Endoscopic snare papillectomy of adenocarcinoma of the major duodenal papilla

Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study

BACKGROUND

Ampullary adenoma is a rare premalignant lesion, but its incidence is increasing. Endoscopic papillectomy has become the first treatment of choice for ampullary adenomas due to its safety and effectiveness, thereby replacing surgical resection. However, recurrence rates and adverse events after endoscopic papillectomy were reported in up to 30% of cases.

AIM

To review the long-term outcomes of endoscopic papillectomy and investigate the factors that affect these outcomes.

METHODS

We retrospectively analyzed the data of patients who underwent endoscopic papillectomy for ampullary adenoma at five tertiary hospitals between 2013 and 2020. We evaluated clinical outcomes and their risk factors. The definitions of outcomes were as follow: (1) curative resection: complete endoscopic resection without recurrence; (2) endoscopic success: treatment of ampullary adenoma with endoscopy without surgical intervention; (3) early recurrence: reconfirmed adenoma at the first endoscopic surveillance; and (4) late recurrence: reconfirmed adenoma after the first endoscopic surveillance.

RESULTS

A total of 106 patients were included for analysis. Of the included patients, 81 (76.4%) underwent curative resection, 99 (93.4%) had endoscopic success, showing that most patients with non-curative resection were successfully managed with endoscopy. Sixteen patients (15.1%) had piecemeal resection, 22 patients (20.8%) had shown positive/uncertain resection margin, 11 patients (16.1%) had an early recurrence, 13 patients (10.4%) had a late recurrence, and 6 patients (5.7%) had a re-recurrence. In multivariate analysis, a positive/uncertain margin [Odds ratio (OR) = 4.023, P = 0.048] and piecemeal resection (OR = 6.610, P = 0.005) were significant risk factors for early and late recurrence, respectively. Piecemeal resection was also a significant risk factor for non-curative resection (OR = 5.424, P = 0.007). Twenty-six patients experienced adverse events (24.5%).

CONCLUSION

Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas. Careful selection and follow-up of patients is mandatory, particularly in cases with positive/uncertain margin and piecemeal resection.

Novel clip device for prevention of bleeding after endoscopic papillectomy

Objectives

Recently, a novel clip device, SureClip^® (Micro‐Tech Co. Ltd., Nanjing, China), has been developed, which improved rotation and reopening performance. We aimed to assess the efficacy of the SureClip^® in prophylactic closure of the mucosal break after endoscopic papillectomy (EP) for ampullary neoplasm.

Methods

We retrospectively reviewed the medical records of 40 patients who underwent EP for ampullary neoplasms between October 2009 and March 2020. Prophylactic closure after resection was performed using the conventional clip between 2014 and 2018, and with the SureClip^® after 2019. The baseline characteristics, techniques, outcomes, and complications of EP were analyzed.

Results

The median age of the patients (25 males and 15 females) was 70 years. The en block resection rate was 82.5% and the curative resection rate was 80.0%. Histologically, 11 (27.5%) patients had malignancy. Prophylactic closure was performed in 29 (72.5%) patients (17 conventional clips, 12 SureClip^®). Complications occurred in 18 (45.0%) patients, including postprocedure bleeding in 9 (22.5%) patients. However, no postprocedure bleeding was observed in the patients who received prophylactic closure using the SureClip^® (p = 0.038). All other factors were not significantly correlated with postprocedure bleeding. The duration of hospital stay after EP was significantly shorter in patients treated with the SureClip^® compared to those treated with a conventional clip or without clips (p < 0.05).

Conclusions

In the present study, prophylactic clipping of the mucosal break using the SureClip^® was effective in preventing bleeding after EP.

Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions

Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8–81.4%, I² = 91.38%) for EA, 96.4% (93.6–99.2%, I² = 37.8%) for SA and 98.9% (98.0–99.7%, I² = 0%) for PD. AEs were 24.7% (19.8–29.6%, I² = 86.4%), 28.3% (19.0–37.7%, I² = 76.8%) and 44.7% (37.9–51.4%, I² = 0%), respectively. Recurrences were registered in 13.0% (10.2–15.6%, I² = 91.3%), 9.4% (4.8–14%, I² = 57.3%) and 14.2% (9.5–18.9%, I² = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.

Study Protocol of the ESAP Study: Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for Ampullary Neoplasm-A Pancreas2000/EPC Study

Background: Lesions of the Ampulla of Vater are a rare condition and represent <10% of peri-ampullary neoplasms. Nevertheless, ampullary adenomas have the potential for malignant transformation to ampullary carcinomas by an adenoma-to-carcinoma sequence. Thus, adequate patient selection and complete resection (R0) of non-invasive ampullary lesions either by endoscopic papillectomy (EP), surgical ampullectomy (SA), or pancreaticoduodenectomy (PD) is essential. Although PD was traditionally performed, recent studies reported considerable efficacy and fewer complications following EP and SA. Since consistent comparative data are lacking, the Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodectomy (ESAP) study will provide evidence for a therapeutic standard and post procedure morbidity in ampullary lesions. Methods: International multicenter retrospective study. Adult patients (>18 years of age) who underwent SA or PD for ampullary neoplasm between 2004 and 2018 or EP between 2007 and 2018 will be evaluated. Main inclusion criteria are ampullary lesions strictly located to the ampulla. This includes adenoma, adenocarcinoma (T1 and T2), neuroendocrine tumors, gastrointestinal stroma tumors and other rare conditions. Exclusion criteria are peri-ampullary lesions, e.g., from the duodenal wall or the head of the pancreas, and interventions for tumor stages higher than T2. The main objective of this study is to analyze rates of complete resection (R0), recurrence and necessity for complementary interventions following EP, SA, and PD. Treatment-quality for each procedure will be defined by morbidity, mortality and complication rates and will be compared between EP, SA, and PD. Secondary objectives include outcome for patients with incomplete resection or initially understated tumors, lesions of the minor papilla, hereditary syndromes, neuroendocrine tumors, mesenchymal lesions, and other rare conditions. Additionally, we will analyze therapy by argon plasma coagulation and radiofrequency ablation. Furthermore, outcome in curative and palliative interventions can be distinguished. Conclusion: The ESAP study will provide evidence for therapeutic algorithms and data for the implementation of guidelines in the treatment of different types of ampullary tumors, including recurrent, or incomplete resected lesions.

Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis

Endoscopic papillectomy (EP) is a viable therapy in ampullary lesions (AL). Many series have reported low morbidity and acceptable outcomes. We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for AL. Electronic databases (Medline, Scopus and EMBASE) were searched up to September 2018. Studies that included patients with endoscopically resected AL were eligible. The rate of adverse events (AEs; primary outcome) and the rates of both technical and clinical efficacy outcomes were pooled by means of a random- or fixed-effects model to obtain a proportion with a 95% confidence interval (CI). Twenty-nine studies were included (1751 patients). The overall AE rate was 24.9%. The post-procedural pancreatitis rate was 11.9%, with the only factor affecting this outcome being prophylactic pancreatic stenting. The complete resection rate was 94.2%, with a rate of oncologically curative resection of 87.1%. The recurrence rate was 11.8% (follow-up: 9.6-84.5 months). EP is a relatively safe and effective option for AL. Our study might definitively suggest the protective role of prophylactic pancreatic stenting against post-procedural pancreatitis.

Ampulla of Vater carcinoma: Molecular landscape and clinical implications

Ampulla of Vater is a peculiar anatomical structure, characterized by the crossroad of three distinct epithelia: Intestinal, ductal pancreatic and biliary. Adenocarcinomas arising in this area represent an opportunity to understand the comparative biology of all periampullary malignancies. These neoplasms can exhibit intestinal, pancreaticobiliary or mixed features, whereas the subclassification based on morphology and immunohistochemical features failed in demonstrating a robust prognostic reliability. In the last few years, the molecular landscape of this tumor entity has been uncovered, identifying alterations that may serve as prognostic and predictive biomarkers. In this review, the histological and genetic characteristics of ampullary carcinomas are discussed, taking into account the main clinical and therapeutic implications related to this tumor type as well.

Intussuscepting Ampullary Adenoma: An Unusual Cause of Gastric Outlet Obstruction Leading to Cavitating Lung Lesions

Ampullary adenomas are a rare clinical entity, occurring at a rate of 0.04–0.12% in the general population. They are premalignant lesions which have the capability to progress to malignancy, and they should be excised if they are causing immediate symptoms and/or are likely to degenerate to carcinoma. Intestinal intussusception in adults is rare and, unlike in children, is often due to a structural pathology. Intussuscepting duodenal/ampullary adenomas have been reported in the literature on 13 previous occasions, however never before with this presentation. We report the case of a woman who presented with a 1-year history of recurrent chest infections. She was treated with numerous antibiotics, whilst intermittent symptoms of recurrent vomiting and weight loss were initially attributed to her lung infections. A chest CT demonstrated multiple cavitating lung lesions, whilst an obstructing polypoid mass was noted at D2 on dedicated abdominal imaging. Due to ongoing nutritional problems, she had a semi-urgent pancreaticoduodenectomy. Intraoperative findings demonstrated a large mass at D2 with a duodeno-duodenal intussusception. Histological analysis reported a duodenal, ampullary, low-grade tubular adenoma, 75 × 28 × 30 mm in size, with intussusception and complete resection margins. The patient recovered well and was discharged on postoperative day 10, with no complications to date. Ampullary adenomas may present with obstruction of the main gastrointestinal tract and/or biliary/pancreatic ducts. Common presentations include gastric outlet obstruction, gastrointestinal bleeding or acute pancreatitis. This unique presentation should remind clinicians of the need to investigate recurrent chest infections for a possible gastrointestinal cause.

Cancer of the ampulla of vater: current evaluation and therapy

Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.

Staging accuracy of ampullary tumors by endoscopic ultrasound: meta-analysis and systematic review

BACKGROUND AND AIM

Accurate preoperative staging of ampullary neoplasms is of paramount importance in predicting prognosis and determining the most appropriate therapeutic approach. The aim of the present review was to evaluate the accuracy of endoscopic ultrasound (EUS) in predicting depth of ampullary tumor invasion (T-stage) and regional lymph node status (N-stage) by carrying out a meta-analysis of all relevant studies.

METHODS

We systematically searched PubMed, Medline and Scopus databases for all studies published between January 1980 and December 2012. Only EUS studies involving ≥ 10 patients with ampullary neoplasms, confirmed by surgical histopathology, with data available for construction of a 2 × 2 table were included.

RESULTS

Meta-analysis of 14 studies involving 422 patients using the Mantel-Haenszel method was performed. Pooled sensitivity and specificity of EUS to diagnose T1-stage tumor were 77% (95% CI: 69-83) and 78% (95% CI: 72-84), respectively. Pooled sensitivity for T4 tumors was 84% (95% CI: 73-92) and specificity was 74% (95% CI: 63-83). Combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio for diagnosing nodal status were 0.70 (95% CI: 0.62-0.77), 0.74 (95% CI: 0.67-0.0.80), 2.49 (95% CI: 1.91-3.24), 0.46 (95% CI: 0.36-0.59) and 6.53 (95% CI: 3.81-11.19), respectively.

CONCLUSION

Based on our pooled estimates, EUS had a moderate strength of agreement with histopathology in preoperative staging of ampullary neoplasms in predicting tumor invasion and lymph node involvement. Additional refinement in EUS technologies and diagnostic criteria may be required to enhance staging accuracy.

Extraduodenal papillectomy: a feasible alternative method of total papillectomy

Rational treatment for neoplasms of the duodenal papilla (NDPs) is still controversial, especially for early stage lesions. Total papillectomies are indicated in patients expected to have adenomas, adenocarcinoma in an adenoma, or mucosal adenocarcinomas with no lymph node metastases. However, the preoperative pathological evaluation of NDPs is still challenging and often inaccurate, mainly because of the complicated anatomical structures involved and the possibility of an adenocarcinoma in an adenoma. Herein, we introduce a new method of total papillectomy, the extraduodenal papillectomy (ExDP). In this method, papillectomy is undertaken from outside of the duodenum, instead of resection from the inside through a wide incision of the duodenal wall as is done in conventional transduodenal papillectomy (TDP). The advantages of ExDP are precise and deeper cutting of the sphincter and shorter exploration time of the tumor compared to conventional TDP. We demonstrate three representative patients, all of whom had an uneventful postoperative course. One of them subsequently underwent a pylorus preserving pancreatoduodenectomy after detailed postoperative pathological evaluation. Including that patient, no recurrence has occurred with 37-46 months of follow-up. In conclusion, ExDP is regarded as a "total biopsy" for early stage borderline lesions and a feasible, less demanding alternative method for the treatment of NDPs.

Primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis: report of a case

A 70-year-old male was treated for gastric ulcers. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. Computed tomography showed an irregular mass in the pancreatic head and dilatation of the main pancreatic duct and bile duct. Pancreatic head carcinoma with infiltration of the duodenum was diagnosed, and pylorus-preserving pancreaticoduodenectomy was performed. A histopathological examination of the resected specimen showed moderately differentiated adenocarcinoma in the minor duodenal papilla and chronic pancreatitis in the pancreatic head. Therefore, primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis was diagnosed. Currently, the patient is alive without recurrence 17 months after the surgery. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. We herein report this case, and also provide a review of the literature.

Review of the investigation and surgical management of resectable ampullary adenocarcinoma

BACKGROUND

Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours.

METHODS

A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours.

RESULTS

Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited.

CONCLUSIONS

Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.

Endoscopic approach to the patient with benign or malignant ampullary lesions

Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.

The diagnostic accuracy and strength of agreement between endoscopic ultrasound and histopathology in the staging of ampullary tumors

AIM

Ampullary tumors are rare. Reports on ampullary tumor staging are heterogeneous and combine both periampullary and ampullary tumors. This study assessed the performance of endoscopic ultrasound (EUS) in the local staging of ampullary tumors only.

METHODS

Data were collected retrospectively. We included patients with an ampullary tumor who underwent EUS and surgical resection. Tumor (T) and nodal (N) TNM staging for EUS and histopathological (HP) staging were compared.

RESULTS

From 2009 to 2010, a total of 79 patients with ampullary tumors were identified. Of these, 26 had both EUS and Whipple's surgery and were included (28 did not undergo resection, 13 had palliative surgery only and 12 had resection without EUS). For T staging by HP, there were 2 (7.7 %) T1, 11 (42.3 %) T2, 12 (46.2 %) T3 and 1 (3.8 %) T4 tumors. The accuracy of EUS T staging was 73.1 % with a Kappa value of 0.564 (p < 0.0001). The sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV) of EUS, respectively were 50.0 %, 91.7 %, 33.3 % and 95.7 % for T1 tumors; 81.8 %, 80.0 %, 75.0 % and 85.7 % for T2; 75.0 %, 92.9 %, 90.0 % and 81.3 % for T3 tumors. For N staging by HP, 17 (65.4 %) were N0 and 9 (34.6 %) N1. The N staging diagnostic accuracy was 80.8 % with a Kappa value of 0.586 (p = 0.003). The sensitivity, specificity, PPV, NPV for N0 disease were 82.4 %, 77.8 %, 87.5 % and 70.0 %, respectively while for N1 they were 77.8 %, 82.4 %, 70.0 % and 87.5 %, respectively.

CONCLUSIONS

EUS had a moderate strength of agreement with histopathology for both T and N staging, and a high diagnostic accuracy for nodal staging.

Diagnosis and management of ampullary adenoma: The expanding role of endoscopy

Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.

Primary adenocarcinoma of the minor duodenal papilla

A 70-year-old man was admitted to our institution due to aggravation of blood-sugar level control and because an abdominal CT showed dilatation of the main pancreatic duct. Upper gastrointestinal endoscopy revealed a flat elevated tumor with central ulceration in the second portion of the duodenum. Subsequent duodenoscopy for a more detailed examination showed that the tumor had originated in the minor duodenal papilla. A biopsy specimen showed moderately differentiated adenocarcinoma. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a slightly dilated main pancreatic duct and obstruction of the accessory pancreatic duct. Endoscopic ultrasonography showed a hypoechoic mass in the minor duodenal papilla with retention of the muscularis propria of the duodenum. These findings suggest that the tumor existed only to a limited extent in the minor duodenal papilla, and that the tumor did not infiltrate into the pancreas. For treatment, pylorus-preserving pancreatoduodenectomy was performed, and histological findings revealed a well-differentiated adenocarcinoma that originated in the minor duodenal papilla. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. Our case is the first report of primary adenocarcinoma of the minor duodenal papilla at an early stage with no infiltration into muscularis propria of the duodenum and pancreas.

Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study

BACKGROUND

Endoscopic papillectomy is performed in selected patients with ampullary neoplasm, and, thus, accurate preoperative tumor staging is indispensable for its application.

DESIGN

Prospective and histopathologically controlled study.

SETTING

Single center.

PATIENTS AND INTERVENTIONS

EUS and transpapillary intraductal US (IDUS) were performed in 40 patients with ampullary neoplasm before surgery (n = 30) or endoscopic papillectomy (n = 10). Ductal infiltration by a tumor into the bile duct (BD) or the pancreatic duct (PD) was also evaluated. The indication for endoscopic papillectomy was determined by findings obtained by EUS and IDUS. These findings were compared with histologic features of the resected specimens.

MAIN OUTCOME MEASUREMENTS AND RESULTS

Thirty-three patients had adenocarcinoma (14 pT1, 11 pT2, 8 pT3-4) and 7 had adenoma. Tumor depiction by EUS and IDUS was achieved in 95% and 100% of the patients, respectively. The diagnostic accuracy of EUS and IDUS in T staging was 62% and 86% in adenoma and pT1, 45% and 64% in pT2, and 88% and 75% in pT3-4, respectively. The overall accuracy by EUS and IDUS in T staging was 63% and 78%, respectively (P = .14). In 10 patients who underwent endoscopic papillectomy, the accuracy of IDUS in T staging with EUS and IDUS was 80% and 100%, respectively. Ductal infiltration into the BD and the PD was correctly assessed in 88% and 90% by EUS and in both BD and the PD in 90% by IDUS, respectively. Ductal infiltration was correctly diagnosed by EUS and IDUS in all patients who had a papillectomy.

CONCLUSION

Although IDUS had a tendency of overestimation in tumor staging for ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for endoscopic papillectomy.

Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

BACKGROUND

Recently, the evidence has been accumulating that endoscopic resection may be curative in treating ampullary adenoma that contains high-grade intraepithelial neoplasia/in situ tumor (HGIN/Tis). However, there are only anecdotal reports of endoscopic management of "focal" T1 ampullary cancer (T1 cancer), and radical surgery is still considered the only accepted treatment modality.

OBJECTIVE

To assess the possibility of endoscopic papillectomy as an alternative to radical surgery for the treatment of ampullary adenoma with HGIN/Tis or focal T1 cancer.

DESIGN

Retrospective evaluation of case series of our hospital from 1996 to 2006.

SETTING

Tertiary-care university teaching hospital.

PATIENTS

Twenty-three patients who had HGIN/Tis or focal T1 cancer in ampullary adenoma resected by endoscopic papillectomy and 60 patients who initially underwent radical surgery for HGIN/Tis or T1 cancer of the ampulla of Vater. "Focal" was defined as a lesion involving only mucosa, with a size less than a fourth the diameter of main adenoma.

INTERVENTIONS

Review of medical records and analysis of surgically or endoscopically resected specimens of ampullary tumors.

MAIN OUTCOME MEASUREMENTS

Locoregional extension and follow-up data.

RESULTS

Patients with HGIN/Tis of the ampulla of Vater had no lymphovascular invasion or lymph-node metastasis, and there were no occurrences of cancer or deaths during a mean (standard error [+/-SE]) 27.1 +/- 5.9 months after endoscopic papillectomy. T1 cancer was shown to have lymphovascular invasion and/or lymph-node metastasis in 10.7% and duct mucosal involvement in another 17.9%. Among them, patients with focal T1 cancer showed no lymphovascular invasion or lymph-node metastasis and no ductal involvement, and none of the patients who underwent endoscopic papillectomy alone had cancer recurrence or disease-related death for mean (+/-SE) 32.2 +/- 6.7 months.

LIMITATIONS

Single-center, retrospective study, small number of patients, and medium-term follow-up period.

CONCLUSIONS

Endoscopic papillectomy may be a curative treatment for ampullary adenoma with HGIN/Tis and should also be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma.

Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth

BACKGROUND

Endoscopic papillectomy of benign papillary tumor is still not widely practiced. Intraductal growth has been considered a contraindication for endoscopic therapy. This prospective study evaluates endoscopic papillectomy for treatment of benign papillary tumors without and with intraductal growth.

METHODS

Monofilament snare and monopolar electrocoagulation were used for papillectomy. A 7F stent was placed in the pancreatic duct. Patients with distal intraductal growth underwent sphincterotomy and endoscopic resection after exclusion of more proximal growth.

RESULTS

Between February 1985 and April 2004, 106 patients (109 lesions), 68 women, 38 men, median age 68 years (range 29-88 years) were included. Median tumor size was 2 cm (range 0.5-6 cm) with one session (range 1-8) required for removal. Nine patients had invasive carcinoma (8%). Surgery for incomplete removal or recurrence was performed in 12% of 75 patients without and 37% of 31 patients with intraductal growth (p < 0.01), respectively. Fifteen patients had recurrence (15%); but, only 4 required surgery. Endoscopic resection was curative (median follow-up, 43 months) in 83% without and 46% with intraductal growth (p < 0.001).

CONCLUSIONS

Endoscopic papillectomy is safe and effective, and may be feasible in cases of intraductal growth. Surveillance and, if required, re-treatment are mandatory because of the risk of recurrence.

Balloon-catheter-assisted endoscopic snare papillectomy for benign tumors of the major duodenal papilla

BACKGROUND

Adenomas of the major duodenal papilla are considered premalignant and should be resected completely. Endoscopic snare papillectomy has been recognized as a safe and feasible treatment. An endoscopic snare papillectomy technique was devised using a balloon catheter inserted into the common bile duct to more efficiently resect papillary tumors en bloc.

METHODS

Two patients with benign adenoma of the major duodenal papilla were included in this study. A balloon catheter linked to a snare was inserted into the bile duct via the accessory channel of a duodenoscope, and snare resection was performed after pulling the expanded balloon toward the duodenal lumen.

RESULTS

En bloc papillectomy was successfully performed, leaving the lateral margin free of tumor as confirmed microscopically. No complications were observed in either case.

CONCLUSIONS

Given an appropriate indication, balloon-catheter-assisted endoscopic snare papillectomy is a useful technique for the treatment of tumors of the major duodenal papilla.