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Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy

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Abstract

Introduction

Pancreatic rest (PR) is an ectopic pancreatic lesion that is usually found incidentally on endoscopy or surgery. While most lesions do not have clinical significance, some patients are symptomatic and rarely, PR can predispose to malignancy. With the growing popularity of bariatric surgery, it has been unclear how to manage PR found on screening endoscopies, prior to bariatric surgery. Through review of the current literature, we propose an algorithm for clinicians to evaluate and manage PR found on screening endoscopies prior to bariatric surgery.

Methods

We performed a literature search in PubMed pertaining to PR, clinical characteristics, risk of malignant transformation, endoscopic characteristics, histological descriptions, and resection techniques. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we found 33 published articles from 2001 to 2019, including case reports, case series, retrospective cohorts, and a review paper.

Results

PR is commonly found incidentally in the gastric antrum. Larger lesions have a higher risk of being symptomatic or predisposing to malignant transformation. Endoscopic ultrasound (EUS) can assist in the diagnosis of PR and guide resection technique. Certain histological characteristics, such as Heinrich class, grading of neoplasia, and genetic alterations, can determine malignancy risk of PR. Resection technique, either endoscopically or surgically, should be based on lesion size, depth of wall invasion, and the endoscopists’ level of skill in endoscopic resection.

Conclusions

Proper evaluation and treatment of PR should be considered because of the risk for symptoms and malignant transformation. Symptomatic lesions and those at risk for malignant transformation should be considered for resection. EUS can guide the diagnosis and type of resection, either endoscopically through EMR or ESD or surgically through sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB).

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Authors and Affiliations

  1. Department of Medicine, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA

    Galen Leung & Juan Carlos Bucobo

  2. Department of Surgery, University of Pittsburgh Medical Center Pinnacle, 4300 Londonderry Road, Harrisburg, PA, 17109, USA

    John Mills

  3. Department of Surgery, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY, 11794, USA

    Salvatore Docimo

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  1. Galen Leung
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  2. John Mills
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  4. Salvatore Docimo
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Correspondence to Galen Leung.

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Salvatore Docimo—Consultant, Boston Scientific. Galen Leung, John Mills, Juan Carlos Bucobo declares that they have no conflict of interest.

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Leung, G., Mills, J., Bucobo, J.C. et al. Evaluation and management of a pancreatic rest noted during pre-bariatric surgery screening endoscopy. Surg Endosc 35, 536–561 (2021). https://doi.org/10.1007/s00464-020-08040-2

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  • DOI: https://doi.org/10.1007/s00464-020-08040-2

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