Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation

Pancreatic duct imaging during aging

As part of the aging process, fibrotic changes, fatty infiltration, and parenchymal atrophy develop in the pancreas. The pancreatic duct also becomes wider with age. This article provides an overview of the diameter of the pancreatic duct in different age groups and different examination methods. Knowledge of these data is useful to avoid misinterpretations regarding the differential diagnosis of chronic pancreatitis, obstructive tumors, and intraductal papillary mucinous neoplasia (IPMN).

Controversies in ERCP: Indications and preparation

The aim of the series of papers on controversies of biliopancreatic drainage procedures is to discuss the pros and cons of the varying clinical practices and techniques in ERCP and EUS for drainage of biliary and pancreatic ducts. The first part focuses on indications, clinical and imaging prerequisites before ERCP, sedation options, post-ERCP pancreatitis (PEP) prophylaxis, and other related technical topics. In the second part, specific procedural ERCP-techniques including precut techniques and its timing as well as management algorithms are discussed. In addition, controversies in EUS-guided bile duct and pancreatic drainage procedures are under preparation.

ENDOSCOPIC PAPILLECTOMY FOR EARLY AMPULLARY NEOPLASTIC LESIONS - A CASE SERIES ANALYSIS

BACKGROUND

Endoscopic papillectomy has been conceived as a less invasive therapeutic option for treatment of early neoplastic lesions located at the major duodenal papilla.

OBJECTIVE

Evaluating patients with early ampullary lesions who underwent curative intent endoscopic papillectomy related to technical success (histopathological tumor margin assessment) and safety (adverse event rate).

METHODS

A retrospective study including consecutive patients who underwent curative intent endoscopic papillectomy for demographic, histopathological and pre-/post-procedural clinical assessment. Endpoints were technical success (histopathological residual tumor assessment) and adverse events rates.

RESULTS

A total of 21 medical records patients with a female predominance (13 cases, 61.9%) were included. The tumor was incidental in 8 (38%) cases. Negative residual tumor resection margin rate was 72% (15 cases); three of these cases confirmed high-grade dysplasia in the resected specimen, and six cases were invasive neoplasia. Tumoral recurrence was seen in two cases, and median follow-up time was 12 months, with a 23% loss rate (five patients). Six (28.5%) patients had adverse events, all of them early (bleeding and pancreatitis); none of them required surgical intervention and there was no mortality.

CONCLUSION

Endoscopic papillectomy allowed for technical successful procedure with complete removal of ampullary neoplastic lesions in the majority of cases with acceptable adverse event rates. Recurrence rate should be carefully assessed in further studies. There was a recent increase in the number of procedures. There was also a low correlation between pre- and post-histopathological assessment regarding the presence of invasive carcinoma and adenoma with high grade dysplasia, with a predominance of superficial neoplastic adenomatous lesions.

Insights and updates on endoscopic papillectomy

INTRODUCTION

Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP.

AREA COVERED

This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions.

EXPERT OPINION

The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.

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.

[Papillary tumors - therapeutic concepts]

Papillary tumors originate from the various structures of the ampulla of Vater; therefore, these rare tumors represent a heterogeneous group of tumor entities. Intestinal differentiated adenomas are the most common benign lesions, whereas intestinal differentiated papillary carcinomas are the most common malignant tumors. Carcinomas with pancreaticobiliary differentiation have a poorer prognosis. Mesenchymal and neuroendocrine tumors are among the least frequent papillary tumors. Diagnosis is performed by side-view upper endoscopy and biopsy. In cases of suspected malignancy a complete staging with computed tomography (CT) and endoscopic ultrasound scanning is indicated to determine local tumor spread.Adenomas are removed by endoscopic snare papillectomy whereas the therapy of choice for papillary carcinomas is pancreatic head resection with systematic lymphadenectomy. Patients with papillary carcinomas are most likely to benefit from adjuvant therapy, which should be determined in an interdisciplinary consensus conference considering the histological differentiation of the tumor.

Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.

Endoscopic papillectomy: Data of a prospective observational study

AIM: To investigate the clinical value of endoscopic papillectomy indicated by feasibility and safety of the procedure in various diseases of the papilla in a representative number of patients in a setting of daily clinical and endoscopic practice and care by means of a systematic prospective observational study.

METHODS: Through a defined time period, all consecutive patients with tumor-like lesions of the papilla, who were considered for papillectomy, were enrolled in this systematic bicenter prospective observational study, and subdivided into 4 groups according to endoscopic and endoscopic ultrasonography (EUS) findings as well as histopathological diagnosis: adenoma; carcinoma/neuroendocrine tumor (NET)/lymphoma; papilla into which catheter can not be introduced; adenomyomatosis, respectively. Treatment results and outcome were characterized by R0 resection, complication, recurrence rates and tumor-free survival.

RESULTS: Over a 7-year period, 58 patients underwent endoscopic papillectomy. Main symptoms prompting to diagnostic measures were unclear abdominal pain in 50% and cholestasis with and without pain in 44%. Overall, 54/58 patients [inclusion rate, 93.1%; sex ratio, males/females = 25/29 (1:1.16); mean age, 65 (range, 22-88) years] were enrolled in the study. Prior to papillectomy, EUS was performed in 79.6% (n = 43/54). Group 1 (adenoma, n = 24/54; 44.4%): 91.6% (n = 22/24) with R0 resection; tumor-free survival after a mean of 18.5 mo, 86.4% (n = 19/22); recurrence, 13.6% (n = 3/22); minor complications, 12.5% (n = 3/24). Group 2 (carcinoma/NET/lymphoma, n = 18/54; 33.3%): 75.0% (n = 12/18) with R0 resection; tumor-free survival after a mean of 18.5 (range, 1-84) mo, 88.9% (n = 8/9); recurrence, 11.1% (n = 1/9). Group 3 (adenomyomatosis, n = 4/54; 7.4%). Group 4 (primarily no introducible catheter into the papilla, n = 8; 14.8%). The overall complication rate was 18.5% (n = 10/54; 1 subject with 2 complications): Bleeding, n = 3; pancreatitis, n = 7; perforation, n = 1 (intervention-related mortality, 0%). In summary, EUS is a sufficient diagnostic tool to preoperatively clarify diseases of the papilla including suspicious tumor stage in conjunction with postinterventional histopathological investigation of a specimen. Endoscopic papillectomy with curative intention is a feasible and safe approach to treat adenomas of the papilla. In high-risk patients with carcinoma of the papilla with no hints of deep infiltrating tumor growth, endoscopic papillectomy can be considered a reasonable treatment option with low risk and an approximately 80% probability of no recurrence if an R0 resection can be achieved. In patients with jaundice and in case the catheter can not be introduced into the papilla, papillectomy may help to get access to the bile duct.

CONCLUSION: Endoscopic papillectomy is a challenging interventional approach but a suitable patient- and local finding-adapted diagnostic and therapeutic tool with adequate risk-benefit ratio in experienced hands.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM: To investigate endoscopic ultrasound (EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.

METHODS: Records of 111 patients seen at our institution from November 1999 to July 2011 with the post-operative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed. Records of patients who underwent preoperative EUS for diagnostic purposes were identified. The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results. In addition, the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome (recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded, compared and analyzed.

RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions. In addition, computed tomography was performed in 18 patients, endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients. There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis (FAP)/other polyposis syndromes. In 38 (81%, P < 0.05) patients, EUS reliably identified absence of submucosal and muscularis invasion. In 4 cases, EUS underestimated submucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90% (P < 0.05). Types of resection performed included endoscopic resection in 22 cases, partial duodenectomy in 9 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 8), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2). Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intra-abdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. After median follow-up of 20 mo there were 6 local recurrences (13%, median follow-up = 20 mo) 4 of which were in patients with FAP.

CONCLUSION: EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection.

Pancreatico-biliary endoscopic ultrasound: A systematic review of the levels of evidence, performance and outcomes

Our aim was to record pancreaticobiliary endoscopic ultrasound (EUS) literature of the past 3 decades and evaluate its role based on a critical appraisal of published studies according to levels of evidence (LE). Original research articles (randomized controlled trials, prospective and retrospective studies), meta-analyses, reviews and surveys pertinent to gastrointestinal EUS were included. All articles published until September 2011 were retrieved from PubMed and classified according to specific disease entities, anatomical subdivisions and therapeutic applications of EUS. The North of England evidence-based guidelines were used to determine LE. A total of 1089 pertinent articles were reviewed. Published research focused primarily on solid pancreatic neoplasms, followed by disorders of the extrahepatic biliary tree, pancreatic cystic lesions, therapeutic-interventional EUS, chronic and acute pancreatitis. A uniform observation in all six categories of articles was the predominance of LE III studies followed by LE IV, IIb, IIa, Ib and Ia, in descending order. EUS remains the most accurate method for detecting small (< 3 cm) pancreatic tumors, ampullary neoplasms and small (< 4 mm) bile duct stones, and the best test to define vascular invasion in pancreatic and peri-ampullary neoplasms. Detailed EUS imaging, along with biochemical and molecular cyst fluid analysis, improve the differentiation of pancreatic cysts and help predict their malignant potential. Early diagnosis of chronic pancreatitis appears feasible and reliable. Novel imaging techniques (contrast-enhanced EUS, elastography) seem promising for the evaluation of pancreatic cancer and autoimmune pancreatitis. Therapeutic applications currently involve pancreaticobiliary drainage and targeted fine needle injection-guided antitumor therapy. Despite the ongoing development of extra-corporeal imaging modalities, such as computed tomography, magnetic resonance imaging, and positron emission tomography, EUS still holds a leading role in the investigation of the pancreaticobiliary area. The major challenge of EUS evolution is its expanding therapeutic potential towards an effective and minimally invasive management of complex pancreaticobiliary disorders.

Clinical evaluation of endoscopic papillectomy for the diagnosis of tumors of the ampulla of Vater

AIM: To evaluate the value of endoscopic papillectomy (EP) for the diagnosis of tumors of the ampulla of Vater.

METHODS: The clinical data for 16 patients with tumors of the ampulla of Vater were analyzed. The clinical efficacy, complications and safety of EP were evaluated.

RESULTS: Before EP, 12 patients were diagnosed with adenoma and 4 with chronic inflammation by endoscopic biopsy. After EP, 2 cases were diagnosed with poorly differentiated adenocarcinoma, 1 with well differentiated adenocarcinoma, and 13 with adenoma (including one case of adenoma with malignant transformation and all 4 cases diagnosed with "chronic inflammation" by endoscopic biopsy). The accuracy of EP was significantly higher than that of endoscopic biopsy (P < 0.05). In 9 cases, EUS showed that the lesions originated from the submucosal layer with dilated pancreatic and biliary ducts. None of the cases had submucosal continuity interruption, invasion to pancreatic/biliary ducts or enlarged retroperitoneal lymph nodes on EUS. Twelve patients with high echoic lesions were confirmed to have adenoma, one patient with hyperechoic lesion with localized low echo area were confirmed to have adenoma with malignant transformation, and 3 patients with low echo lesions were confirmed to have adenocarcinoma. After EP, residual lesions were found in bile duct orifice in 2 cases of poorly differentiated adenocarcinoma, 1 case of adenoma with malignant transformation and 1 case of adenoma, indicating invasion to the bile duct. All of them had a negative preoperative EUS. Lesions were completely resected in 1 case of well differentiated adenocarcinoma and 11 cases of adenoma, and the resection stump was histologically negative for neoplasm. After EP, two patients developed transient melena, but no acute pancreatitis, perforation or other complications occurred. There was no procedural-related death in this group of patients.

CONCLUSION: EP is safe and has a higher accuracy in the diagnosis of tumors of the ampulla of Vater.

Endoscopic ultrasound in the papilla and the periampullary region

Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected. Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS, for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.