Post written by Robert Bechara, MD, from Queen’s University, Kingston Health Sciences Center, Kingston, Ontario, Canada.

This is a case of a 75-year-old woman with gastrogastric intussusception and acute pancreatitis caused by a 6-cm dysplastic pyloric gland adenoma, which we treated using endoscopic submucosal dissection (ESD).

The decision to showcase this video was driven by the unique educational value of the case. Gastrogastric intussusception in adults is extremely rare, with only a handful of cases reported in the literature.

Moreover, the presence of a large pyloric gland adenoma causing acute pancreatitis by obstructing the ampulla of Vater is a clinical scenario that many endoscopists might never encounter.

Furthermore, this case underscores the advantages of ESD over EMR in certain situations. ESD was selected over EMR for the following reasons:

• Oncologic:
  • Gastric adenomatous lesions >2 cm have a significant risk of carcinoma. This lesion was 6 cm in size.
• Hemostatic:
  • In ESD, notably more precise cutting is achievable and complemented by the capability to visualize and perform hemostasis on vessels prior to cutting them. This contrasts with EMR, where a larger area is transected rapidly with less precision and without the ability to visualize or proactively coagulate the vasculature.
• Perforation risk:
  • Given the lesion’s role in causing intussusception and its considerable bulk, EMR was considered a less safe option. In some cases, what is presumed to be a stalk during snaring in EMR might actually be the muscularis propria drawn into the lumen, and transecting it with EMR could lead to a significant perforation. In contrast, ESD, with its greater precision, enables identification of the muscularis propria and meticulous dissection of the submucosa. If a small defect in the muscularis propria occurs, it can be readily recognized and repaired, making a large perforation much less likely.

Our experience with this unique case offers several key insights for other endoscopists. First, the rarity of gastrogastric intussusception in adults, as seen in this case, highlights the need for awareness of such uncommon presentations.

Second, the extension of large gastric neoplasms causing intussusception into the duodenum, potentially leading to acute pancreatitis, underscores the importance of thorough evaluation in similar scenarios.

In addition, occurrence of pyloric gland adenomas is typically associated with autoimmune gastritis and more common in women. This reinforces the importance of a detailed endoscopic examination of the background mucosa to ensure that autoimmune gastritis, which leads to a high risk of gastric cancer, is not missed.

Notably, this case demonstrates the effectiveness of ESD as an alternative to surgery for managing lesions traditionally considered for surgical intervention because of malignancy risks. This case also emphasizes the effectiveness of using traction techniques, such as multipoint traction, in the safe and efficient management of large, bulky gastric lesions.

Finally, it provides a valuable learning experience in evaluating the risks and benefits of ESD versus EMR, especially in the context of bulky gastric lesions.

A, Endoscopic image showing gastric wall intussusception with the adenoma protruding into the duodenum. B, Retroflexed view revealing the pyloric gland adenoma along the greater curve after reduction by air insufflation. C, Endoscopic submucosal dissection. D, Low-power view of the pyloric gland adenoma stained with hematoxylin phloxine saffron (orig. mag. ×100).

Read the full article online.

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