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Han S, Turkeltaub JA, Jonas D, Attwell AR, Duloy AM, Edmundowicz SA, Hammad HT, Wagh MS, Wani S, Shah RJ. The timing of recurrence after endoscopic papillectomy. Surg Endosc 2024; 38:688-696. [PMID: 38015261 DOI: 10.1007/s00464-023-10567-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/23/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Endoscopic papillectomy (EP) offers a safe and effective method for resection of ampullary adenomas. Data regarding the long-term resolution of adenoma following EP are limited. The aim of this study therefore was to examine the timing of recurrence after EP of ampullary adenomas. METHODS This was a single-center retrospective study including patients who received EP for ampullary adenomas from 8/2000 to 1/2018. Patients with confirmed complete eradication of adenoma were included in the recurrence analysis with recurrence defined as finding adenomatous histology after 1 negative surveillance endoscopy. Kaplan-Meier estimates were calculated to determine recurrence rates. RESULTS Of the 165 patients who underwent EP, 136 patients (mean age 61.9, 51.5% female) had adenomatous histology with a mean lesion size of 21.2 mm. A total of 124 (91.2%) achieved complete eradication with a follow-up of 345.8 person-years. Recurrence occurred in 20 (16.1%) patients at a mean of 3.2 (± 3) years (range 0.5-9.75 years) for a recurrence rate of 5.8 (95% CI 3.6-8.8) per 100 person-years. Nine (45%) recurrences occurred after the 1st 2 years of surveillance. Recurrence rate did not differ by baseline pathology [low-grade dysplasia: 5.2 (95% CI 3.0-9.0), high-grade dysplasia: 6.9 (95% CI 2.3-15.5), adenocarcinoma: 7.7 (95% CI 0.9-25.1)]. CONCLUSION Recurrence remains a significant concern after EP. Given the timing of recurrence, long surveillance periods may be necessary. Larger multicenter studies are needed, however, to determine appropriate surveillance intervals.
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Affiliation(s)
- Samuel Han
- Division of Gastroenterology, Hepatology, and Nutrition, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Joshua A Turkeltaub
- Division of Digestive Health and Liver Disease, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Daniel Jonas
- Division of Gastroenterology and Nutrition, Loyola University Medicine, Chicago, IL, USA
| | - Augustin R Attwell
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Anna M Duloy
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Steven A Edmundowicz
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Hazem T Hammad
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Mihir S Wagh
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Raj J Shah
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, 1635 Aurora Ct, Mail Stop F735, Rm. AIP 2.031, Aurora, CO, 80045, USA.
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Nojima H, Shimizu H, Hirota M, Murakami T, Yamazaki M, Yamazaki K, Shuto K, Kosugi C, Mori M, Usui A, Sazuka T, Koda K. An ampullary adenoma presenting with jaundice caused by duodenal intussusception: a case report. Surg Case Rep 2024; 10:25. [PMID: 38252200 PMCID: PMC10803710 DOI: 10.1186/s40792-024-01822-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Ampullary adenomas are premalignant lesions. However, biliary obstruction causing jaundice is rare. Duodenal intussusception secondary to an ampullary adenoma rarely occurs because of the fixed position of the duodenum in the retroperitoneum. Herein, we have described a rare case of ampullary adenoma with jaundice caused by duodenal intussusception. CASE PRESENTATION A 40-year-old woman presenting with vomiting and yellowish discoloration of the skin was admitted to another hospital. The patient had experienced recurrent epigastric pain and vomiting for the past 18 months. Blood test results showed elevated levels of bilirubin (3.9 mg/dL), and abdominal computed tomography (CT) showed a 60-mm hypovascular mass in the third part of the duodenum and a left lateral shift of the dilated common bile duct. The patient was referred to our hospital for further evaluation. She recovered from hyperbilirubinemia spontaneously (levels of bilirubin, 1.0 mg/dL), and the CT showed a tumor shift from the third part of the duodenum to the second part and improvement of the dilated common bile duct. Hypotonic duodenography revealed a tumor that moved easily from the second to the third portion of the patient's position. Upper gastrointestinal endoscopy revealed a large papillary tumor occupying the second part of the duodenum, which was diagnosed as an adenoma through biopsy. The possibility of malignancy could not be negated owing to the presence of jaundice and an elevated carbohydrate antigen 19-9 level (76.0 U/mL). Pancreaticoduodenectomy was performed. The resected specimen showed a 60 × 40 × 40-mm pedunculated ampullary mass with submucosal elongation. The pathological examination indicated that the ampullary tumor was a high-grade intestinal adenoma. The postoperative course was uneventful, and the patient was discharged 26 days postoperatively. CONCLUSIONS This report describes a rare case of a patient with an ampullary adenoma presenting with jaundice resulting from duodenal intussusception. Owing to the possibility of a postoperative cancer diagnosis which may have caused the biliary obstruction and the difficulty in making an accurate preoperative diagnosis, it is imperative to choose the appropriate surgical procedure such as a pancreaticoduodenectomy.
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Affiliation(s)
- Hiroyuki Nojima
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Hiroaki Shimizu
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan.
| | - Mihono Hirota
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Takashi Murakami
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Masato Yamazaki
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Kazuto Yamazaki
- Department of Pathology, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Kiyohiko Shuto
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Chihiro Kosugi
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Mikihito Mori
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Akihiro Usui
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Tetsutaro Sazuka
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
| | - Keiji Koda
- Department of Surgery, Teikyo University Chiba Medical Center, Anesaki, Ichihara, Chiba, 3426-3299-0011, Japan
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Garg R, Thind K, Bhalla J, Simonson MT, Simons-Linares CR, Singh A, Joyce D, Chahal P. Long-term recurrence after endoscopic versus surgical ampullectomy of sporadic ampullary adenomas: a systematic review and meta-analysis. Surg Endosc 2023:10.1007/s00464-023-10083-0. [PMID: 37221416 DOI: 10.1007/s00464-023-10083-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 04/17/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND AND AIMS Ampullary adenomas are treated both surgically and endoscopically, however, data comparing both techniques are lacking. We aimed to compare long-term recurrence of benign sporadic adenomas after endoscopic (EA) and surgical ampullectomy (SA). METHODS A comprehensive literature search of multiple databases (until December 29, 2020) was performed to identify studies reporting outcomes of EA or SA of benign sporadic ampullary adenomas. The outcome was recurrence rate at 1 year, 2-year, 3 year and 5 years after EA and SA. RESULTS A total of 39 studies with 1753 patients (1468 EA [age 61.1 ± 4.0 years, size 16.1 ± 4.0 mm], 285 SA [mean age 61.6 ± 4.48 years, size 22.7 ± 5.4 mm]) were included in the analysis. At year 1, pooled recurrence rate of EA was 13.0% (95% confidence interval [CI] 10.5-15.9], I2 = 31%) as compared to SA 14.1% (95% CI 9.5-20.3 I2 = 15.8%) (p = 0.82). Two (12.5%, [95% CI, 8.9-17.2] vs. 14.3 [95% CI, 9.1-21.6], p = 0.63), three (13.3%, [95% CI, 7.3-21.6] vs. 12.9 [95% CI, 7.3-21.6], p = 0.94) and 5 years (15.7%, [95% CI, 7.8-29.1] vs. 17.6% [95% CI, 6.2-40.8], p = 0.85) recurrence rate were comparable after EA and SA. On meta-regression, age, size of lesion or enbloc and complete resection were not significant predictors of recurrence. CONCLUSION EA and SA of sporadic adenomas have similar recurrence rates at 1, 2, 3 and 5 years of follow up.
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Affiliation(s)
- Rajat Garg
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Komal Thind
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jaideep Bhalla
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marian T Simonson
- Cleveland Clinic Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - C Roberto Simons-Linares
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Amandeep Singh
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Daniel Joyce
- Department of Hepatopancreaticobiliary Surgery, Digestive Diseases and Surgery Institute Cleveland Clinic, Cleveland, OH, USA
| | - Prabhleen Chahal
- Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, 9500 Euclid Avenue Cleveland Clinic Foundation, Cleveland, OH, USA.
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Feng Y, Zhang Y, Wang F, Liang Y, Liu Y, Ren L. Radiation-free endoscopic papillectomy for ampullary adenoma: experience from a Chinese tertiary hospital. Surg Endosc 2023; 37:4097-4103. [PMID: 37024584 DOI: 10.1007/s00464-023-10038-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Accepted: 03/12/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Conventional endoscopic papillectomy (ESP) for ampullary adenoma is performed as a hybrid endoscopy and fluoroscopy guided procedure. In this study, we report our preliminary experience of non-radiation ESP. METHODS The present method includes endoscopic snare resection, non-radiation endoscopic biliary and pancreatic stenting and endoclipping. Data from ten patients who underwent non-radiation ESP due to ampullary adenoma were collected. Procedure details, adverse events and follow-up were analyzed. RESULTS Complete resection was accomplished in all patients, with en bloc resection and piecemeal resection in nine and one patient(s), respectively. Both biliary and pancreatic stenting and biliary stenting alone were achieved in eight and two patients, respectively. Endoclipping was performed in all patients. Hyperleukocytosis and hyperamylasemia occurred in two and one patient(s), respectively. No other complications occurred. No lesion residual or recurrence occurred during follow-up. CONCLUSIONS Radiation-free ESP can be technically feasible and safely executed by experienced endoscopists. Our study provides a novel strategy for endoscopic resection of major papilla adenoma.
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Affiliation(s)
- Yadong Feng
- Department of Gastroenterology, School of Medicine, Zhongda Hospital Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China.
| | - Yinqiu Zhang
- Department of Gastroenterology, School of Medicine, Zhongda Hospital Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Fangjun Wang
- Department of Gastroenterology, Jiangyin Hospital Affiliated to Nantong University, No. 3 Yingrui Road, Jiangyin, 214400, China
| | - Yan Liang
- Department of Gastroenterology, School of Medicine, Zhongda Hospital Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Yang Liu
- Department of Gastroenterology, School of Medicine, Zhongda Hospital Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Lihua Ren
- Department of Gastroenterology, School of Medicine, Zhongda Hospital Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, China
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Paterakos P, Rojas AE, Choi SH. Robotic Transduodenal Ampullectomy: Tips for Safe Reimplantation of Biliary and Pancreatic Duct. J Gastrointest Surg 2022; 26:1550-1. [PMID: 35318596 DOI: 10.1007/s11605-022-05305-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/13/2022] [Indexed: 01/31/2023]
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6
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Choi SJ, Lee HS, Kim J, Choe JW, Lee JM, Hyun JJ, Yoon JH, Kim HJ, Kim JS, Choi HS. Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study. World J Gastroenterol 2022; 28:1845-1859. [PMID: 35633905 PMCID: PMC9099193 DOI: 10.3748/wjg.v28.i17.1845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/26/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Seong Ji Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jiyeong Kim
- Lab of Biostatistical Consulting and Research, Medical Research Collaborating Center, Industry-University Cooperation Foundation, Hanyang University, Seoul 04763, South Korea
| | - Jung Wan Choe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jai Hoon Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
| | - Hyo Jung Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jae Seon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Ho Soon Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
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Abstract
BACKGROUND Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth. OBJECTIVE Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors. MATERIAL AND METHODS A review of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. RESULTS AND CONCLUSION Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry a risk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and level II dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.
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Affiliation(s)
- Martin Schneider
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Markus W Büchler
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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8
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Haraldsson E, Halimi A, Rangelova E, Valente R, Löhr JM, Arnelo U. Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection? Surg Endosc 2021; 36:2401-2411. [PMID: 33942182 DOI: 10.1007/s00464-021-08521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/17/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions. MATERIALS AND METHODS Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen. RESULTS In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma. CONCLUSIONS In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden. .,Department of Surgery, Skaraborg Hospital, Skövde, Sweden.
| | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.,Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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9
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Muro S, Kato H, Matsumi A, Ishihara Y, Saragai Y, Yabe S, Takata S, Uchida D, Tomoda T, Matsumoto K, Horiguchi S, Okada H. The Long-Term Outcomes of Endoscopic Papillectomy and Management of Cases of Incomplete Resection: A Single-Center Study. J Gastrointest Surg 2021; 25:1247-52. [PMID: 32583320 DOI: 10.1007/s11605-020-04532-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic papillectomy is increasingly performed as an alternative to surgery for early ampullary tumors. AIM This retrospective study aimed to evaluate the long-term results of endoscopic papillectomy, the management of cases with incomplete endoscopic resection, and the long-term recurrence rates. METHODS All 46 patients who underwent endoscopic papillectomy for ampullary tumors between November 2003 and March 2018 were retrospectively evaluated. RESULTS The final pathological diagnoses were adenoma (n = 44) and adenocarcinoma (n = 2). Histopathological evaluations after endoscopic papillectomy revealed that complete resection was achieved in 19 patients (19/46, 41.3%). Among the 27 patients with incomplete resection, the margin was histopathologically positive in 14 patients and difficult to evaluate in 13. Additional surgery was performed for 2 of the 14 patients with positive margins. Excluding 2 patients who received additional surgery, 7 of the 25 patients with incomplete resection had recurrence, and 18 had no recurrence during the follow-up period. Ten (77%) of the 13 patients in whom the margin was difficult to evaluate had no recurrence. CONCLUSION Approximately 80% of the patients in whom the histopathological evaluation of the resected margin was difficult had no recurrence even after approximately 5 years of follow-up. Thus, careful observation may be considered for these patients.
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10
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Choi YH, Yoon SB, Chang JH, Lee IS. The Safety of Radiofrequency Ablation Using a Novel Temperature-Controlled Probe for the Treatment of Residual Intraductal Lesions after Endoscopic Papillectomy. Gut Liver 2021; 15:307-314. [PMID: 32616684 PMCID: PMC7960966 DOI: 10.5009/gnl20043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Treatment of residual intraductal lesions after endoscopic papillectomy for ampullary adenomas is relatively difficult. Few studies have been conducted using intraductal radiofrequency ablation (RFA) in the treatment of such lesions, and no study has aimed to reduce the side effects of excessive heat caused by RFA. Recently, a temperature-controlled RFA probe was developed to avoid excessive heat. This study aimed to investigate the safety of this new RFA probe in the treatment of intraductal lesions of ampullary adenoma. Methods Patients who received RFA for residual intraductal lesions after endoscopic papillectomy between November 2017 and June 2019 were retrospectively reviewed. A novel temperature- controlled probe (ELRA) was used for intraductal RFA, and clinical data including adverse events were collected. Results Ten patients were included in this study. Intraductal adenomas showed low-grade dysplasia in eight patients and high-grade dysplasia in two patients. The median diameter of intraductal adenomas was 9 mm (range, 5 to 10 mm) in the common bile duct and 5 mm (range, 4 to 11 mm) in the pancreatic duct. Adverse events occurred in three patients (30.0%), of which two were mild pancreatitis and one was asymptomatic biliary stricture. Over a median follow-up period of 253 days, only one patient underwent additional surgery, as the remainder showed no adenomatous lesions on follow-up biopsies. Conclusions The new temperature-controlled RFA probe can be used with acceptable safety for the treatment of residual intraductal lesions after endoscopic papillectomy. Further evaluation through future prospective studies is needed.
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Affiliation(s)
- Young Hoon Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuck Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Zimmer V, Emrich K. Cold Snare Papillectomy for Re-redo Endoscopic Resection of a Defiant Adenoma Recurrence with a Unique Growth Pattern. Euroasian J Hepatogastroenterol 2021; 11:43-44. [PMID: 34316464 PMCID: PMC8286367 DOI: 10.5005/jp-journals-10018-1333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Endoscopic papillectomy has become the mainstay treatment in early papillary neoplasia. However, local recurrence remains the Achilles heel of the procedure due to the complex anatomy and limited ductal involvement unappreciated on endoscopic ultrasound (EUS) and/or endoscopic retrograde cholangiopancreatography (ERCP). While re-do papillectomy is, in general, technically feasible and widely accepted to treat recurrent adenoma, re-redo procedures to this end have rarely been reported. Likewise, utilization of cold snare technology is rarely considered in papillectomy and has, in fact, only once been reported in the literature before. We present a unique clinical case with a highly atypical growth pattern with a bonnet-like pedunculated lesion with a small insertion point just at the pancreatic duct orifice treated by re-redo cold snare papillectomy. How to cite this article: Zimmer V, Emrich K. Cold Snare Papillectomy for Re-redo Endoscopic Resection of a Defiant Adenoma Recurrence with a Unique Growth Pattern. Euroasian J Hepato-Gastroenterol 2021;11(1):43–44.
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Affiliation(s)
- Vincent Zimmer
- Department of Medicine II, Saarland University Medical Center, Homburg, Germany.,Department of Medicine II, Saarland University Medical Center, Homburg, Germany
| | - Kai Emrich
- Department of Medicine, Institute of Pathology, Saarbrücken-Rastpfuhl, Saarbrücken, Germany
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Yasuda I, Kobayashi S, Takahashi K, Nanjo S, Mihara H, Kajiura S, Ando T, Tajiri K, Fujinami H. Management of Remnant or Recurrent Lesions after Endoscopic Papillectomy. Clin Endosc 2020; 53:659-662. [PMID: 31794653 PMCID: PMC7719432 DOI: 10.5946/ce.2019.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 09/17/2019] [Indexed: 02/05/2023] Open
Abstract
Endoscopic papillectomy (EP) for ampullary adenomas achieves cure rates ranging from 76% to 90%, and recurrence rates are as high as 33%. If remnant or recurrent lesions after prior EP are endoscopically visible and are not suspected of intraductal extension into the biliary or pancreatic duct, repeated snaring and cutting can be performed until all visible lesions are completely resected. However, endoscopic ablative therapies, particularly argon plasma coagulation, can be attempted for tiny or uncertain remnant and recurrent lesions. In addition, intraductal radiofrequency ablation has recently been attempted for residual intraductal lesions after EP at several institutions. Although still under investigation, it has shown some promise. It might be offered as an alternative to surgery, particularly in patients who are unfit for surgery or those who refuse to undergo surgery.
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Affiliation(s)
- Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
- Correspondence: Ichiro Yasuda Third Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan Tel: +81-76-434-7300, Fax: +81-76-434-5027, E-mail:
| | - Saito Kobayashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kosuke Takahashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Sohachi Nanjo
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Mihara
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shinya Kajiura
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Takayuki Ando
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kazuto Tajiri
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Haruka Fujinami
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
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Wang ZK, Liu F, Wang Y, Wang XD, Tang P, Li W. Preliminary experience of hybrid endoscopic submucosal dissection by duodenoscope for recurrent laterally spreading papillary lesions. World J Gastroenterol 2020; 26:5673-5681. [PMID: 33088160 PMCID: PMC7545392 DOI: 10.3748/wjg.v26.i37.5673] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/08/2020] [Accepted: 09/11/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The management strategies for recurrent ampullary adenoma after endoscopic papillectomy are still controversial. Patients with the recurrent papillary lesions need to receive repetitive endoscopic interventions due to the limitations of conventional endoscopic techniques.
AIM To assess the feasibility, efficacy, and safety of hybrid endoscopic submucosal dissection (ESD) by duodenoscope for recurrent, laterally spreading papillary lesions.
METHODS We enrolled two patients with recurrent, laterally spreading, duodenal papillary adenomas with no intraductal extension confirmed by follow-up between March 2017 and September 2018. After marking the resection borders of the lesion using a dual knife, a submucosal cushion was created by injecting a mixture of saline solution, methylene blue, and adrenaline. A total circumferential incision and submucosal excision was performed by dual knife combined with insulated-tip diathermic knife, and then the lesion was ligated and resected using an electric snare. Endoscopic hemostasis was applied during the endoscopic procedures. Moreover, the endoscopic retrograde cholangiopancreatography (ERCP) procedures, including selective cannulation and stent implantation of biliary and pancreatic ducts, were performed. Additionally, we performed endoclip closure for mucosal defect after ESD.
RESULTS Hybrid ESD using a duodenoscope and biliary and pancreatic stent placement were performed successfully in two patients. The endoscopic size of recurrent papillary lesions was no more than 2 cm. Generally, the average total procedure time was 95.5 min, and the procedure time of ESD and ERCP was 38.5 min and 15.5 min, respectively. No serious complications occurred during the intraoperative and postoperative periods. The histopathological examination revealed tubulovillous adenoma negative for neoplastic extension at the cut margin in both patients. The duodenoscopic follow-up and histopathology of biopsy specimens at 3 mo after ESD showed no residual or recurrent lesions in ampullary areas in both cases. Both cases have been followed up with no recurrence to June 2020.
CONCLUSION Hybrid ESD by duodenoscope is technically challenging, and may be curative for recurrent, laterally spreading papillary adenomas < 2 cm. It should be performed cautiously in selected patients by experienced endoscopists.
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Affiliation(s)
- Zi-Kai Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Fang Liu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yun Wang
- Department of Pathology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, Beijing, China
| | - Xiang-Dong Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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Campbell DR Jr, Lee JH. A Comprehensive Approach to the Management of Benign and Malignant Ampullary Lesions: Management in Hereditary and Sporadic Settings. Curr Gastroenterol Rep 2020; 22:46. [PMID: 32654103 DOI: 10.1007/s11894-020-00784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to examine the historical roots of endoscopic management of ampullary lesions and explore emerging data on improved techniques, technologies, and outcomes. Of specific interest was answering whether there exists a reasonable body of data to support one resection technique or strategy above others. RECENT FINDINGS Review of recent literature suggests the continued use of endoscopic ampullectomy is a safe and effective means of curative treatment of ampullary adenomas. Complications are relatively infrequent and complete endoscopic resection is possible in a majority of cases, with proper patient and lesion selection. Greater than 2 decades of experience with endoscopic ampullectomy have shown this to be a viable, well-tolerated, and highly effective means of treating ampullary adenomas. While few concrete guidelines exist to advise endoscopists on the ideal technique for resection, experience, patient selection, and prior planning can greatly influence the technical and clinical success of endoscopic ampullectomy.
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Silva LC, Arruda RM, Botelho PFR, Taveira LN, Giardina KM, de Oliveira MA, Dias J, Oliveira CZ, Fava G, Guimarães DP. Cap-assisted endoscopy increases ampulla of Vater visualization in high-risk patients. BMC Gastroenterol 2020; 20:214. [PMID: 32646369 PMCID: PMC7346639 DOI: 10.1186/s12876-020-01361-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 06/30/2020] [Indexed: 12/13/2022] Open
Abstract
Background Periampullary adenocarcinoma is a major clinical problem in high-risk patients including FAP population. A recent modification for visualizing the ampulla of Vater (AV) involves attaching a cap to the tip of the forward-viewing endoscope. Our aim was to compare the rates of complete visualization of AV using this cap-assisted endoscopy (CAE) approach to standard forward-viewing endoscopy (FVE). We also determined: (i) the rates of complications and additional sedation; (ii) the mean time required for duodenal examination; and (iii) the reproducibility among endoscopists performing this procedure. Methods We performed esophagogastroduodenoscopy for AV visualization in 102 > 18 years old using FVE followed by CAE. Video recordings were blinded and randomly selected for independent expert endoscopic evaluation. Results The complete visualization rate for AV was higher in CAE (97.0%) compared to FVE (51.0%) (p < 0.001). The additional doses of fentanyl, midazolam, and propofol required for CAE were 0.05, 1.9 and 36.3 mg. in 0.9, 24.5, and 77.5% patients, respectively. The mean time of duodenal examination for AV visualization was lower on CAE compared to FVE (1.41 vs. 1.95 min, p < 0.001). Scopolamine was used in 34 FVE and 24 CAE, with no association to AV complete visualization rates (p = 0.30 and p = 0.14). Three more ampullary adenomas were detected using CAE compared to FVE. Cap displacement occurred in one patient, and there was no observed adverse effect of the additional sedatives used. Kappa values for agreement between endoscopists ranged from 0.60 to 0.85. Conclusions CAE is feasible, reproducible and safe, with a higher success rate for complete visualization compared to FVE. Trial registration: ClinicalTrials.gov, NCT02867826, 16 August 2016.
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Affiliation(s)
- Leonardo Correa Silva
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Rondinelle Martins Arruda
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Paula Fortuci Resende Botelho
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Leonardo Nogueira Taveira
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Kelly Menezio Giardina
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | | | - Julia Dias
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | | | - Gilberto Fava
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil
| | - Denise Peixoto Guimarães
- Department of Endoscopy, Barretos Cancer Hospital, Antenor Duarte Villela, 1331, Zip Code: 14784 400, Barretos, São Paulo, Brazil. .,Molecular Oncology Research Center, Barretos Cancer Hospital, Barretos, Brazil.
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Hirata M, Shirakata Y, Yamanaka K. Duodenal intussusception secondary to ampullary adenoma: A case report. World J Clin Cases 2019; 7:1857-1864. [PMID: 31417932 PMCID: PMC6692261 DOI: 10.12998/wjcc.v7.i14.1857] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Revised: 05/13/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Masaaki Hirata
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
| | - Yoshiharu Shirakata
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
| | - Kenya Yamanaka
- Department of Surgery, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Hyogo 660-0892, Japan
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic and therapeutic tool to a predominantly therapeutic tool. There is a limited role for diagnostic ERCP with widespread availability of magnetic resonance cholangiopancreatography and endoscopic ultrasound (EUS). Since its introduction, EUS evolved from a diagnostic imaging modality to one with combined diagnostic and therapeutic capabilities. Currently, ERCP remains the standard of care for biliary decompression. In future, it is possible that EUS guided transmural biliary drainage may replace ERCP for certain indications. Given the risk of adverse events related with these more invasive endoscopic procedures, a multidisciplinary team-based approach is recommended.
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Affiliation(s)
| | - Andrew Ross
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, WA 98101, USA.
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18
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van der Wiel SE, Poley JW, Koch AD, Bruno MJ. Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study. Surg Endosc. 2019;33:1180-1188. [PMID: 30167949 PMCID: PMC6430826 DOI: 10.1007/s00464-018-6392-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/20/2018] [Indexed: 12/13/2022]
Abstract
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.
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McCluney SJ, Balarajah V, Giakoustidis A, Chin-Aleong J, Lovett B, Kocher HM. Intussuscepting Ampullary Adenoma: An Unusual Cause of Gastric Outlet Obstruction Leading to Cavitating Lung Lesions. Case Rep Gastroenterol 2016; 10:545-552. [PMID: 27920640 PMCID: PMC5121554 DOI: 10.1159/000450540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 08/31/2016] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Simon J McCluney
- Department of HPB Surgery, Barts and the London HPB Centre, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Vickna Balarajah
- Department of HPB Surgery, Barts and the London HPB Centre, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Alex Giakoustidis
- Department of HPB Surgery, Barts and the London HPB Centre, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Joanne Chin-Aleong
- Department of HPB Pathology, Barts and the London HPB Centre, Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Bryony Lovett
- Department of General Surgery, Basildon and Thurrock University Hospital, Essex, UK
| | - Hemant M Kocher
- Department of HPB Surgery, Barts and the London HPB Centre, Barts Health NHS Trust, The Royal London Hospital, London, UK
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Espinel J, Pinedo E, Ojeda V, Rio MGD. Endoscopic management of adenomatous ampullary lesions. World J Methodol 2015; 5:127-135. [PMID: 26413485 PMCID: PMC4572025 DOI: 10.5662/wjm.v5.i3.127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/30/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
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.
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Tsuji S, Itoi T, Sofuni A, Mukai S, Tonozuka R, Moriyasu F. Tips and tricks in endoscopic papillectomy of ampullary tumors: single-center experience with large case series (with videos). J Hepatobiliary Pancreat Sci 2015; 22:E22-7. [PMID: 25688984 DOI: 10.1002/jhbp.207] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Accepted: 12/09/2014] [Indexed: 12/18/2022]
Abstract
Endoscopic papillectomy (EP) has been recognized as a safe and reliable treatment for ampullary adenomas. In this article, we describe important tips and tricks in EP of ampullary tumors on the basis of our large case series outcome. Between May 1999 and April 2014, 115 patients underwent EP at Tokyo Medical University hospital. The mean tumor diameter was 16.2 (6-35) mm. The final pathological diagnoses were adenoma, cancer in adenoma, cancer, and hyperplasia in 85, 13, 10, and seven patients, respectively. "En bloc" or "piecemeal" EP was performed with a polypectomy snare forceps using "Endocut® mode". Prophylactic pancreatic duct stents were placed after EP. Consequently, a single treatment session was possible in 93 (80.9%) patients. Additional treatment was required in the remaining 22 (19.1%) patients. For these 22 patients, the postresection pathological diagnoses were adenoma in 15 patients and cancer in seven patients. Two patients with cancer and venous permeation required surgical operation. The final complete resection rate was 98.2%. Several complications observed included pancreatitis (10.4%), bleeding (18.2%), perforation (2.6%), cholangitis (1.7%), and papillary stenosis (4.3%). One patient died of procedure-related complications. In conclusion, endoscopic papillectomy showed a high technical success rate. However, possible complications and occasional fatal complications should be considered when using EP.
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Affiliation(s)
- Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Abstract
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.
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Affiliation(s)
- Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Hyun Jong Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
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He XD, Wu Q, Liu W, Hong T, Li JJ, Miao RY, Zhao HT. Association of metabolic syndromes and risk factors with ampullary tumors development: A case-control study in China. World J Gastroenterol 2014; 20:9541-9548. [PMID: 25071350 PMCID: PMC4110587 DOI: 10.3748/wjg.v20.i28.9541] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 02/22/2014] [Accepted: 05/19/2014] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the risk factors for ampullary adenoma and ampullary cancer.
METHODS: This case-control study included ampullary tumor patients referred to Peking Union Medical College Hospital. Controls were randomly selected from an existing database of healthy individuals at the Health Screening Center of the same hospital. Data on metabolic syndromes, medical conditions, and family history were collected by retrospective review of the patients’ records and health examination reports, or by interview.
RESULTS: A total of 181 patients and 905 age- and sex-matched controls were enrolled. We found that a history of diabetes, cholecystolithiasis, low-density lipoprotein, and apolipoprotein A were significantly related to ampullary adenomas. Diabetes, cholecystolithiasis, chronic pancreatitis, total cholesterol, high-density lipoprotein, and apolipoprotein A were also significantly related to ampullary cancer.
CONCLUSION: Some metabolic syndrome components and medical conditions are potential risk factors for the development of ampullary tumors. Cholelithiasis, diabetes, and apolipoprotein A may contribute to the malignant transformation of benign ampullary adenomas into ampullary cancer.
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Shim CN, Chung MJ, Bang S, Park SW, Song SY, Chung JB, Park JY. Clinicopathologic characteristics associated with complications and long-term outcomes of endoscopic papillectomy for adenoma. Yonsei Med J 2014; 55:644-50. [PMID: 24719130 PMCID: PMC3990097 DOI: 10.3349/ymj.2014.55.3.644] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 08/19/2013] [Accepted: 09/27/2013] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP. MATERIALS AND METHODS Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11). RESULTS The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months. CONCLUSION If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.
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Affiliation(s)
- Choong Nam Shim
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungmin Bang
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Woo Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Si Young Song
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
- Brain Korea 21 Project for Medical Science, Seoul, Korea
| | - Jae Bock Chung
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jeong Youp Park
- Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc 2011; 3:241-7. [PMID: 22195233 PMCID: PMC3244941 DOI: 10.4253/wjge.v3.i12.241] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2011] [Accepted: 08/28/2011] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Payam Chini
- Payam Chini, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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