Endoscopic vs surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg. 2013;257:315-322. [PMID: 23059497 DOI: 10.1097/sla.0b013e318269d010]

Duodenal intussusception secondary to ampullary adenoma: A case report

BACKGROUND

Because the duodenum is fixed onto the retroperitoneum, duodenal intussusception is usually impossible except in cases of malrotational abnormality. Although cases of duodenal intussusception without malrotational abnormalities have been reported, it is unclear whether they constitute true intussusception or simple mucosal prolapse.

CASE SUMMARY

A 66-year-old woman presented with whole-body edema and malaise. Blood analysis indicated severe anemia and cholestasis. Endoscopic examination revealed a pedunculate polyp on the second part of the duodenum that migrated distally with mucosal elongation. Computed tomography showed duodenal intussusception. A tumor as the lead point and retroperitoneal structure, including the head of the pancreas and fat, invaginated beyond the duodenojejunal flexure. She was diagnosed with ampullary adenoma caused repeated intussusception that reduced spontaneously and underwent pancreaticoduodenectomy. Laparotomy showed tumor prolapse beyond the duodenojejunal flexure without intussusception. There was no evidence of malrotational abnormality. She was discharged with no complications.

CONCLUSION

We report true duodenal intussusception without malrotational abnormality. This phenomenon was also associated with mucosal prolapse.

The impact of endoscopic ultrasound in preoperative evaluation for ampullary adenomas

OBJECTIVE

We aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in assessing locoregionally and determining therapeutic options for ampullary adenomas and the related factors.

METHODS

Patients undergoing EUS and surgical or endoscopic resection for biopsy-proven ampullary adenomas between 2009 and 2016 were retrospectively analyzed. The depth of tumor invasion, intraductal extension, and regional lymph node staging evaluated by EUS were compared with post-treatment pathological findings.

RESULTS

Altogether 120 patients were enrolled in this study. The overall accuracy for EUS in T staging was 81.7%. The sensitivity and specificity of EUS for T staging were 93.9%, 45.5% for adenoma and T1, 50.0% and 96.5% for T2, 66.7% and 97.4% for T3, 50.0% and 97.5% for T4 lesions, respectively. The sensitivity, specificity, and accuracy of EUS for the diagnosis of any intraductal extension were 89.5%, 86.1%, and 86.7%, respectively. The overall accuracy of EUS for regional lymph node staging was 75.0%. The sensitivity and specificity of EUS for diagnosing N1 were 62.5% and 87.5%. By multivariate analysis no factors were found to be independently associated with EUS accuracy for tumor invasive depth. However, small lesion size (≤15 mm) and dilated duct were associated with an overestimation in intraductal extension.

CONCLUSION

EUS may be a useful diagnostic tool for selecting endoscopic or surgical treatment for ampullary adenomas.

Surgical method choice and coincidence rate of pathological diagnoses in transduodenal ampullectomy: A retrospective case series study and review of the literature

BACKGROUND

Transduodenal ampullectomy (TDA) is not in wide clinical use due to its low radical effect and a high recurrence rate of tumors. However, TDA is still an effective treatment method; it has great clinical value in cases of duodenal benign tumors, precancerous lesions, and benign and malignant borderline tumors, and can avoid the risks associated with pancreaticoduodenectomy with larger resection range and greater thoroughness than endoscopic papillectomy.

AIM

To investigate the surgical method choice and the coincidence rate of pathological diagnoses in TDA for ampullary neoplasms.

METHODS

Ten patients with ampullary neoplasms underwent TDA based on the fact that their endoscopic biopsy results suggested benign lesions, and the endoscopic ultrasound (EUS)-assessed tumors were resectable. All cases underwent duodenal ampullary lesion endoscopic biopsy, intraoperative frozen-section pathological examination, and postoperative pathological examination.

RESULTS

This study included seven patients with benign tumors and three with malignant tumors (1 pTis, 2 pT1), according to the postoperative pathology results. The coincidence rate of the postoperative pathology results with the intraoperative frozen-section biopsy results was 100% (10/10), and the coincidence rate with the endoscopic biopsy results was 70% (7/10) based on pathological characteristics. The endoscopic biopsy false-negative rate was 30% (3/10). All patients were followed for 6 to 70 mo without tumor recurrence or metastasis.

CONCLUSION

The coincidence rate of postoperative pathology results, intraoperative frozen-section pathology results, and endoscopic biopsy results is the restraining factor of TDA clinical application. Endoscopic biopsy results and EUS have importance relevance to surgical planning. Intraoperative frozen-section pathology results have a significant influence on the choice of surgical procedure.

Clinical outcomes of ampullary neoplasms in resected margin positive or uncertain cases after endoscopic papillectomy

BACKGROUND

Endoscopic papillectomy (EP) for benign ampullary neoplasms could be a less-invasive alternative to pancreatoduodenectomy (PD). There are some problems and limitations with EP. The post-EP resection margins of ampullary tumors are often positive or uncertain because of the burning effect of EP. The clinical outcomes of resected margin positive or uncertain cases after EP remain unknown.

AIM

To investigate the clinical outcomes of resected margin positive or uncertain cases after EP.

METHODS

Between January 2007 and October 2018, all patients with ampullary tumors who underwent EP at Kobe University Hospital were included in this study. The indications for EP were as follows: adenoma, as determined by preoperative endoscopic biopsy, without bile/pancreatic duct extension, according to endoscopic ultrasound or intraductal ultrasound. The clinical outcomes of resected margin positive or uncertain cases after EP were retrospectively investigated.

RESULTS

Of the 45 patients, 29 were male, and 16 were female. The mean age of the patients was 65 years old. Forty-one patients (89.5%) underwent en bloc resection, and 4 patients (10.5%) underwent piecemeal resection. After EP, 33 tumors were histopathologically diagnosed as adenoma, and 12 were diagnosed as adenocarcinoma. The resected margins were positive or uncertain in 24 patients (53.3%). Of these cases, 15 and 9 were diagnosed as adenoma and adenocarcinoma, respectively. Follow-up observation was selected for all adenomas and 5 adenocarcinomas. In the remaining 4 adenocarcinoma cases, additional PD was performed. Additional PD was performed in 4 cases, and residual carcinoma was found after the additional PD in 1 of these cases. In the follow-up period, local tumor recurrence was detected in 3 cases. Two of these cases involved primary EP-diagnosed adenoma. The recurrent tumors were also adenomas detected by biopsy. The remaining case involved primary EP-diagnosed adenocarcinoma. The recurrent tumor was also an adenocarcinoma. All of the recurrent tumors were successfully treated with argon plasma coagulation (APC). There was no local or lymph node recurrence after the APC. The post-APC follow-up periods lasted for 57.1 to 133.8 mo. No ampullary tumor-related deaths occurred in all patients.

CONCLUSION

Resected margin positive or uncertain cases after EP could be managed by endoscopic treatment including APC, even in cases of adenocarcinoma. EP could become an effective less-invasive first-line treatment for early stage ampullary tumors.

The usefulness of wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

OBJECTIVES

Although endoscopic papillectomy is useful for treating papillary tumors, it is associated with a high rate of complications including pancreatitis; therefore, safer treatment options are needed. We examined the utility of wire-guided endoscopic papillectomy by comparing the pancreatic duct stenting and pancreatitis rates before and after wire-guided endoscopic papillectomy was introduced at our institution.

METHODS

We retrospectively examined the data from 16 consecutive patients who underwent conventional endoscopic papillectomy between November 1995 and July 2005 and the data from 33 patients in whom wire-guided endoscopic papillectomy was first attempted at our institution between August 2005 and April 2017. We compared the pancreatic duct stenting and pancreatitis rates between the two groups.

RESULTS

Of the 33 patients in whom wire-guided endoscopic papillectomy was first attempted, the procedure was completed in 21. Pancreatic duct stenting was possible in 30 of the 33 patients in whom wire-guided endoscopic papillectomy was attempted (91%), and this rate was significantly higher than that before the introduction of wire-guided endoscopic papillectomy (68.8%). The incidence of pancreatitis before the introduction of wire-guided endoscopic papillectomy was 12.5%, but after August 2005, the incidence was reduced by half to 6.1%, which includes those patients in whom wire-guided endoscopic papillectomy could not be completed.

CONCLUSIONS

Although wire-guided endoscopic papillectomy cannot be completed in some patients, we believe that this method shows some potential for reducing the total incidence of post-endoscopic papillectomy pancreatitis owing to more successful pancreatic duct stenting.

Robotic transduodenal ampullectomy: A novel minimally invasive approach for ampullary neoplasms

BACKGROUND

The adoption of minimally invasive surgery for transduodenal ampullectomy has been slow because of special characteristics and complexity of this procedure.

METHODS

Six patients underwent robotic transduodenal ampullectomy. We employed novel methods to facilitate exposure of the ampulla.

RESULTS

All patients completed robotic transduodenal ampullectomy, but one patient was immediately converted to robotic pancreaticoduodenectomy because of presence of invasive carcinoma on frozen biopsy. The final pathologic report revealed high-grade dysplasia in four patients, low-grade dyplasia in one, and T2N0 in one patient who converted to pancreaticoduodenectomy. There was no immediate postoperative complication or mortality. One patient was readmitted after 3 months because of stricture of the bile duct outlet. There was no recurrence over a median follow-up period of 20 months.

CONCLUSION

An appropriate combination of patient positioning and retraction method helps the robot surgical system to provide competent performance for sophisticated and precise manipulation of ampullary lesions.

Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study

Background

Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions.

Methods

All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence.

Results

We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733).

Conclusion

Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.

Transduodenal ampullectomy for ampullary tumors - single center experience of consecutive 26 patients

Purpose

Transduodenal ampullectomy (TDA) has been reported in a limited number of cases and in a small number of case series. The aim of this study was to analyze perioperative and long-term oncological outcomes of patients with ampullary tumors who underwent TDA in a single large-volume center.

Methods

Through a retrospective review of data from 2004 to 2016, we identified 26 patients who underwent TDA at Asan Medical Center.

Results

Eleven of 26 patients underwent TDA for T1 and carcinoma in situ (high-grade dysplasia) cancer; these patients are still alive without recurrence. A major in-hospital complication (3.8%) occurred in 1 case, but there was no case of 90-day mortality. In addition, none of the patients was diagnosed as having newly developed diabetes mellitus after TDA. No significant differences were found between open and laparoscopic-TDA in terms of operation time, painkiller use, and hospital stay.

Conclusion

TDA is a feasible and effective surgical procedure for the treatment of selected patients with ampullary tumors. It is an alternative treatment option in cases of ampullary tumors not amenable to endoscopic papillectomy or pancreaticoduodenectomy.

Secondary tumours of the ampulla of Vater: Case report and review of the literature

Secondary tumours of the ampulla of Vater are rare. Underlying primary tumours, clinical presentation, macroscopic appearance, treatment strategies and outcome of secondary ampullary lesions have not been systematically analysed. The present case study reported a 57-year old patient with an ampullary metastasis from renal cancer and a literature review was performed in which a further 32 patients were included. The most common responsible primary tumours were malignant melanoma and renal clear cell carcinoma, followed by breast cancer. The time interval between the diagnosis of the primary tumour and the ampullary metastasis was highly variable, and may be as long as 10 years, particularly for renal cancer. Patients may present with unspecific abdominal discomfort, jaundice or upper gastrointestinal bleeding. The gross appearance was largely indistinguishable from that of a primary tumour. Lesions may present as polypoid or irregular, soft and friable tumour mass, in certain cases with superficial ulceration. In ~50% of cases, the ampullary metastasis was the only metastatic lesion, while in the remaining cases, the cancer had spread to one or more organs. The prognosis was generally poor. The management requires a multi-modal approach, including endoscopic, surgical and oncological procedure.

Surgical Ampullectomy with Complete Resection of the Common Bile Duct: a New Procedure for Radical Resection of Non-invasive Ampulloma with Biliary Extension

Extension of ampulloma into the lower common bile duct (CBD) is observed in up to 30% of cases. This biliary extension can prevent complete tumor resection thus is considered as a contraindication for endoscopic and even surgical ampullectomy. For ampullomas associated with a prolonged biliary extension, a pancreaticoduodenectomy is associated with a high morbidity and can be considered as an overtreatment for a benign neoplasm. The present study describes a new surgical approach including ampullectomy with complete resection of the intrapancreatic CBD and restoration of both biliary and pancreatic flow by two separate anastomoses. This procedure was performed in seven patients for a non-invasive ampulloma with a 25- to 70-mm CBD involvement. No patients died and three developed postoperative complications. Resection was R0 in all patients but one. With a 24-month median follow-up (range = 3-84), no patients developed pancreatic insufficiency or tumor recurrence.

Management of duodenal polyps

Duodenal adenomas are the most common type of polyp arising from the duodenum. These adenomas can occur within and outside of genetic syndromes, and are broadly classified as non-ampullary or ampullary depending on their location. All adenomas have malignant potential and are therefore appropriately treated by endoscopic resection. However, the unique anatomical properties of the duodenum, namely its relatively thin and vascular walls, narrow luminal diameter and relationship to the ampulla and its associated pancreatic and biliary drainage, pose an increased degree of complexity for any endoscopic interventions in this area. This review will discuss the epidemiology of duodenal adenomas, their endoscopic detection and diagnosis, and techniques for safe and effective endoscopic resection of ampullary and non-ampullary lesions.

Endoscopic ampullectomy: a technical review

BACKGROUND AND AIM

This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges.

METHODS

We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques.

RESULTS

Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy.

CONCLUSIONS

Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.

Endoscopic and surgical ampullectomy for non-invasive ampullary tumors: Short-term outcomes

Non-invasive ampullary tumors, may be treated with endoscopic (EA) or surgical ampullectomy (SA). However, evidence on the morbidity of these techniques remains limited. This pilot study aimed to assess and compare morbidity of EA and SA. Patients undergoing EA or SA for non-invasive ampullary tumors were retrospectively analyzed and compared. Outcomes were postoperative complications graded with Clavien Classification and Comprehensive Complication Index (CCI), and length of stay (LoS). A review of the literature was performed to propose an evidence-based algorithm to treat ampullary tumors. A total of 11 EA and 19 SA were identified and analyzed. EA was associated with shorter intervention (51 vs. 191 min, p < 0.001) and decreased blood loss (0 vs. 100 mL, p < 0.001). Postoperative complications were more frequent after surgery compared to endoscopy (9% vs. 68%, p = 0.002). Surgical patients showed a higher CCI (0 vs. 8.7, p < 0.001). LoS was reduced in patients undergoing endoscopy (0 vs. 14 days, p < 0.001), with comparable readmissions rates (p = 0.126). Necessity of subsequent treatment was more frequent after endoscopic, compared to SA (5 vs. 1, p = 0.016). EA was associated with lower morbidity than SA and appeared as an appropriate first-line treatment for non-invasive ampullary tumors. SA remains a valuable alternative after EA failure.

Does ampullary adenoma size predict invasion on EUS? Does invasion on EUS predict presence of malignancy?

Background and study aims: It is common practice to perform ampullectomy without endoscopic ultrasound (EUS) for ampullary lesions < 1 cm but no data exists to support it. No studies have explored whether EUS findings of invasion correlate with malignancy or high-grade dysplasia (HGD) on pathology. We explored the association between adenoma size, pathology results, and invasion on EUS.  Patients and methods: This was a single-center retrospective cohort study at a large tertiary care academic hospital. Chart review was performed for 161 patients with benign ampullary lesions on endoscopic biopsy (identified by pathology records). The primary outcomes were mean size (mm) of adenomas and pathology findings with and without intraductal and/or duodenal wall invasion on EUS.  Results: Invasion was identified by EUS in 41 (34.1 %) of 120 patients who underwent EUS. The mean size of the lesion in these patients was 20.9 mm (± 11.6 mm) compared to 13.9 mm (± 11.3 mm, P = 0.0001) in patients without invasion. A receiver operating characteristic (ROC) curve (AUC 0.73, 95 % CI 0.63 - 0.83) revealed 100 % sensitivity for absence of invasion on EUS in lesions less than 6.5 mm. Invasion on EUS had sensitivity of 63.0 % (95 % CI 47.0 % - 77.0 %) and specificity 88.0 % (95 % CI 78.0 % - 95.0 %) for presence of malignancy, HGD or invasion on pathology. Conclusions: EUS should be considered for ampullary lesions > 6.5 mm. This study provides evidence to support the practice of ampullectomy without EUS for smaller adenomas. EUS evidence of invasion is highly specific for pathologic malignancy, HGD, or invasion (which preclude endoscopic ampullectomy).

Transduodenal Ampullectomy for the Treatment of Early-Stage Ampulla of Vater Cancer

BACKGROUND

Transduodenal ampullectomy (TDA) is a less invasive procedure than pancreaticoduodenectomy (PD). However, the outcomes of TDA and PD have been compared rarely in early ampullary cancer.

METHODS

From September 1994 to June 2013, the patients who underwent curative surgery for Tis or T1 ampulla of Vater neoplasm were identified. The patients were divided into two groups according to the types of surgery; TDA group and PD group. The patient characteristics and survival outcomes were retrospectively investigated between the two groups.

RESULTS

Total 137 patients were included in this study. The 18 patients underwent TDA and 119 patients underwent PD for Tis or T1 ampullary cancer. There was no lymph node metastasis in the patients with Tis tumor although 10 of 104 patients had lymph node metastasis in T1 cancer. After a median follow-up of 50 months (range, 6-148), there were no recurrence after TDA for Tis tumor. However, the TDA was associated with higher local recurrence rate than PD in the patients with T1 ampullary cancer on Kaplan-Meier survival analysis (p = 0.007).

CONCLUSION

The TDA is feasible treatment for Tis ampulla of Vater neoplasm. However, TDA is unsuitable for the treatment of T1 ampulla of Vater cancer.

[Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management]

Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.

Can endoscopic papillectomy be curative for early ampullary adenocarcinoma of the ampulla of Vater?

BACKGROUND

The therapeutic role of endoscopic papillectomy (EP) for early ampullary cancer (AC) is still controversial. The aim of the present study was to evaluate the curative potential of EP for early AC and to identify predictors of lymph node metastases (LNMs).

METHODS

We retrospectively reviewed 173 patients who were prospectively included in a database and who underwent EP between 1999 and 2013. Adenocarcinoma was present in 28 resected specimens. An additional surgery was proposed in cases of duodenal submucosal infiltration, duct ingrowth, R1 resection or lymphovascular invasion. Clinicopathological information and outcomes were collected, and predictors of LNMs were evaluated.

RESULTS

Duodenal submucosal invasion was present in 16/28 cases and LNMs, in 9/28 cases. ACs of the biliopancreatic subtype were smaller (NS); 100 % had submucosal invasion, and 71 % had LNMs. Smaller tumour size, biliopancreatic subtype and submucosal invasion were significantly correlated with LNMs (p < 0.028, p < 0.028 and p < 0.014). Predictive factors of LNMs in the multivariate analysis were submucosal invasion and tumour size (OR 0.032, p < 0.023 and OR 0.711, p < 0.035). EP was curative in 100 % of cancers with R0 resection and no evidence of submucosal or lymphovascular invasion.

CONCLUSION

EP may be curative for patients with AC limited to the duodenal mucosa or the sphincter of Oddi without lymphovascular invasion. Due to the presence of more invasive stages at diagnosis, EP may not be curative for ACs of the biliopancreatic subtype. The significance of tumour size is limited by other confounders, such as the histological subtype.

Characteristic endoscopic ultrasound findings of ampullary lesions that predict the need for surgical excision or endoscopic ampullectomy

Background and Objectives:

The management of ampullary lesions has evolved to include endoscopic ampullectomy (EA) as a curative approach to cancers of the ampulla of Vater. With this change comes a need to risk-stratify patients at initial diagnosis.

Materials and Methods:

Patients with verified ampullary lesions (N = 50) were analyzed in a case-control design. We evaluated endoscopic ultrasound (EUS) data to define characteristics that yield a high sensitivity in selecting candidates for EA.

Results:

Using data from previously published studies yielded a sensitivity of 0.765 in appropriately identifying the 34 surgical cases. Expanding these characteristics increased the sensitivity of EUS to 0.971 in identifying surgical candidates. Additionally, of advanced disease cases, the expanded characteristics correctly identified these cases with a sensitivity of 1.0-improved over 0.708 using prior published data.

Conclusion:

EA should be strongly considered if ampullary lesions are found to fit the following characteristics after EUS evaluation: lesion size <2.5 cm, invasion ≤4 mm, pancreatic duct dilatation ≤3 mm, ≤T1 lesion, no lymph nodes present, and no ductal stent in place. Furthermore, EUS data can be used to identify all high-risk lesions. With these characteristics identified, clinicians are better able to risk-stratify patients using EUS as either appropriate for or too high-risk for endoscopic resection.

Transduodenal ampullectomy provides a less invasive technique to cure early ampullary cancer

Background

The aim of this study was to evaluate the clinical efficiency of transduodenal ampullectomy (TDA) compared to conventional pancreatoduodenectomy (PD) in patients with early ampullary cancers.

Methods

We carried out a retrospective study by reviewing the medical records of 43 patients with early ampullary cancer who underwent either TDA or PD from January 2001 to December 2014. TDA and PD were performed on 22 patients and 21 patients, respectively. Clinical data, perioperative clinical outcomes and prognosis were evaluated. The median follow-up was 75 (range, 38–143) months.

Results

The sensitivity of intraoperative frozen resection was 100 % (4/4) and 94.9 % (37/39) in patients with pTis and pT1 tumors compared to final histologic diagnoses. The 5-year survival rate of patients with early ampullary cancer was 77.3 % in TDA group and 75.9 % in PD group (P = 0.927). Patients with lymph node metastasis presented a shorter 5-year survival rate (P = 0.014). TDA was associated with lower surgical morbidity (P = 0.033), estimated blood loss (P = 0.002), medical cost (P = 0.028) compared to PD. No pancreatic fistula and surgical mortality occurred in TDA group.

Conclusions

TDA could produce satisfactory clinical efficiency in patients fulfilled the following criteria simultaneously: pTis or pT1 stage, tumor size ≤ 2 cm, without lymph node metastasis. To achieve favorable outcomes, intraoperative frozen section examinations should be reliable and resection margins should be negative.

Development and evaluation of a 3D printed endoscopic ampullectomy training model (with video)

BACKGROUND

Endoscopic ampullectomy is a technically challenging, high-risk procedure with limited training opportunities. Although simulation models can assist with endoscopic skill acquisition, an ampullectomy model does not currently exist.

OBJECTIVE

To develop a training model that can be used to improve technical skills, knowledge, and confidence in performing endoscopic ampullectomy.

DESIGN

Experimental study.

SETTING

Tertiary hospital innovation laboratory.

SUBJECTS

Twenty-one endoscopists attending an endoscopic resection workshop.

INTERVENTIONS

A prototype for endoscopic ampullectomy was created by computer-aided design and 3-dimensional printing of an ampullary mount and base to which a chicken heart was attached and inserted into a silicone stomach-duodenum model. Study participants performed an ampullectomy and evaluated the prototype with a pre- and postampullectomy questionnaire by using a scale of 1 to 5 (very low to very high).

MAIN OUTCOME MEASUREMENTS

Evaluation of core procedural steps, technical and visual realism, and proceduralist technical knowledge and confidence.

RESULTS

Sixteen endoscopists participated in the study. All core procedural steps were completed by 14 participants. The mean overall technical and visual realism scores were 3.1 (standard deviation [SD], 0.9) and 3.2 (SD, 0.9), respectively. Ten participants (10/15, 66.7%) thought that their technical knowledge had improved, and 11 thought that it would increase further with additional sessions (11/15, 73.3%). Mean confidence score before and after using the model was 2.2 (SD, 1.2) and 2.9 (SD, 1.1), respectively (P=.132).

LIMITATIONS

Pilot study, lack of follow-up of participants' endoscopic practice after model experience.

CONCLUSION

Although further studies are necessary for validation, this novel prototype appears useful for endoscopic ampullectomy training.

Approach to the endoscopic resection of duodenal lesions

Duodenal polyps or lesions are uncommonly found on upper endoscopy. Duodenal lesions can be categorized as subepithelial or mucosally-based, and the type of lesion often dictates the work-up and possible therapeutic options. Subepithelial lesions that can arise in the duodenum include lipomas, gastrointestinal stromal tumors, and carcinoids. Endoscopic ultrasonography with fine needle aspiration is useful in the characterization and diagnosis of subepithelial lesions. Duodenal gastrointestinal stromal tumors and large or multifocal carcinoids are best managed by surgical resection. Brunner's gland tumors, solitary Peutz-Jeghers polyps, and non-ampullary and ampullary adenomas are mucosally-based duodenal lesions, which can require removal and are typically amenable to endoscopic resection. Several anatomic characteristics of the duodenum make endoscopic resection of duodenal lesions challenging. However, advanced endoscopic techniques exist that enable the resection of large mucosally-based duodenal lesions. Endoscopic papillectomy is not without risk, but this procedure can effectively resect ampullary adenomas and allows patients to avoid surgery, which typically involves pancreaticoduodenectomy. Endoscopic mucosal resection and its variations (such as cap-assisted, cap-band-assisted, and underwater techniques) enable the safe and effective resection of most duodenal adenomas. Endoscopic submucosal dissection is possible but very difficult to safely perform in the duodenum.

Surgical ampullectomy: an underestimated operation in the era of endoscopy

INTRODUCTION

Benign neoplastic, inflammatory or functional pathologies of the ampulla of Vater are mainly treated by primary endoscopic interventions. Consequently, transduodenal surgical ampullectomy (TSA) has been abandoned in many centres, although it represents an important tool not only after unsuccessful endoscopic treatment. The aim of the study was to analyse TSA for benign lesions of the ampulla of Vater.

PATIENTS AND METHODS

All patients who underwent TSA between 2001 and 2014 were included. Patients were analysed in terms of indications, postoperative morbidity and mortality as well as long-term success.

RESULTS

Eighty-three patients underwent TSA. Indications included adenomas in 44 and inflammatory stenosis in 39 patients. 96% of the patients had undergone endoscopic therapeutic approaches prior to TSA (median no. of interventions n = 3). Postoperative morbidity occurred in 20 patients (24%). There was one procedure-associated death (mortality 1.2%). The mean follow-up was 54 months. Long-term overall success rate for TSA was 83.6%. After TSA for ampullary adenoma, the recurrence rate was 4.5%.

CONCLUSION

TSA is an underestimated surgical procedure, which can be performed safely with high long-term efficacy. It can be implemented in clinical algorithms for patients with benign pathologies of the ampulla of Vater, particularly after unsuccessful endoscopic treatment.

Endoscopic management of adenomatous ampullary lesions

Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

Endoscopic papillectomy and KRAS expression in the treatment of adenoma in the major duodenal papilla

OBJECTIVE

The use of endoscopic papillectomy for resecting adenomas in the major duodenal papilla is increasing. This study focuses on the following three issues: Can endoscopic papillectomy be performed as a safe diagnostic and/or therapeutic procedure in biopsy-verified or suspected ampullary adenoma? Does expression of mutated KRAS in resected adenomatous tissue predict long-term outcome? What other factors may affect long-term outcome and should, therefore, be considered in decision making prior to endoscopic papillectomy?

MATERIAL AND METHODS

Thirty-six prospectively collected patients who underwent endoscopic papillectomy at Karolinska University Hospital between 2005 and 2014 were analyzed.

RESULTS

The rate of exact agreement between the histomorphological grading of the endoscopic biopsies and the papillectomy specimens was low (48%). Obstructive jaundice at presentation increased the risk of undetected adenocarcinoma (RR = 3.98; 95% CI = 1.46-10.85, p = 0.007). Lesions with malignancies were significantly larger (mean 30.6 mm) than those where only adenomas were found (mean 14.4 mm, p = 0.001). Mutated KRAS was detected in 9 of the 36 post-papillectomy specimens, including 4 of the 5 cases of ampullary adenocarcinoma. Eighteen cases were endoscopically cured after a mean follow-up period of 47 months (range 16-92 months).

CONCLUSIONS

Endoscopic papillectomy is a valuable staging tool because of the limitations of endoscopic biopsy. Endoscopic papillectomy concomitantly offers a curative treatment for most patients with adenoma in the major duodenal papilla. Jaundice at presentation and large adenomas may indicate the presence of more advanced disease. Determination of mutated KRAS seems to be of limited value in predicting long-term outcome.

Performance characteristics of EUS for locoregional evaluation of ampullary lesions

BACKGROUND

The accuracy of EUS in the locoregional assessment of ampullary lesions is unclear.

OBJECTIVES

To compare EUS with ERCP and surgical pathology for the evaluation of intraductal extension and local staging of ampullary lesions.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care referral center.

PATIENTS

All patients who underwent EUS primarily for the evaluation of an ampullary lesion between 1998 and 2012.

INTERVENTION

EUS.

MAIN OUTCOME MEASUREMENTS

Comparison of EUS sensitivity/specificity for intraductal and local extension with ERCP and surgical pathology by using the area under the receiver-operating characteristic (AUROC) curves and outcomes of the subgroup referred for endoscopic papillectomy.

RESULTS

We identified 119 patients who underwent EUS for an ampullary lesion, of whom 99 (83%) had an adenoma or adenocarcinoma. Compared with ERCP (n = 90), the sensitivity/specificity of EUS for any intraductal extension was 56%/97% (AUROC = 0.77; 95% confidence interval [CI], 0.64-0.89). However, when using surgical pathology as the reference (n = 102), the sensitivity/specificity of EUS (80%/93%; AUROC = 0.87; 95% CI, 0.76-0.97) and ERCP (83%/93%; AUROC = 0.88; 95% CI, 0.77-0.99) were comparable. The overall accuracy of EUS for local staging was 90%. Of 58 patients referred for endoscopic papillectomy, complete resection was achieved in 53 (91%); in those having intraductal extension by EUS or ERCP, complete resection was achieved in 4 of 5 (80%) and 4 of 7 (57%), respectively.

LIMITATION

Retrospective design.

CONCLUSIONS

EUS and ERCP perform similarly in evaluating intraductal extension of ampullary adenomas. Additionally, EUS is accurate in T-staging ampullary adenocarcinomas. Future prospective studies should evaluate whether EUS can identify characteristics of ampullary lesions that appropriately direct patients to endoscopic or surgical resection.

Current status of endoscopic papillectomy for ampullary tumors

Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.

Adenoma of the ampulla of Vater: a case report

Introduction

Lesions of the ampulla of Vater are rare histological entities with an incidence of between 0.1 and 0.2% of gastrointestinal tumors. Until recently the main response to this kind of lesion was duodenopancreatectomy, regardless of the cellular atypia and local edema. In this study, we propose the application of transduodenal local excision of the ampulla of Vater especially in recognized cases of nonmalignant adenomas.

Case presentation

In this case report we analyze the case of a 78-year-old Greek man who revealed symptoms such as icterus, abdominal pain without constipation and bloody stools. A physical examination showed painless swelling of the gallbladder (Courvoisier sign). No previous abdominal operations or hernias were identified. Blood tests, computed tomography scan analysis, gastroscopy and endoscopic retrograde cholangiopancreatography along with biopsies and cytological tests diagnosed nonmalignant adenoma of the ampulla of Vater with high-grade dysplasia. The treatment we followed was transduodenal local excision of his ampulla of Vater.

Conclusions

Transduodenal local excision of the ampulla of Vater has limited side effects and postoperative complications, suggesting this particular technique to be the proper treatment for nonmalignant cases of adenomas.

Endoscopic papillectomy: risk factors for incomplete resection and recurrence during long-term follow-up

BACKGROUND

Endoscopic papillectomy is increasingly used as an alternative to surgery for ampullary adenomas and other noninvasive ampullary lesions.

OBJECTIVE

To measure short-term safety and efficacy of endoscopic papillectomy, define patient and lesion characteristics associated with incomplete endoscopic resection, and measure adenoma recurrence rates during long-term follow-up.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care academic medical center.

PATIENTS

All patients who underwent endoscopic papillectomy for ampullary lesions between July 1995 and June 2012.

INTERVENTION

Endoscopic papillectomy.

MAIN OUTCOME MEASUREMENTS

Patient and lesion characteristics associated with incomplete endoscopic resection and ampullary adenoma-free survival analysis.

RESULTS

We identified 182 patients who underwent endoscopic papillectomy, 134 (73.6%) having complete resection. Short-term adverse events occurred in 34 (18.7%). Risk factors for incomplete resection were jaundice at presentation (odds ratio [OR] 0.21; 95% confidence interval [CI] 0.07-0.69; P = .009), occult adenocarcinoma (OR 0.06; 95% CI, 0.01-0.36; P = .002), and intraductal involvement (OR 0.29; 95% CI, 0.11-0.75; P = .011). The en bloc resection technique was strongly associated with a higher rate of complete resection (OR 4.05; 95% CI, 1.71-9.59; P = .001). Among patients with ampullary adenoma who had complete resection (n = 107), 16 patients (15%) developed recurrence up to 65 months after resection.

LIMITATIONS

Retrospective analysis.

CONCLUSION

Jaundice at presentation, occult adenocarcinoma in the resected specimen, and intraductal involvement are associated with a lower rate of complete resection, whereas en bloc papillectomy increases the odds of complete endoscopic resection. Despite complete resection, recurrence was observed up to 5 years after papillectomy, confirming the need for long-term surveillance.

Laparoscopic transduodenal local resection of periampullary neuroendocrine tumor: A case report

Studies on laparoscopic transduodenal local resection have not been readily available. Only three cases have been reported in the English-language literature. We describe herein a case of 25-year-old woman with periampullary neuroendocrine tumor (NET). Endoscopic ultrasonography revealed a duodenal papilla mass originated from the submucosa and close to the ampulla. The periampullary tumor was successfully managed with laparoscopic transduodenal local resection without any procedure-related complications. Pathological examination showed a NET (Grade 2) with negative margin. The patient was followed up for six months without signs of recurrence. This case suggests that laparoscopic transduodenal local resection is a feasible procedure in selected patients with periampullary tumor.