5: Pancreatic tissue is in submucosa overlying gastric mucosa (× 40).