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Background and aim The effect of real-time analysis of needle-based confocal laser endomicroscopy (nCLE) for gastric subepithelial lesions (SELs) on the diagnostic value is unclear. The study aimed to investigate the diagnostic efficacy of real-time nCLE for gastric SELs and to assess the technical aspects and safety of real-time nCLE. Methods Consecutive patients with gastric SELs ≥ 1 cm were prospectively investigated by endoscopic ultrasound (EUS), followed by nCLE. During EUS-nCLE, real-time nCLE diagnosis was made by an expert endoscopist. The procedure-relative adverse events were assessed and recorded. One-month washout period later, nCLE videos were reviewed off-line by the same endoscopist. The nCLE diagnoses were compared with corresponding pathological results. Additionally, image quality and interobserver agreements for the criteria were evaluated by three experienced endomicroscopists. Results Except for one failing to be punctured, 60 patients completed EUS-nCLE procedures successfully. Real-time nCLE had high diagnostic accuracies of ≥ 88.3% for gastric SELs. There were no significant differences between real-time and off-line nCLE diagnoses for gastric SELs (P > 0.05). The overall accuracy of real-time nCLE for diagnosis of gastric SELs was 86.7%. There were no procedure-relative adverse events occurred. In addition, the mean image quality score was 3.6 (1 = poor and 5 = excellent). The interobserver agreement was "almost perfect" for ectopic pancreas and "substantial" for gastrointestinal stromal tumor, leiomyoma, and carcinoma. Conclusions Endoscopic ultrasound-nCLE could provide in vivo real-time diagnostic imaging with a high diagnostic accuracy. Meanwhile, real-time nCLE was feasible and had a satisfactory safety profile.

Ectopic pancreas (EP) is typically found within other gastrointestinal organs. Its discovery in other parts of the body, especially in the mediastinum, is exceedingly rare. This paper presents a case of a 17‐year‐old female patient with EP in a large, rapidly growing thymic cyst. She presented to our institution with persistent chest pain. Video‐assisted thoracic surgery revealed a mediastinal mass in the setting of pleural effusion. Analysis of the fluid contents of the mass and the pleural effusion demonstrated high levels of pancreatic amylase, which supported the presence of pancreatic tissue within the mass. This is the first reported case of EP in a thymic cyst with an active pancreatic exocrine function. It is also the first reported case of mediastinal EP rupture secondary to autodigestion by amylase., Ectopic pancreas (EP) is typically found within other gastrointestinal organs. Its discovery in other parts of the body, especially in the mediastinum, is exceedingly rare. This paper presents a case of a 17‐year‐old female patient with EP in a large, rapidly growing thymic cyst.

Background and Aim The study aims to evaluate contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) for the differential diagnosis of submucosal tumors (SMT) of the upper gastrointestinal tract. Methods Between June 2008 and May 2015, 157 consecutive patients with submucosal lesions of the upper gastrointestinal tract were evaluated by CH-EUS. This was a single-center retrospective analysis of prospectively collected data in a registry. The data from 73 patients who later underwent surgical resection were analyzed in this study. Surgical specimens served as the final diagnoses. The two CH-EUS variables of blood flow (hyper-enhancement vs hypo-enhancement) and homogeneity of enhancement pattern were evaluated. Results The final diagnoses were 58 gastrointestinal stromal tumors (GISTs) and 15 benign SMTs (two lipomas, five leiomyomas, five schwannomas, two glomus tumors, and one ectopic pancreas). On CH-EUS, 49 of 58 (84.5%) GISTs presented with hyper-enhancement, whereas 4 of 15 (26.7%) benign SMTs showed hyper-enhancement; 21 of 58 (36.2%) GISTs showed inhomogeneous contrast enhancement, while only 2 of 15 (13.3%) benign SMTs demonstrated inhomogeneous contrast enhancement. If hyper-enhancement was considered to indicate GISTs, the sensitivity, specificity, and accuracy were 84.5%, 73.3%, and 82.2%, respectively. If inhomogeneous enhancement was considered to indicate GISTs, the sensitivity, specificity, and accuracy were 36.2%, 86.7%, and 46.6%, respectively. In lesions of less than 2 cm, hyper-enhancement was a more sensitive indicator of GISTs than inhomogeneous enhancement. Conclusions Hyper-enhancement and inhomogeneous enhancement were found to be a characteristic of GISTs. CH-EUS was useful for discrimination of benign SMTs from GISTs.

Using endoscopic ultrasonography (EUS), it is practicable to diagnose subepithelial lesions (SEL) with originating layer, echo level, and internal echo pattern etc. Lipoma, lymphangioma, and cyst have characteristic features; therefore, there is no need for endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Ectopic pancreas and glomus tumors, which originate from the third and fourth layers, are frequently seen in the antrum. However, ectopic pancreas located in the fundus or body is large and originates from the third and fourth layers (thickening of fourth layer). Each subepithelial lesion has characteristic findings. However, imaging differentiation of tumors originating from the fourth layer is very difficult, even if contrast echo is used. Therefore, EUS-FNA should be done in these tumors, but the diagnostic yield for small lesions is not sufficient for clinical demands. Generally, those tumors, including small ones, should be first followed up in 6 months, then yearly follow up in cases of no significant change in size and features. When those tumors become larger than 1-2 cm, EUS-FNA is recommended. Furthermore, unusual SEL and SEL with malignant findings such as nodular, heterogeneous, anechoic area, and ulceration indicate EUS-FNA. Cap-attached forward-viewing echoendoscope is very helpful for EUS-FNA of small SEL.

Ectopic pancreas located in the mediastium is an extremely rare anomaly. We present a case of an ectopic pancreas located in a giant mediastinal cyst in an 18-year-old man. He presented with symptoms of dyspnea due to external compression of the cyst on the left main bronchus. Complete surgical resection was performed through median sternotomy, with relief of the bronchial compression postoperatively. Literature review showed 20 previously reported cases. These masses were usually large (>10 cm), almost exclusively located in the anterior mediastinum, predominately cystic in nature and generally benign. Surgical resection was performed in all reported cases with a favorable prognosis. Due to the size of these masses, operative treatment can be challenging and should be carefully planned, with specific considerations regarding anesthetic and surgical management.

Objective We aimed to validate a new scoring system for the differential diagnosis of gastric subepithelial tumors (SET) based on endoscopic ultrasonography (EUS) findings, and to determine its diagnostic yield for different gastric SET. Methods Data of patients with gastric SET treated with endoscopic mucosal resection, endoscopic submucosal dissection or surgical resection from April 2001 to October 2012 at the Soonchunhyang University Hospital (Bucheon, Korea) were retrospectively reviewed. Four variables, including location, shape, layer of origin and echogenicity of the tumor on EUS were used to validate the new scoring system. Results Among the 226 patients with gastric SET, 69 (30.5%) had gastrointestinal stromal tumors (GIST), 68 (30.1%) had ectopic pancreas and 35 (15.5%) had leiomyoma. Most GIST were located at the fundus and body (79.7%), whereas most leiomyomas were found at the cardia (80.0%). Ectopic pancreas was mostly found at the antrum (88.2%). GIST were mainly irregular and round in shape, while ectopic pancreas and lipoma were oval and leiomyomas were irregularly shaped on EUS. With a score range of 0–1 for leiomyoma, 2–3 for GIST, 4–6 for ectopic pancreas and 7–8 for lipoma, the sensitivity and specificity of the scoring system were 75.8% and 85.4% for GIST, 84.6% and 73.1% for ectopic pancreas, 75.9% and 99.5% for leiomyoma and 91.7% and 96.7% for lipoma, respectively. Conclusions The new scoring system was simple and relatively useful for predicting the histology of gastric SET without acquiring tissues. Prospective studies with large sample sizes are needed in the future.

Although ectopic pancreas and intussusception are not unusual conditions, intussusception caused by ectopic pancreas is extremely rare. Its presence along with a ruptured congenital mesenteric vascular band raises the possibility of an anomaly of the vitelline vascular system. We report the case of a 26-year-old man presenting with acute abdominal pain, vomiting, and diarrhea. CT scan showed a large amount of free fluid in his abdomen and an ileo-ileal intussusception. At laparotomy he was found to have hemoperitoneum with a ruptured, actively bleeding congenital band attached to the ileal mesentery, which was ligated, with ileo-ileal intussusception that was resected. Histopathology showed ectopic pancreatic tissue as the lead point for the intussusception. It was likely to be a ruptured mesodiverticular band and along with other findings suggested a constellation of anomalies of the vitello-intestinal tract.

Summary Background Although recent immunochemical analysis enabled the discrimination of gastrointestinal stromal tumour (GIST) to other mesenchymal tumours, preoperative diagnosis of these tumours is not always easy. Aim To discriminate between ectopic pancreas (EP) and mesenchymal tumours, including GIST, 12 years surgical experience at Keio University Hospital was reviewed. Methods Clinicopathological findings were analysed for 131 patients with gastric submucosal tumours (SMT), including GIST (67 cases), myogenic tumour (21 cases), Schwannoma (11 cases), EP (12 cases) and others (20 cases) surgically treated at Keio University Hospital since 1993. Results Analysis of clinicopathological findings of these tumours showed that GIST, myogenic tumour and Schwannoma mimic each other from the standpoint of size and location of the tumour. In contrast, comparison of mesenchymal tumours showed that, compared with gastrointestinal mesenchymal tumour, EP tends to exist at middle or lower third of the stomach (P = 0.004), and the tumour size was smaller than 3 cm (P = 0.0006). All EPs were laparoscopically resected and no malignant features were evident. Conclusion To avoid unnecessary surgery for EP, SMT smaller than 3 cm occurring in the middle or lower third of the stomach should be carefully selected as a candidate of surgical resection.

The case of an ectopic pancreatic mass at the umbilicus in an 8-day-old male neonate is reported, the youngest patient with this condition ever reported in an English-language journal. The patient was healthy except for a protruding mass with intermittent mucous discharge at the base of the umbilical stump. Surgical intervention was performed under the impression of the umbilical mass. Pathology diagnosed an ectopic pancreas with acute hemorrhage. To the best of our knowledge, only one case of ectopic pancreas presenting as an umbilical mass with intermittent mucous discharge has previously been reported.

In recent years, there have been a number of well-documented examples demonstrating that one cell type can be converted to another. Two such examples are the appearance of ectopic pancreas in the liver and formation of hepatic tissue in the pancreas. The conversion of liver to pancreas raises the intriguing possibility of generating insulin-producing beta cells for therapeutic transplantation into diabetics. There is now a striking addition to the growing list of pancreatic conversions: the formation of pancreatic tissue in the developing biliary system.

Purpose We evaluated the accuracy of high-resolution transabdominal sonography (TAUS) in identifying and characterizing gastric submucosal masses previously detected by endoscopy. Methods Patients given endoscopy for suspected submucosal gastric lesions and 2 patients with gastric wall cysts were enrolled. Patients underwent TAUS and then endoscopic sonography (EUS) on the same day, and the sonographic results were compared with endoscopic and histologic findings. Results Among 101 patients with gastric submucosal masses on endoscopy, TAUS revealed a mass in 94 (93%); of these 94 patients, 60 underwent EUS. The final diagnoses were 31 leiomyomas, 10 leiomyosarcomas, 13 ectopic pancreases, 2 cysts, and 1 glomus tumor, 1 carcinoid tumor, 1 lipoma, and 1 fibroma. Leiomyomas (mean size, 3.2 cm) and leiomyosarcomas (mean size, 7.1 cm) were shown sonographically to originate from the muscular layer. Ectopic pancreases (mean size, 1.2 cm) were shown to originate from the submucosal layer and had a homogeneously echogenic pattern. Gastric cysts were found in the submucosal layer and were anechoic. The glomus tumor and the carcinoid tumor were found in the muscular layer and were hypoechoic. The lipoma and the fibroma were located in the submucosal layer and were echogenic on TAUS. Conclusions TAUS had a detection rate of 93% in visualizing submucosal gastric masses previously identified by endoscopy. TAUS is less invasive than EUS and can be used to follow submucosal gastric masses that are not excised. © 2000 John Wiley & Sons, Inc. J Clin Ultrasound 28:125–132, 2000.

We present a case of a submucosal tumor in the stomach that was suspicious for malignancy on preoperative endosonography. The resected tumor was histologically diagnosed as a ductal adenocarcinoma that originated in ectopic pancreatic tissue in the gastric wall. Although malignant transformation in ectopic pancreas is extremely rare, it remains an important consideration in the differential diagnosis of gastric submucosal masses.

Background and Aim: Ectopic pancreas is a common submucosal lesion in the stomach, but its histological diagnosis is usually difficult when tissue samples are obtained with a conventional biopsy forceps. The aim of this study was to describe the endosonographic features of gastric ectopic pancreas. Methods: We retrospectively analyzed a database of all patients who underwent endoscopic ultrasonography (EUS) at Pusan National University Hospital from July 2006 to August 2010. A total of 26 patients with histologically confirmed ectopic pancreas were included in the study. The EUS features of their lesions were analyzed. Results: Ten lesions were located in the antrum, and 16 lesions were located in the body. Nine lesions (34.6%) showed an umbilication or central dimpling on the surface, and a mural growth pattern was most commonly observed (61.5%). Twenty-four lesions (92.3%) showed hypoechoic echogenicity, and 13 lesions (50.0%) were heterogeneous. The borders were indistinct in 16 lesions (61.5%) and lobulated margins were observed in 16 lesions (61.5%). Anechoic cystic or tubular structures appeared in 17 lesions (65.4%), and 20 lesions (76.9%) involved two or more sonographic layers. Conclusions: The characteristic EUS features of ectopic pancreas are indistinct borders, lobulated margins, presence of anechoic duct-like structures, a mural growth pattern, and localization within two or more layers. These EUS features are potentially useful for differentiating ectopic pancreas from other mesenchymal tumors in the stomach.

UNLABELLED: Communicating oesophageal duplication cyst with heterotopic pancreatic tissue is rare congenital anomaly and unusual cause of recurrent pneumonia in children. We report a 10-month-old boy who presented with history, examination and investigations suggestive of aspiration pneumonia since birth. The imaging studies revealed a thin walled cavity communicating with the oesophageal lumen that was excised by surgery. Histopathology showed squamous epithelial lining of cyst with heterotopic pancreatic tissue. CONCLUSION: Communicating oesophageal cyst causing persistent signs and symptoms can be an unusual cause of recurrent pneumonia in an infant that can be diagnosed by further imaging studies.

Purpose To evaluate safety of laparoscopic resection of submucosal gastric lesions performed in Whangarei Based Hospital. Methodology From November 2002 to December 2006, 8 consecutive patients underwent the above mention surgery. (M : F = 5 : 3; Average age 63 [range, 43–83]). All patients underwent pre-operative gastroscopy. Wedge resections were performed for anterior wall lesions. (n = 3). Posterior wall lesions were resected via transgastric approach. (n = 4). Retroperitoneal resection was performed for the foregut duplication cyst. (n = 1). All except one lesion were resected using endoscopic GIA stapler. The medical records of the patients were reviewed retrospectively. Results All patients were successfully treated laparoscopically. No conversion to open surgery. Pathology included: Gastrointestinal-stromal tumor (GIST) (n = 5), Malignant leiomyosarcoma (n = 1), Ectopic pancreas (n = 1), and Foregut duplication cysts (n = 1). All achieved adequate negative surgical margin. Average operation time was 106.14 minutes. [Range, 75–150]. Average length of hospital stay was 3.42 days [range, 1–5]. Complication included one wound infection, and one pyloric stenosis. Average length of follow up was 10.96 months [range, 0.46–31.73]. No recurrence detected and all are still alive till date. Conclusion Laparoscopic resection of submucosal gastric lesions is a safe and appropriate alternative to open surgery. Its main advantage over open technique includes shorter length of hospital stay, lower recurrence rate and lower mortality rates. Surgical technique depends very much on tumor size and location. Outcome of the patients described from our centre is comparable to the others published till date.

The case is reported of an infant with cystic fibrosis and duodenal obstruction relieved by surgery and caused by an affected submucosal ectopic pancreas in the third part of the duodenum.