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Rare solitary giant hamartomatous polyp of the stomach removed by endoscopic submucosal dissection

Open AccessPublished:October 24, 2022DOI:https://doi.org/10.1016/j.vgie.2022.08.006

      Video

      (mp4, (102.28 MB)

      Endoscopic submucosal dissection of a large solitary gastric hamartomatous polyp.

      Abbreviations:

      ESD (endoscopic submucosal dissection), SGHP (solitary gastric hamartomatous polyp)
      The incidence of solitary gastric hamartomatous polyps (SGHPs) is extremely low, with fewer than 12 cases reported in the literature.
      • Yoshizawa N.
      • Yamaguchi H.
      • Kaminishi M.
      Differential diagnosis of solitary gastric Peutz-Jeghers-type polyp with stomach cancer: a case report.
      Common symptoms include abdominal pain, bleeding, and anemia. While most SGHPs are benign, dysplastic changes have been reported.
      • Yoshizawa N.
      • Yamaguchi H.
      • Kaminishi M.
      Differential diagnosis of solitary gastric Peutz-Jeghers-type polyp with stomach cancer: a case report.
      ,
      • Lunca S.
      • Porumb V.
      • Velenciuc N.
      • et al.
      Giant solitary gastric Peutz-Jeghers polyp mimicking a malignant gastric tumor: the largest described in literature.
      Hence, large lesions are typically referred for resection.
      • Yoshizawa N.
      • Yamaguchi H.
      • Kaminishi M.
      Differential diagnosis of solitary gastric Peutz-Jeghers-type polyp with stomach cancer: a case report.
      In this video, we present a case of an SGHP resected with endoscopic submucosal dissection (ESD) (Video 1, available online at www.giejournal.org).
      A 73-year-old man with medical history significant for atrial fibrillation on antithrombotic therapy and congestive heart failure was evaluated for weight loss and iron deficiency anemia. He underwent an EGD, video capsule endoscopy, colonoscopy, and CT scan of the abdomen/pelvis. All tests were unremarkable except for a large gastric mass identified on the EGD, with forceps biopsy histopathology suggestive of a hyperplastic polyp. The patient was referred to our institution for possible resection. On EGD, a large sessile, lobulated polyp with a convoluted surface (Paris classification Is+IIc) was located on the posterior wall and greater curvature of the stomach (Fig. 1). Mucosal surface of the lesion was smooth without ulceration and high-definition white light and narrow-band imaging did not show microvascular morphology suggestive of deep invasion. Given the patient’s symptoms and consideration for a malignant component because of the size of the lesion, the decision was to proceed with ESD. Cautery marks were placed along the outer margins of the lesion. A lifting solution (6% hetastarch admixed with methylene blue) was injected into the submucosa at the anal aspect of the target lesion followed by mucosal incision using a needle-injection electrosurgical knife (Hybrid I-type knife; ERBE, Marietta, Ga, USA) (Fig. 2A). Following this, ESD was completed using the submucosal tunneling technique as previously described.
      • Aslan F.
      • Akpinar Z.
      • Kucuk M.
      • et al.
      Multiple tunneling technique for treatment of rectal circumferential laterally spreading tumor with endoscopic submucosal dissection.
      In brief, a mucosal incision was performed on the oral side followed by submucosal dissection by creating a tunnel underneath the lesion (Fig. 2B). Upon completion of the submucosal tunnel, the lateral mucosal margins were excised and dissected (Fig. 2C). There was no evidence of bleeding or perforation at the conclusion of the procedure (Fig. 3). Total procedure time was 147 minutes. The resected specimen (170 × 72 mm) was retrieved en bloc, mounted onto a cork board, and fixed in formalin (Fig. 3). The patient developed acute onset of abdominal pain on postoperative day 1. A CT scan revealed pneumoperitoneum and fluid collection on the greater curvature of the stomach consistent with delayed perforation (Fig. 4). Surgery was consulted who agreed with endoscopic intervention. While definitive perforation was not identified on repeat EGD, based on clinical presentation and CT findings, we proceeded with endoscopic closure of the entire resection bed, which was successfully achieved by placing 4 interrupted sutures in a “Z” pattern with the endoscopic suturing system (Overstitch; Apollo Endosurgery, Austin, Tex, USA) (Fig. 5). Following this, a CT-guided percutaneous drain was placed for the small fluid collection. An upper GI series showed no evidence of contrast extravasation, and the patient was able to advance his diet (Fig. 6). The drain was removed, and patient was discharged on postoperative day 7. He completed a 14-day course of amoxicillin-clavulanate 875-125 mg and was doing well 4 weeks postprocedure.
      Figure thumbnail gr1
      Figure 1Large sessile, lobulated polyp identified on the greater curvature of the stomach on forward (A) and retroflexed (B) endoscopic views.
      Figure thumbnail gr2
      Figure 2Mucosal incision with dissection on the anal side of the lesion (A). Submucosal tunneling underneath the lesion (B) followed by lateral margin incision and dissection (C).
      Figure thumbnail gr3
      Figure 3Endoscopic submucosal dissection resection bed (A). The specimen was retrieved en bloc (B) and mounted onto a cork board (C). Final resected specimen measured 170 × 70 mm.
      Figure thumbnail gr4
      Figure 4A (arrows), CT of the abdomen and pelvis revealing pneumoperitoneum. B (arrows), Fluid collection along the greater curvature of the stomach.
      Figure thumbnail gr5
      Figure 5Endoscopic suturing (A) of the endoscopic submucosal dissection resection bed in the setting of delayed perforation with (B) successful complete closure.
      Figure thumbnail gr6
      Figure 6Upper GI series showing no evidence of contrast extravasation following endoscopic closure of the endoscopic submucosal dissection resection bed. A percutaneous drain was applied at the site of a small perigastric fluid collection.
      Final histopathology was consistent with a benign gastric hamartomatous polyp (Fig. 7). The patient reported no family history of GI polyposis, associated mucocutaneous pigmentations, nor other polyps in the GI tract, consistent with the diagnosis of an SGHP. Because of its rarity, there are no clear guidelines in the management of SGHPs. Superficial forceps biopsies are often misdiagnosed as hyperplastic.
      • Yoshizawa N.
      • Yamaguchi H.
      • Kaminishi M.
      Differential diagnosis of solitary gastric Peutz-Jeghers-type polyp with stomach cancer: a case report.
      SGHPs have a highly vascular stroma, which explains their tendency to bleed. Given the reported risk for neoplastic transformation, SGHPs are generally referred for resection.
      • Zou B.C.
      • Wang F.F.
      • Zhao G.
      • et al.
      A giant and extensive solitary Peutz-Jeghers-type polyp in the antrum of stomach.
      ,
      • Vyas M.
      • Yang X.
      • Zhang X.
      Gastric hamartomatous polyps—review and update.
      ESD may be an alternative to surgery for selected cases. We recommend close postoperative monitoring as delayed perforation can occur after large resections, and prompt recognition and intervention can prevent peritonitis and need for surgery. Our case is the largest SGHP reported that has been removed endoscopically.
      Figure thumbnail gr7
      Figure 7Gastric hamartoma. A, Low-power view (H&E, org. mag. ×20) showing polypoid surface with prominent adipose tissue. B, High-power view (H&E, org. mag. ×100) showing polyp composed of glands, adipose tissue, and smooth muscle bundles with no evidence of dysplasia.

      Disclosure

      Dr Yang is a consultant for Olympus, Fujifilm, Apollo Endosurgery, and Medtronic. Dr Arain is a consultant for Boston Scientific, Olympus, Cook Medical, and Medtronic. Dr Hasan is a consultant for Boston Scientific and Olympus. All other authors disclosed no financial relationships.

      Supplementary data

      References

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