Clinical Case Summary

Gastric neuroendocrine tumors (NETs) are classified into three types based on their pathogenesis. Type 3 NETs are sporadic, not hypergastrinemia associated , and typically present as solitary, aggressive lesions with a higher metastatic potential. Current ENETS guidelines recommend surgical resection for lesions larger than 20 mm, particularly for Type 3 NETs, to minimize the risk of metastasis. We present the case of a 54-year-old male admitted for syncopal episodes and anemia (Hb 10.5 g/dL). After treatment with acetylsalicylic acid and enoxaparin for suspected myocardial ischemia, he developed a pre-syncopal event and a drop in hemoglobin to 6.8 g/dL. Urgent esophagogastroduodenoscopy (EGDS) revealed a 20 mm pedunculated polyp in the gastric body (Fig 1-2-3). Biopsies confirmed a neuroendocrine tumor (NET) with a Ki67 index of 1%. Systematic gastric mucosal mapping showed no other histological abnormalities, supporting the diagnosis of a sporadic Type 3 NET. Staging with contrast-enhanced CT, 68Gallium PET (68Ga-DOTATOC), and endoscopic ultrasound (EUS) excluded local invasion, nodal involvement, and distant metastases. Given the 0-Ip morphology according to the Paris classification, an endoscopic resection was performed using a hot snare technique with endoloop placement at the base of the peduncle. Histology confirmed a 21 mm NET G2 (Ki67 8%) with submucosal infiltration but no vascular or lymphatic invasion (Fig 4-5). Resection margins were clear. At six months, EGDS and 68Ga-PET showed no evidence of recurrence or residual disease. This case underlines how, even in Type 3 NETs larger than 20 mm, the pedunculated morphology can allow for complete and safe endoscopic resection, similarly to what is observed in the management of colonic polyps. Further studies are needed to better define the role of morphology in therapeutic strategies for gastric NETs. This is the only reported case of a pedunculated Type 3 NET of this size successfully treated endoscopically.

References

Figure 1. Upper gastrointestinal endoscopy revealed a 20 mm pedunculated polyp in the gastric body, corresponding to a Paris 0-Ip lesion. The surface appeared smooth, with signs of erosion and ulceration.

Figure 2. Linked Color Imaging (LCI) enhanced the vascular and mucosal pattern, showing a well-circumscribed lesion with preserved pit pattern, suggestive of a subepithelial neoplasm suitable for endoscopic resection.

Figure 3. Endoscopic view of the resection using a hot snare technique and prophylactic endoloop placement at the stalk base. Complete resection was achieved without complications.

Figure 4. Hematoxylin and eosin staining, 10x. The tumor arises from histologically normal oxyntic mucosa, without adjacent endocrine hyperplasia, consistent with a sporadic Type 3 gastric neuroendocrine tumor.

Figure 5. Immunohistochemistry panel of the resected specimen. The tumor shows diffuse positivity for Chromogranin A, Synaptophysin, and Somatostatin Receptor 2 (SSTR2). The Ki67 (MIB-1) proliferation index was 8%, consistent with a Grade 2 NET. No lymphovascular invasion was identified, and resection margins were clear.

Introduction

The impact of antral preservation versus antral resection in sleeve gastrectomy remains a subject of debate due to its potential effects on weight loss, metabolic outcomes, and gastrointestinal function. This meta-analysis aims to provide a comparative assessment of these surgical techniques.

Aims & Methods

The Meta-Analysis aims to provide a comprehensive analysis between ​these two surgical techniques.
A systematic review and meta-analysis were conducted using 10 studies published between 2014 and 2025 that compared sleeve gastrectomy with antral preservation versus antral resection. The primary outcomes included excess weight loss (EWL) at different time points, while secondary outcomes assessed metabolic parameters (C-peptide, GLP-1, HbA1c), gastric emptying, gastroesophageal reflux disease (GERD), and resolution of comorbidities.

Results

A total of 10 studies were included. Patients undergoing antral resection exhibited greater excess weight loss at 6 and 12 months (MD: -4.50, 95% CI: -5.98 to -3.02; MD: -6.11, 95% CI: -7.74 to -4.47, respectively; p<0.00001), though the difference diminished by 24 months (MD: -3.37, 95% CI: -7.04 to 0.30; p=0.07). No significant differences were observed in overall GERD incidence (RR: 1.00, 95% CI: 0.75–1.33) or complications (RR: 1.00, 95% CI: 0.74–1.42). Metabolic outcomes showed marginal differences, with C-peptide (SMD: 0.02, 95% CI: -0.38 to 0.42) and GLP-1 (SMD: -0.22, 95% CI: -0.90 to 0.47) exhibiting minimal changes between groups.

Conclusion

Antral resection in sleeve gastrectomy is associated with superior short-term weight loss, but long-term differences remain inconclusive. Metabolic outcomes and postoperative complications appear comparable between techniques. Further randomized controlled trials with extended follow-up are warranted to refine surgical recommendations.

References

Disclosure

The author(s) declare no conflict of interest

Clinical Case Summary

Background: Enteric duplication cysts are one of the rarest lesions detected in the pancreas. Pancreatic duplication cysts can be challenging to distinguish from neoplastic lesions, particularly in symptomatic patients. Radiologic imaging, such as Computed Topography (CT) and Magnetic Resonance Imaging (MRI), may not always provide a clear differentiation, leading to potential misdiagnosis.
Case presentation: We present the case of a Fifty-seven male patient with a history of long-standing epigastric pain, dyspepsia, and weight loss. Upper and lower endoscopy showed only mild gastritis. Abdominal CECT abdomen showed a well-circumscribed pancreatic lesion of about 20x25 mm with no vascular invasions. Endoscopic ultrasound showed a well-circumscribed pancreatic neck lesion about 20x22 mm, anechoic, negative color flow doppler, soft on elastography, free surrounded vessels with no posterior acoustic enhancement. EUS suggested a cystic lesion versus a vascular NET. EUS fine-needle aspiration (FNA) was done with aspiration of gelatinous material and onsite cytopathology suggested a benign cystic lesion. Further pathological interpretation confirms the diagnosis of a duplication cyst leading to appropriate management without avoidance of major invasive surgical intervention.
Conclusion: EUS and EUS-guided biopsy have a crucial role in differentiating benign pancreatic conditions from malignancies, particularly in patients presenting with nonspecific symptoms and ambiguous radiologic findings. EUS should be considered early in the diagnostic process to avoid misdiagnosis and unnecessary surgical procedures.

Disclosure

Nothing to disclose

Clinical Case Summary

A 54-year-old man was referred to a Gastroenterology appointment due to weight loss and abnormal pancreatic findings on a CT scan, which revealed massive pancreatic enlargement. He had no relevant medical history. Endoscopic ultrasound demonstrated a globular pancreas with a hypoechoic but highly heterogeneous echotexture, multiple subcentimetric nodular formations and numerous millimetric hyperechoic foci, consistent with calcifications. Chromogranin A level was elevated at 143.2 ng/mL.
A 22G fine-needle aspiration of the pancreatic parenchyma was performed, but the result was inconclusive. Subsequently, PET/CT with 68Ga-peptides revealed a focal area of markedly increased uptake in the pancreatic tail (SUV max 47.8), highly suggestive of a neuroendocrine neoplasm, with increased radiotracer uptake throughout the pancreas. As a result, a percutaneous biopsy of the neoplasm and surrounding parenchyma (tail and body) was performed, confirming a well-differentiated (G1) pancreatic neuroendocrine tumor with amyloid stroma. Treatment was initiated with octreotide, later transitioned to lanreotide.
The patient underwent genetic evaluation, which revealed likely pathogenic variants c.1176+1_1176+7del p.? and c.361T>C p.(Cys121Arg) in the GCGR gene (heterozygous), confirming a diagnosis of Mahvash disease.
Two years later, during follow-up, abnormal liver function tests prompted abdominal magnetic resonance imaging, revealing liver nodules with characteristics of hypervascular metastases and signs of portal hypertension. An upper endoscopy was performed, revealing large esophageal varices with red spots, which were treated with two prophylactic elastic band ligations.
This case illustrates the development of portal hypertension arising from an extremely rare genetic disorder, with only about 15 confirmed cases of Mahvash disease reported to date. It is comprehensively documented through CT, PET imaging, histology, endoscopic ultrasound and upper endoscopy iconography.

References

- Yu, Run. “Plea to radiologists: Please consider Mahvash disease when encountering an enlarged pancreas.” World journal of radiology vol. 16,8 (2024): 371-374. doi:10.4329/wjr.v16.i8.371
- Robbins, Justin et al. “Liver Transplantation in a Woman with Mahvash Disease.” The New England journal of medicine vol. 389,21 (2023): 1972-1978. doi:10.1056/NEJMoa2303226

Introduction

Self-expandable metallic stent (SEMS) placement is a palliative treatment for inoperable esophageal malignancies to improve the quality of life. Traditional methods rely on fluoroscopy and endoscopy, but anatomical landmarks can simplify the procedure.

Aims & Methods

To evaluate the technical success, safety and reproducibility of using vertebral column and diaphragm landmarks for SEMS placement.
This retrospective observational study included 801 patients with inoperable esophageal malignancies undergoing SEMS placement for dysphagia due to malignant esophageal strictures, by using vertebral column and diaphragm as landmarks, from 1^st January 2006 to 31^st December 2024. The primary endpoint was to assess the technical success, safety and reproducibility of this unique technique for SEMS placement.
Methodology for Stent Placement in Esophageal Tumors:
1. For Proximal or Mid-Esophageal Tumor, following algorithm was followed: Step 1: Identify key anatomical landmarks using fluoroscopy. Step 2: With the scope in place, under fluoroscopic guidance, identify the vertebra in line with the distal extent of the tumor using the diaphragm as a reference, followed by identification of vertebra at the proximal extent of the tumor. Count the vertebrae between the distal and proximal extent of the tumor. Assign a length of 2.5 cm per vertebral body. Ascertain the desired size of SEMS by calculating the total length of the stricture by counting the vertebrae, adding one vertebral body above and below the tumor for proper stent placement. Step 3: Using fluoroscopy, position the stent. Place the distal end of the stent at the distal vertebral marker. Position the proximal end of the stent at the proximal vertebral marker. Release the stent at the appropriate position to ensure full coverage of the stricture.
2. For Tumor Extending Beyond the Gastro-Esophageal Junction (GEJ), following algorithm was followed: Step 1: Identify the proximal extent of the tumor. Align the proximal extent of the tumor with the vertebra, using the diaphragm as a reference for precise alignment. Measure the distance from the proximal end of the tumor to the proximal stomach using the scope to decide the required size of the stent. Step 2: Place the stent under fluoroscopic guidance. Position the upper end of the stent at the identified vertebra. Extend the distal end of the stent into the stomach, past the GE junction to ensure proper coverage. Release the stent.

Results

408 (50.9%) patients were females. The age range was 18-95 years (mean50±Standard deviation15). Predominant presenting complaint was dysphagia (85.39%). Average duration of dysphagia was 3.84 months. 594 (74.16%) patients had squamous cell carcinoma, whereas 207 (25.84%) patients were diagnosed with adenocarcinoma on histopathology. 365 (45.57%) patients had tumor confined to the lower one-third of esophagus. Major cause of inoperability was distant metastasis (52.81%). 240 (30%) patients had involvement of GEJ. Average length of malignant stricture was 8.4 cm. 139 (17.40%) patients required dilatation by using savary gilliard dilators before SEMS placement. TEF was present in 48 (6%) patients. Range of length of SEMS was 8-18 cm (12.5±2.26). Technical success was achieved in 100% cases. No major immediate complications occurred. Minor complications were rare.

Conclusion

Using vertebral column and diaphragm landmarks is a reliable, safe, simplified and reproducible approach for SEMS placement in patients with inoperable esopahgeal malignancies.

References

1. Lander S, Lander E, Gibson MK. Esophageal Cancer: Overview, Risk Factors, and Reasons for the Rise. Curr Gastroenterol Rep. 2023 Nov;25(11):275-279. doi: 10.1007/s11894-023-00899-0. Epub 2023 Oct 9. PMID: 37812328.

2. Li J, Xu J, Zheng Y, Gao Y, He S, Li H, Zou K, Li N, Tian J, Chen W, He J. Esophageal cancer: Epidemiology, risk factors and screening. Chin J Cancer Res. 2021 Oct 31;33(5):535-547. doi: 10.21147/j.issn.1000-9604.2021.05.01. PMID: 34815628; PMCID: PMC8580797.

3. Asghar MS, Khan NA, Kazmi SJH, Hassan M, Rasheed U, Jawed R, Yaseen R, Naqvi SAA. Clinical, epidemiological, and diagnostic characteristics of esophageal carcinoma in a Pakistani population. Ann Saudi Med. 2021 Mar-Apr;41(2):91-100. doi: 10.5144/0256-4947.2021.91. Epub 2021 Apr 1. PMID: 33818145; PMCID: PMC8020643.

Introduction

Perihilar cholangiocarcinoma (pCCA) is a rare malignancy originating from the bile duct bifurcation which is often diagnosed in an advanced stage. Most patients require endoscopic or percutaneous biliary drainage, as they present themselves with jaundice and/or cholangitis. In most Western countries, only palliative chemotherapy (pCTx) is offered to these patients, positively impacting overall survival and quality of life. Unfortunately, median survival is still poor, with only 10.6 months in patients receiving pCTx, compared to a dismal 4.0 months in patients receiving best supportive care (1). For non-resected pCCA, there is much debate on the optimal technique of biliary drainage, which is often deemed necessary to initiate pCTx. This study aimed to investigate the impact of biliary drainage on pCTx initiation and survival in patients with non-resected pCCA.

Aims & Methods

Individual patient data from all Dutch patients diagnosed with non-resected pCCA between 2015 and 2020 were retrieved from the Netherlands Cancer Registry. Survival data was last updated on 1^st of February 2024. Data was retrieved and de-identified by trained data clerks. The primary outcome was pCTx initiation. Secondary outcome was overall survival. For both the primary and secondary outcome, associations were investigated for several (biliary drainage) factors by multivariable competing risk regression analysis. Initial drainage procedure and initiation of pCTx were treated as time-varying covariates. Sensitivity analysis for pathologically proven pCCA was performed.

Results

A total of 1265 patients (median age of 74 years [IQR: 66-82 years]) were included, of whom 242 patients (19.1%) received pCTx after a median interval of 72 days [IQR 43-110 days] after initial presentation. Patients who underwent biliary drainage did not receive pCTx more often. If performed, drainage at a referral hospital (HR:0.65, 95%CI: 0.42-0.99), ≥3 drainage procedures performed (HR:0.53, 95%CI: 0.32-0.88), and drainage performed ≥14 days after presentation (HR:0.70, 95%CI: 0.49-0.99) were associated with no pCTx. Median overall survival for those who received pCTx and those who did not was 12.8 months [95%CI: 11.7-14.2] and 2.7 months [95%CI: 2.4-3.1]. Receiving of pCTx was associated with improved overall survival (HR:0.61, 95%CI: 0.51-0.73), but biliary drainage was not. If performed, biliary drainage by percutaneous trans-hepatic catheter placement compared to endoscopic plastic stenting (HR:1.27, 95%CI: 1.02-1.57) was associated with diminished survival, and drainage performed ≥14 days after presentation (HR: 0.76, 95% CI: 0.65-0.88) was associated with improved overall survival. Sensitivity analysis for pathologically confirmed pCCA showed similar results.

Conclusion

The need for biliary drainage did not affect the initiation of pCTx. When indicated, biliary drainage should be performed as quick as possible in an academic center to improve the rate of patients receiving pCTx.

References

1. Izquierdo-Sanchez L, Lamarca A, La Casta A, Buettner S, Utpatel K, Klumpen HJ, et al. Cholangiocarcinoma landscape in Europe: Diagnostic, prognostic and therapeutic insights from the ENSCCA Registry. J Hepatol. 2022;76(5):1109-21.

Disclosure

J. de Vos-Geelen has served as a consultant for Amgen, AstraZeneca, MSD, Pierre Fabre, and Servier, and has received institutional research funding from Servier (all outside the submitted work). RPV reports a research grant and consultancy fees from Boston Scientific, research grant from Prion medical, Consultancy fee from Cook Medical, Speakersfee Viatris. N Haj Mohammad has served as a consultant for Merck, BMS, Astra Zeneca, Servier and has received institutional research funding from Servier. M.J. Bruno serves as a consultant and receives support for industry and investigator-initiated studies from Boston Scientific and Cook Medical and receives support for investigator-initiated studies from Pentax Medical, 3 M, Interscope, and Mylan. W.J. Lammers acts as a consultant/lecturer for Mediglobe. The remaining authors declare no conflicts of interests.