Endoscopic resection of a complex gastric duplication cyst using a submucosal tunneling technique.

Abstract

A 48-year-old woman was incidentally found to have a submucosal lesion (~3 cm) in the antrum, while being evaluated for dyspeptic symptoms (▶Fig. 1). Imaging including endoscopic ultrasound and computed tomography suggested a cystic lesion in the antrum (▶Fig. 2). She underwent endoscopic resection of the cystic submucosal lesion using a tunneling technique (▶Video 1). Marks were made around the lesion using a closed triangular knife in soft coagulation mode (effect 4, 80W). A submucosal lifting injection was performed with diluted indigo carmine dye at the proximal edge of the lesion using a sclerotherapy needle. Subsequently, a longitudinal incision measuring about 2 cm was made. The submucosal fibers along the incision were cleared and the gastroscope was passed into the tunnel. After performing submucosal dissection for about 1 cm, it was possible to visualize the submucosal cystic lesion. The surrounding attachments were systematically cleared using triangular and insulated-tip knives; care was taken to avoid injury to the cyst wall. After dissection had been completed, the lesion was sucked into the cap and brought out via the oral cavity (▶Fig. 3). Histopathological examination revealed a large cyst consisting of multiple smaller cysts. Each cyst wall consisted of mucosa, submucosa, and muscularis propria, suggesting a diagnosis of gastric duplication cyst (▶Fig. 4 a). In addition, a focal island of pancreatic acini lined by pyramidal cells could be seen, signifying pancreatic heterotopia (▶Fig. 4b). Gastric duplication cysts are extremely rare and account for about 4% of all gastrointestinal duplication cysts [1]. Although, the majority of the cases are incidentally diagnosed, bleeding, pain, gastric outlet obstruction, and rarely malignant transformation have been reported [2]. The diagnosis is usually suspected on imaging, especially endoscopic ultrasound [3]. Traditionally, surgery has been used for the management of these lesions. With recent advancements in therapeutic endoscopy, a substantial proportion of these lesions can be resected using submucosal endoscopy techniques [4].