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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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Abstract
Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system. They are typically diagnosed at an earlier stage than other types of tumours in this region, due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct. Consequently, many are potentially curable by excision. Surgical ampullectomy (SA) (or transduodenal ampullectomy) for an ampullary tumour was first described in 1899, but was soon surpassed by pancreatoduodenectomy (PD), which offered a more extensive resection resulting in a lower risk of recurrence. Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy (EP), particularly for adenomas and even early cancers. The vast majority of resectable ampullary tumours are now treated using either PD or EP. However, SA continues to play a role in specific circumstances. Many authors have suggested specific indications for SA based on their own data, practices, or interpretations of the literature. However, certain issues have attracted controversy, such as its use for early ampullary cancers. Consequently, there has been a lack of clarity regarding indications for SA, and no evidence-based consensus guidelines have been produced. All studies reporting SA have employed observational designs, and have been heterogeneous in their methodologies. Accordingly, characteristics of patients and their tumours have differed substantially across treatment groups. Therefore, meaningful comparisons of clinical outcomes between SA, PD and EP have been elusive. Nevertheless, it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival, hence its role in this setting warrants further clarification, while it can also be useful in the management of specific benign entities. Whilst the commissioning of a randomised controlled trial seems unlikely, well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA, potentially informing the eventual development of consensus guidelines. In this comprehensive review, we explore the role of SA in the modern management of ampullary lesions.
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Affiliation(s)
- Darren L Scroggie
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol Medical School, Bristol BS8 2PS, United Kingdom
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
- Department of Surgery, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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Nappo G, Gentile D, Galvanin J, Capretti G, Ridolfi C, Petitti T, Spaggiari P, Carrara S, Gavazzi F, Repici A, Zerbi A. Trans-duodenal ampullectomy for ampullary neoplasms: early and long-term outcomes in 36 consecutive patients. Surg Endosc 2020; 34:4358-4368. [PMID: 31646438 DOI: 10.1007/s00464-019-07206-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 06/11/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Trans-duodenal ampullectomy (TDA) is a surgical option for the treatment of selected ampullary neoplasms. The aim of this study was to evaluate our experience with TDA for the treatment of ampullary neoplasms, focusing on indications, technical aspects, and short- and long-term outcomes. METHODS All TDAs for ampullary neoplasms performed between January 2010 and December 2018 at our institution were retrospectively evaluated. Patients had ampullary neoplasms with low-grade dysplasia or in situ carcinoma (Tis) not suitable for an endoscopic approach, ampullary carcinoma unfit for pancreaticoduodenectomy (PD), or ampullary neuroendocrine G1-tumours. RESULTS Thirty-six patients were included in the study: 9 (25.0%) with neoplasms with low-grade dysplasia, 4 (11.1%) with G1 neuroendocrine tumours and 23 (63.9%) with Tis or invasive carcinoma. Mean operative time was 252.5 min. Overall and severe (Clavien-Dindo > IIIa) morbidity rate was 44.4% and 13.9%, respectively. No 90-day mortality was observed. At follow-up, no deaths were observed and local recurrence rate was 11.1% for patients with ampullary adenomas with low-grade dysplasia. Among four patients with neuroendocrine neoplasms, only one developed recurrence (pulmonary). Tis, T1 and T2 lesions were found in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients, respectively: recurrence occurred in 3 patients with Tis lesions (one malignant), no patients with T1 neoplasms and 2 patients with T2 lesions (3 patients had a survival of > 3 years). CONCLUSIONS TDA is a feasible and effective surgical procedure for the treatment of ampullary adenomas with low-grade dysplasia when endoscopic approach is contraindicated or has failed. For lesions with evidence of malignancy, TDA seems to be an oncological safe procedure for Tis ampullary cancer and a good palliative procedure for patients unfit for PD. Moreover, TDA may be appropriate for the treatment of G1 ampullary neuroendocrine neoplasms. A large multicentre study of TDA for early ampullary cancers is needed.
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Affiliation(s)
- Gennaro Nappo
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.
| | - Damiano Gentile
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Jacopo Galvanin
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Giovanni Capretti
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Cristina Ridolfi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | | | - Paola Spaggiari
- Pathology Department, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Cancer Center - IRCCS, Rozzano, Milan, Italy
| | - Francesca Gavazzi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Cancer Center - IRCCS, Rozzano, Milan, Italy.,Humanitas University, Rozzano, Milan, Italy
| | - Alessandro Zerbi
- Pancreatic Surgery Unit, Humanitas Clinical and Research Center - IRCCS, Alessandro Manzoni 56, Rozzano, 20089, Milan, Italy.,Humanitas University, Rozzano, Milan, Italy
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Sauvanet A, Dokmak S, Cros J, Cazals-Hatem D, Ponsot P, Palazzo M. Surgical Ampullectomy with Complete Resection of the Common Bile Duct: a New Procedure for Radical Resection of Non-invasive Ampulloma with Biliary Extension. J Gastrointest Surg 2017; 21:1533-1539. [PMID: 28560704 DOI: 10.1007/s11605-017-3457-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 05/15/2017] [Indexed: 01/31/2023]
Abstract
Extension of ampulloma into the lower common bile duct (CBD) is observed in up to 30% of cases. This biliary extension can prevent complete tumor resection thus is considered as a contraindication for endoscopic and even surgical ampullectomy. For ampullomas associated with a prolonged biliary extension, a pancreaticoduodenectomy is associated with a high morbidity and can be considered as an overtreatment for a benign neoplasm. The present study describes a new surgical approach including ampullectomy with complete resection of the intrapancreatic CBD and restoration of both biliary and pancreatic flow by two separate anastomoses. This procedure was performed in seven patients for a non-invasive ampulloma with a 25- to 70-mm CBD involvement. No patients died and three developed postoperative complications. Resection was R0 in all patients but one. With a 24-month median follow-up (range = 3-84), no patients developed pancreatic insufficiency or tumor recurrence.
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Affiliation(s)
- Alain Sauvanet
- Department of Hepatic and Pancreatic Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD) Hospital Beaujon, AP-HP, University Paris Diderot, 100 Boulevard du Général Leclerc, 92110, Clichy, France.
| | - Safi Dokmak
- Department of Hepatic and Pancreatic Surgery, Pôle des Maladies de l'Appareil Digestif (PMAD) Hospital Beaujon, AP-HP, University Paris Diderot, 100 Boulevard du Général Leclerc, 92110, Clichy, France
| | - Jérôme Cros
- Department of Pathology, Hospital Beaujon, AP-HP, University Paris Diderot, 92110, Clichy, France
| | - Dominique Cazals-Hatem
- Department of Pathology, Hospital Beaujon, AP-HP, University Paris Diderot, 92110, Clichy, France
| | - Philippe Ponsot
- Department of Endoscopy, Pôle des Maladies de l'Appareil Digestif (PMAD) Hospital Beaujon, AP-HP, University Paris Diderot, 92110, Clichy, France
| | - Maxime Palazzo
- Department of Endoscopy, Pôle des Maladies de l'Appareil Digestif (PMAD) Hospital Beaujon, AP-HP, University Paris Diderot, 92110, Clichy, France
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Ardengh JC, Kemp R, Lima-Filho &ER, Santos JSD. Endoscopic papillectomy: The limits of the indication, technique and results. World J Gastrointest Endosc 2015; 7:987-994. [PMID: 26265992 PMCID: PMC4530332 DOI: 10.4253/wjge.v7.i10.987] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [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: 10/29/2014] [Revised: 12/31/2014] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy (EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.
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