The usefulness of traction-assisted endoscopic papillectomy for ampullary early tumors(with video)

Objective Endoscopic papillectomy(EP) is a minimally invasive treatment for early ampullary tumors. However, the optimal method is unclear. The aim of this study is to explore the efficacy and safety of traction-assisted EP treatments for ampullary early tumors.Methods We retrospective analyzed the patients with ampullary adenoma or early adenocarcinoma underwent endoscopic papillectomy between January 2010 and August 2023, including patient characteristics, lesion size, papilla type, pathological diagnosis and lesion surrounding conditions, en-bloc resection rate, complete resection rate, procedure time, complications, recurrences.Results During the study period, a total of 106 patients with ampullary adenoma or early adenocarcinoma underwent EP. The number of patients in traction group (clip combined with dental floss traction, CDT-EP) and non-traction group (hot snare papillectomy, HSP or endoscopic mucosal resection, EMR) were 45 and 61 respectively. The traction group has a higher en-bloc resection rate and complete resection rate than the non-traction group (92.86% vs. 68.85%, p = 0.003; 90.48% vs. 60.66%, p = 0.001), and the procedure time is slightly shorter[(1.57 ± 1.93)min vs. (1.98 ± 1.76)min, p = 0.039]. The complications and recurrence in the traction group were lower than those in the non-traction group (7.14% vs. 19.72%, p = 0.076; 7.14% vs. 11.78%, p = 0.466), and all complications were successfully treated by endoscopy or conservative medical treatment. There was no statistical difference between the two groups in terms of patient characteristics, papilla type, pathological diagnosis and lesion surrounding conditions (p > 0.050), but there were differences in lesion size[(13 ± 1.09)mm vs. (11 ± 1.65)mm, p = 0.002]. The recurrence rate of the traction group is lower than that of the non-traction group, but the difference is not significant(7.14% vs. 13.11%, p = 0.335), and the non-traction group mainly has early recurrence. Further analysis shows that the size of the lesion, whether en-bloc resection or not, and the method of resection as independent risk factors for incomplete resection (OR = 1.732, p = 0.031; OR = 3.716, p = 0.049; OR = 2.120, p = 0.027).Conclusions CDT- EP, HSP and EMR are all suitable methods for the treatment of ampullary adenoma or early adenocarcinoma. Assisted traction technology can reduce the operation difficulty of large and difficult to expose lesions, thereby improving the efficacy and safety of EP.

Endoscopic papillectomy could be rewarding to patients with early stage duodenal ampullary carcinoma?

BACKGROUND/PURPOSE

There is currently no consensus on the use of endoscopic papillectomy (EP) for early stage duodenal ampullary adenocarcinoma. This study aimed to evaluate the feasibility of EP for patients with early stage duodenal ampullary adenocarcinoma.

METHODS

Patients who underwent EP for ampullary adenocarcinomas were investigated. Complete and clinical complete resection rates were evaluated. Clinical complete resection was defined as either complete resection or resection with positive or unknown margins but no cancer in the surgically resected specimen, or no recurrence on endoscopy after at least a 1-year follow-up.

RESULTS

Adenocarcinoma developed in 30 patients (carcinoma in situ [Tis]: 21, mucosal tumors [T1a(M)]: 4, tumors in the sphincter of Oddi [T1a(OD)]: 5). The complete resection rate was 60.0% (18/30) (Tis: 66.7% [14/21], T1a[M]: 50.0% [2/4], and T1a[OD]: 40.0% [2/5]). The mean follow-up period was 46.8 months. The recurrence rate for all patients was 6.7% (2/30). The clinical complete resection rates of adenocarcinoma were 89.2% (25/28); rates for Tis, T1a(M), and T1a(OD) were 89.4% (17/19), 100% (4/4), and 80% (4/5), respectively.

CONCLUSIONS

EP may potentially achieve clinical complete resection of early stage (Tis and T1a) duodenal ampullary adenocarcinomas.

Outcomes of endoscopic papillectomy of ampullary carcinoma and factors affecting additional surgery

BACKGROUND/PURPOSE

Data on the prognosis of endoscopic papillectomy (EP) for ampullary carcinoma (AC) is limited; therefore, we aimed to identify the factors associated with endoscopically controlled AC.

METHODS

Between January 2003 and October 2022, 75 patients underwent EP for ampullary tumors and were diagnosed with AC based on the pathological features of the resected tissue. The factors associated with additional surgery after EP were also evaluated.

RESULTS

A total of 67 patients had ACs ranging from carcinoma in situ to tumors limited to the mucosa (M group), and eight patients had ACs ranging from those limited to the sphincter of Oddi to those invading the duodenal muscularis propria (OD group). The 3-year endoscopic tumor control (condition not requiring additional surgery) rates in the M and OD groups were 90.8% and 84.6% (p = .033), respectively. In the M group, the presence of tumor components in the resection margins was the only significant factor associated with additional surgeries (p = .010) in the univariate analysis. The 3-year endoscopic tumor control rates were 100% for negative and uncertain resection margins and 76.6% for positive margins (p = .009).

CONCLUSIONS

If the AC is confined to the mucosa and the resection margins are negative or uncertain, the tumor can be well-controlled endoscopically.

Incidence and risk factors for recurrence of ampullary adenomas after endoscopic papillectomy: Comparative analysis of familial adenomatous polyposis and sporadic ampullary adenomas in an international multicenter cohort

OBJECTIVES

Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA.

METHODS

We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease.

RESULTS

In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence.

CONCLUSION

Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients.

Current status of and future issues related to endoscopic papillectomy

Endoscopic papillectomy is widely performed to treat duodenal papillary tumors, particularly at high-volume centers. It is indicated for adenomas without intraductal extension of the bile or pancreatic ducts. However, despite numerous reports of carcinomas that expand the indications to include well-differentiated adenocarcinomas that do not invade the sphincter of Oddi, the low agreement between biopsy and final pathological diagnosis, as well as the current inability of imaging modalities to diagnose sphincter of Oddi invasion, makes it difficult to consider expanding indications. Although complications can be prevented by certain methods, such as pancreatic duct stenting, and the frequency of severe complications has decreased, the safety of the procedure remains unconfirmed. In the future, this technology is expected to progress and enable wider applications, including those in tumors with extensive horizontal spread and those with intraductal extension of the bile and pancreatic ducts. Such technology may also improve the safety and accuracy of diagnosis.

The Significance of Histopathological Findings on Clinical Outcomes in Endoscopic Papillectomy with Endocut

This study aimed to evaluate primary clinical outcomes in patients who underwent endoscopic papillectomy (EP) using the Endocut mode while examining the pathological characteristics of the margin of the resected specimen. To this end, 70 patients who underwent Endocut EP were included. Resection margins were classified according to pathological findings as "negative", "positive", or "uncertain (difficult pathological evaluation)". The effect of pathological resection margins on residual tumor recurrence rates was evaluated. The median follow-up was 47 months (range, 22-84). Eleven patients (15.7%) were diagnosed with residual tumors, ten of whom were diagnosed within 6 months after EP. The resection margins were pathologically negative in 27 patients, positive in 15, and uncertain in 28; residual tumors occurred in 5 patients (33.3%) in the positive group, 5 (17.9%) in the uncertain group, and 1 (3.7%) in the negative group. The patient in the negative group had familial adenomatous polyposis (FAP). Female sex, FAP, and uncertain or positive resection margins were significantly more common in residual patients (p = 0.009, 0.044, and 0.041, respectively). Pathological resection margins can be used to infer the residual tumor incidence, leading to early post-treatment of residual tumors.

Updates on the Management of Ampullary Neoplastic Lesions

Ampullary neoplastic lesions (ANLs) represent a rare cancer, accounting for about 0.6-0.8% of all gastrointestinal malignancies, and about 6-17% of periampullary tumors. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis (FAP). Usually, noninvasive ANLs are asymptomatic and detected accidentally during esophagogastroduodenoscopy (EGD). When symptomatic, ANLs can manifest differently with jaundice, pain, pancreatitis, cholangitis, and melaena. Endoscopy with a side-viewing duodenoscopy, endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP) play a crucial role in the ANL evaluation, providing an accurate assessment of the size, location, and characteristics of the lesions, including the staging of the depth of tumor invasion into the surrounding tissues and the involvement of local lymph nodes. Endoscopic papillectomy (EP) has been recognized as an effective treatment for ANLs in selected patients, providing an alternative to traditional surgical methods. Originally, EP was recommended for benign lesions and patients unfit for surgery. However, advancements in endoscopic techniques have broadened its indications to comprise early ampullary carcinoma, giant laterally spreading lesions, and ANLs with intraductal extension. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of ampullary neoplastic lesions.

Acute cholecystitis associated with a novel integrated biliary stent and nasobiliary drainage catheter system

A novel biliary drainage system consisting of an integrated biliary stent and nasobiliary drainage catheter system is expected to be clinically useful. However, Yamamoto and colleagues report two cases of acute cholecystitis after use of the system, suggesting that there are risks of adverse events associated with its unique design.

Novel self-assembling hemostatic agent with a supportive role in hemostatic procedures for delayed bleeding after endoscopic papillectomy

PuraStat is a newly developed self-assembling hemostatic gel which is expected to be applied to bleeding from various lesions of the gastrointestinal tract. Yamamoto and colleagues describe the practical use of this hemostatic gel for delayed bleeding after endoscopic papillectomy, with accompanying video.

[The first Russian experience of radiofrequency ablation in the treatment of adenoma of the major duodenal papilla with intraductal growth in the common bile duct]

Adenoma of the major duodenal papilla can cause bile flow blockade and obstructive jaundice. We present successful endoscopic radiofrequency ablation for adenoma of the major duodenal papilla with intraductal growth in the common bile duct.

Successful biliary cannulation using the hybrid endoscopic ultrasound-guided rendezvous technique for bile duct stenosis after endoscopic papillectomy

Management of papillary stenosis after endoscopic papillectomy is technically challenging. Yamamoto et al. report a case of successful biliary cannulation for bile duct stenosis after endoscopic papillectomy using the "guidewire placed in the scope" technique, which is a hybrid procedure that combines the advantages of conventional endoscopic ultrasound-guided rendezvous techniques.

Endoscopic papillectomy or pancreaticoduodenectomy for ampullary lesions: a single center retrospective cohort study

BACKGROUND

This study aimed to compare post-operative morbidity, mortality, and completeness of resection following endoscopic vs. radical surgical resection for ampullary lesions.

METHODS

A retrospective analysis of the prospectively collected data from a surgical database for patients with ampullary lesions at our institution was performed. All consecutive patients undergoing endoscopic papillectomy (EP) or pancreaticoduodenectomy (PD) for ampullary lesions between 2007 and 2021 were eligible for this analysis.

RESULTS

A total of 85 patients were included of whom 42 underwent EP whereas 43 received a PD. The resected lesion was a tubulovillous adenoma in 26 patients (61.9%) in the EP cohort, and 37 patients (86.0%) in the PD cohort had adenocarcinomas. The completeness of resection was equal in both cohorts. Significantly more patients of the PD cohort had to undergo reinterventions. After a mean follow up of 36 months (EP) vs. 16 months (PD), the rate of tumor recurrence did not differ between both groups.

CONCLUSION

Equivalently high completeness of resection rates and correspondingly low recurrence rates can be achieved after EP and PD. Our results regarding residual tumor and recurrence rates show that even large tumors can be resected endoscopically with high primary success and completeness of resection rates.

Efficacy analysis of hemostatic spray following endoscopic papillectomy: A multicenter comparative study

BACKGROUND AND AIM

Endoscopic post-papillectomy bleeding is a serious adverse event with a prevalence ranging from 2% to 45.3%. Conventional hemostatic methods, including diluted epinephrine injection before papillectomy or argon plasma coagulation after papillectomy, did not show a preventive role in reducing immediate or delayed post-papillectomy bleeding. Therefore, we aimed to assess the efficacy and safety of a hemostatic powder spray for post-papillectomy bleeding and compare with those of conventional modalities.

METHODS

Patients who underwent endoscopic papillectomy were enrolled in five tertiary hospitals. The group was divided into hemostatic spray and conventional control groups according to the bleeding control methods. The main outcome measurements were delayed bleeding rate and any adverse events related to the procedures.

RESULTS

A total of 40 patients who received a hemostatic spray (n = 18) or conventional hemostatic methods (n = 22) after endoscopic papillectomy were included. The prevalence of delayed bleeding was not different in the two groups: 27.8% and 36.4% in hemostatic spray and conventional control groups (P = 0.564), respectively. The adverse events such as post-papillectomy pancreatitis and cholangitis were not different in the two groups. There were no procedure-related mortalities.

CONCLUSION

Hemostatic spray is technically feasible and safe for the prevention or management of post-papillectomy bleeding. Hemostatic spray can be one of the options for post-papillectomy bleeding control methods owing to its convenient use.

Analysis of risk factors for post-endoscopic papillectomy bleeding

BACKGROUND

Endoscopic papillectomy (EP) is an effective treatment for ampullary lesions but technically challenging because of anatomical specificities concerning the high rate of adverse events. Bleeding is one of the most feared complications and can be potentially life-threatening.

AIM

To study the risk factors for bleeding after EP are presented with the goal of establishing preventive measures.

METHODS

A total of 173 consecutive patients with ampullary lesions undergone EP from January 2006 to October 2020 were enrolled in this study. They were divided into a bleeding group and a non-bleeding group depending on whether postoperative bleeding occurred. Related factors were analyzed by univariate and multivariate logistics regression.

RESULTS

Postoperative bleeding was experienced in 33 patients (19.07%). Multivariate analysis also identified intraoperative bleeding (OR: 4.38, 95% CI: 1.87-11.15, p = .001) and endoscopic closure (OR: 0.25, 95% CI: 0.10-0.58, p = .001) as independent factors significantly associated with bleeding after EP. Lesion size (≥3 cm) was shown as an independent factor significantly associated with intraoperative bleeding (OR: 4.25, 95% CI: 1.21-16.44, p = .028).

CONCLUSIONS

This retrospective evaluation found that endoscopic closure was associated with reduced risk and intraoperative bleeding with increased risk of bleeding after EP. Lesion size may indirectly influence the risk of postoperative bleeding by increasing the risk of intraoperative bleeding.

Two Cases of Hemorrhagic Ampullary Lesions Successfully Treated by Endoscopic Papillectomy

We herein report two cases of hemorrhagic ampullary lesions in which endoscopic papillotomy was performed to control bleeding and resulted in successful treatment. Both patients were pathologically diagnosed with an underlying pathology characterized by inflammatory cell infiltration and capillary proliferation. They also had disposing factors for bleeding, such as antithrombotic therapy and idiopathic thrombocytopenic purpura. Endoscopic treatment was selected because the risk of surgical resection was high due to the patients' hemorrhagic condition. Both patients were successfully treated without any serious adverse events and had an uneventful postoperative course with no relapse of bleeding.

Efficacy and safety of endoscopic papillectomy: a multicenter, retrospective, cohort study on 227 patients

BACKGROUND

Endoscopic papillectomy is a minimally invasive treatment for benign tumors of the ampulla of Vater or early ampullary carcinoma. However, reported recurrence rates are significant and risk factors for recurrence are unclear.

OBJECTIVE

The aims of this study were to evaluate the efficacy and safety of endoscopic papillectomy and to identify risk factors for recurrence and adverse events.

METHODS

All patients who underwent endoscopic papillectomy at five tertiary referral centers between January 2008 and December 2018 were included. Recurrence was defined as the detection of residue on one of the follow-up endoscopies. Treatment success was defined as the absence of tumor residue on the last follow-up endoscopy.

RESULTS

A total of 227 patients were included. The resections were en bloc in 64.8% of cases. The mean lesion size was 20 mm (range: 3-80) with lateral extension in 23.3% of cases. R0 resection was achieved in 45.3% of cases. The recurrence rate was 30.6%, and 60.7% of recurrences were successfully treated with additional endoscopic treatment. Finally, treatment success was achieved in 82.8% of patients with a median follow-up time of 22.3 months. R1 resection, intraductal invasion, and tumor size > 2 cm were associated with local recurrence. Adverse events occurred in 36.6% of patients and included pancreatitis (17.6%), post-procedural hemorrhage (11.0%), perforation (5.2%), and biliary stenosis (2.6%). The mortality rate was 0.9%.

CONCLUSION

Endoscopic papillectomy is an effective and relatively well-tolerated treatment for localized ampullary tumors. In this series, R1 resection, intraductal invasion, and lesion size > 2 cm were associated with local recurrence.

Clinical practice guidelines for endoscopic papillectomy

The Japan Gastroenterological Endoscopy Society has developed the "Clinical Practice Guidelines for Endoscopic Papillectomy (EP)" as a fundamental guideline using scientific approach. EP is a recently spreading therapeutic modality for ampullary tumors ranked as high risk endoscopic technique. Because of the paucity of high level of evidence, strength of recommendations had to be determined by a consensus among specialists. These guidelines, shed light on the following five issues: Indications, Preoperative/intraoperative preparations and techniques, Early adverse events, Therapeutic outcomes and remnants/recurrences, and Follow-up and late adverse events, to guide current clinical practice on EP.

Endoscopic papillectomy for tumors of the minor duodenal papilla: A case series of six patients and literature review

BACKGROUND/PURPOSE

Various tumors of the minor duodenal papilla have been reported, most of which are treated by laparotomy. Although early-stage tumors of the major papilla are increasingly being treated by endoscopic resection with relative ease and low invasiveness, there are only a few reports on endoscopic resection of tumors in the minor papilla.

METHODS

Six patients with tumors in the minor papilla were treated by endoscopic papillectomy (EP), and their clinical and histopathological data were analyzed retrospectively.

RESULTS

The final pathological diagnoses were carcinoma in adenoma in two patients and adenoma, neuroendocrine neoplasm (G1), hyperplastic lesion, and no neoplastic lesion (disappearance of adenoma after biopsy) in one patient each. En bloc resection was performed in five patients and piecemeal resection in one patient. There were no procedure-related adverse events, such as bleeding, pancreatitis, or perforation. There was one case with a residual lesion, which was treated by ablation therapy, and no recurrences during a mean follow-up of 12 ± 10.33 months (maximum, 28 months) from the date of EP.

CONCLUSIONS

Endoscopic papillectomy appears to be an effective minimally invasive treatment for ampullary tumors of the minor duodenal papilla.

Investigation of the Indications for Endoscopic Papillectomy and Transduodenal Ampullectomy for Ampullary Tumors

OBJECTIVE

The standard treatment for ampullary tumors is pancreaticoduodenectomy. However, minimally invasive procedures such as endoscopic papillectomy (EP) and transduodenal ampullectomy (TDA) have recently gained popularity. Therefore, we aimed to evaluate the effectiveness of these minimally invasive procedures for ampullary tumors.

METHODS

We conducted a retrospective study of 42 patients who underwent either EP or TDA for ampullary tumors between June 2011 and November 2020.

RESULTS

We found that in patients with significantly larger tumors, TDA was often selected. Patients who underwent EP had significantly shorter hospital stays. No significant differences were observed regarding procedural accidents, tumor size, and recurrence.

CONCLUSION

No differences were observed regarding the treatment outcomes of EP and TDA except hospital stay. EP is less invasive and can be the initial choice of procedure. TDA is performed when EP is not technically feasible. No significant relationship was noted between tumor size and recurrence, and careful observation of the patient's postoperative course is required.

[Management of obstructive jaundice in patients with neoplasms of the major duodenal papilla]

OBJECTIVE

To develop the indications and assess an effectiveness of treatment of patients with ampullary tumors followed by mechanical jaundice.

MATERIAL AND METHODS

There were 26 patients with major duodenal papilla neoplasms for the period 2015-2020 at the Sklifosovsky Research Institute for Emergency Care.

RESULTS

Twenty patients underwent transpapillary interventions: papillosphincterotomy followed by lithoextraction and bilio-duodenal stenting in 4 (15.3%) patients, bilio-duodenal stenting in 12 (46.1%) patients, nasobiliary drainage in 2 (7.6%) patients, pancreaticoduodenal stenting in 2 (7.6%) patients. Percutaneous transhepatic microcholecystostomy was performed in 6 (23.4%) patients. In all cases, laboratory values decreased in 5-7 days after drainage. Eight (30.7%) patients refused further surgical treatment and were discharged in satisfactory condition. Another 8 (44.5%) patients underwent endoscopic submucosal papillectomy. There were no postoperative complications. Patients were discharged after 5-7 days. Four (22.2%) patients underwent tumor resection via laparotomy. One of these patients required redo laparotomy in postoperative period due to acute perforated duodenal ulcer. Six (33.3%) patients underwent palliative bilio-duodenal stenting.

CONCLUSION

Invasion of muscle layer or distal parts of the common bile duct, as well as abnormal vascularization are indications for open surgery or palliative endoscopic treatment. Tumor location within mucous and muscle layers without invasion of distal third of the common bile duct and no abnormal vascularization of tumor justify endoscopic papillectomy. Endoscopic approach can be considered as a final minimally invasive method with minimal risk of postoperative complications in case of benign ampullary tumor.

Predictive factor of recurrence after endoscopic papillectomy for ampullary neoplasms

BACKGROUND/PURPOSE

Recurrence of ampullary neoplasms after endoscopic papillectomy (EP) has not been well elucidated. This study aimed to clarify the predictive factors for recurrences after EP. We also aimed to investigate the retreatment of the recurrent lesions and their outcomes.

METHODS

This multicenter, retrospective cohort study included 96 patients with ampullary neoplasms who underwent EP at four tertiary centers between January 2000 and October 2018.

RESULTS

The pathological diagnoses of resected specimens confirmed adenoma in 62 and adenocarcinoma in 34 patients (six Tis, 24 T1a, three T1b, one inconclusive). Complete resection was confirmed for 79 patients (82.3%). Recurrent lesions were observed in 13 patients (13.5%) during a median follow-up of 3 months (1-36 months) after EP. The predictive factors of recurrence were piecemeal resection, and non-negative horizontal or vertical margin in univariate analysis. Non-negative vertical margin was the only independent predictive factor of recurrence in the multivariate analysis. The recurrent lesions were treated endoscopically in 11 patients. Recurrence after the endoscopic retreatments was observed in one patient.

CONCLUSIONS

Complete resection with negative vertical margin is an important factor in preventing the recurrence of ampullary neoplasms after EP. Endoscopic retreatments are also feasible for recurrent lesions.

Therapeutic Outcomes and Risk Factors for Complications of Endoscopic Papillectomy: A Retrospective Analysis of a Single-Center Study

Purpose

Endoscopic papillectomy (EP) has been accepted as a viable alternative therapy to surgery in benign duodenal papillary lesions. However, postoperative complications limit its widespread clinical application. This study aimed to evaluate the overall safety of the EP procedure and identify significant risk factors of post-EP complications.

Patients and Methods

We retrospectively collected 76 patients who had undergone EP in Chinese PLA General Hospital from 2016 to 2019 and graded their postoperative complications. We assessed twelve patient-, disease- or procedure-related variables to identify risk factors related to the occurrence of post-EP complications using both univariate and multivariate analyses.

Results

Among the 76 patients included in this study, the incidence of entire post-EP complications was 36.8%, most of which were in a mild form. In both univariate and multivariate analyses, the pathologic tumor types, especially high-grade intraepithelial neoplasia (HIN), and the placement of stents were significantly associated with the occurrence of post-EP complications. Patients with HIN tumors were more likely to have post-EP pancreatitis, bleeding, and overall complications (odds ratio (OR) 11.66, 95% confidence interval (CI) 2.91–62.5, P = 0.001; OR 6.52, 95% CI 1.45–46.77, P = 0.027; OR 9.81, 95% CI 2.75–44.04, P = 0.001, respectively). Pancreatic stent placement may contribute to the occurrence of post-EP pancreatitis (OR 7.61, 95% CI 1.37–64.53, P = 0.033). While biliary stent placement was found negatively related to the occurrence of post-EP bleeding and overall complications (OR 0.02, 95% CI 0–0.37, P = 0.016; OR 0.11, 95% CI 0.01–0.99, P = 0.05, respectively).

Conclusion

EP is a safe procedure for papillary lesion treatment with a low rate and generally mild postoperative complications. Two factors are significantly associated with the occurrence of complications. The selection of eligible patients and suitable procedures is important to reduce the complication rate and severity.

[Diagnosis and treatment of benign neoplasms of the major duodenal papilla]

OBJECTIVE

To evaluate an efficacy of surgical treatment of patients with benign tumors of the major duodenal papilla.

MATERIAL AND METHODS

For the period from January 2015 to January 2020, sixteenth patients with benign tumors of the major duodenal papilla were treated at the Sklifosovsky Research Institute for Emergency Care. There were 7 men (43.7%) and 9 women (56.3%). Tumor dimension ranged from 1.0 to 4.0 cm (mean 2.5 cm).

RESULTS AND DISCUSSION

Tumor resection through laparotomy was performed in 4 (25%) patients. Six (37.5%) patients underwent endoscopic submucosal papillectomy. Other 6 (37.5%) patients refused surgical treatment due to regression of symptoms. Postoperative re-laparotomy was performed in 1 patient (10%) with acute perforated duodenal ulcer. There were no complications after endoscopic papillectomy. Control endoscopic examination identified no signs of tumor recurrence in all patients after 3 and 6 months. In our opinion, endoscopic papillectomy is preferable for adenoma of the major duodenal papilla due to reduced surgical trauma. We assume that stenting of the bile ducts and the major pancreatic duct prevented acute pancreatitis and obstructive jaundice.

CONCLUSION

Endoscopic papillectomy is an effective minimally invasive treatment of tumors of the major duodenal papilla. Despite a considerable number of complications, most of them can be resolved by conservative treatment or endoscopic procedures. Thus, endoscopic papillectomy may be considered as preferable method in the treatment of patients with benign tumors of the major duodenal papilla.

Three Cases of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy: A Case Report and Literature Review

We herein report three cases of patients with an ampullary neuroendocrine tumor (NET), who underwent endoscopic papillectomy (EP). No tumor recurrence or metastasis was detected in the patients for more than two years after EP. Generally, surgical resection is recommended for ampullary NETs by the European Neuroendocrine Tumor Society. However, as EP is less invasive than surgical resection, there are some reports of low-grade small ampullary NETs curatively treated by EP with long-term follow-up. We consider that EP may be a curative treatment for small and low-grade ampullary NETs without regional or distant metastasis.

A Novel Technique of Endoscopic Papillectomy with Hybrid Endoscopic Submucosal Dissection for Ampullary Tumors: A Proof-of-Concept Study (with Video)

BACKGROUND

Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Since hybrid endoscopic submucosal dissection (ESD) had been established as an alternative option for relatively large and difficult gastrointestinal tumors, we evaluated a novel EP with hybrid ESD (hybrid ESD-EP) for curative safe margin in this proof-of-concept study.

METHODS

A total of eight cases who underwent hybrid ESD-EP between 2018 and 2020 were identified from our prospectively maintained database. Hybrid ESD-EP involved a (sub)circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated.

RESULTS

En bloc resection was achieved by hybrid ESD-EP in all eight cases, with the median procedure time of 112 (range: 65-170) minutes. The median diameters of the resected specimens and tumors were 18 and 12 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in three (38%), resulting in the complete resection rate of 63%. Postoperative bleeding and pancreatitis developed in each one (13%). No tumor recurrence was observed even in those cases with uncertain vertical margin, after a median follow-up of 244 (range, 97-678) days.

CONCLUSIONS

Hybrid ESD-EP seems to be feasible and promising in ensuring the lateral resection margin. However, further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required.

Insights and updates on endoscopic papillectomy

INTRODUCTION

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

AREA COVERED

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

EXPERT OPINION

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

Effect of preventive closure of the frenulum after endoscopic papillectomy: A prospective pilot study

BACKGROUND AND AIM

The usefulness of preventive closure of the frenulum after endoscopic papillectomy (EP) could reduce bleeding. The feasibility and safety of clipping were evaluated in this prospective pilot study.

METHODS

This study involved 40 consecutive patients who underwent preventive closure of the frenulum by clipping just after EP. The outcome data were compared with those of the previous 40 patients in whom no preemptive closure had been performed (no-closure group) (UMIN000014783). Additionally, the bleeding sites were examined.

RESULTS

The clipping procedure was successful in all patients. As compared to the no-closure group, the rate of bleeding (P = 0.026) and period of hospital stay (P < 0.001) were significantly reduced in the closure group. There was no difference in the procedure time between the two groups. Furthermore, the incidence rates of pancreatitis and perforation were comparable in the two groups. The bleeding was noted in the frenulum area rather than at any other site in 90.9% of cases.

CONCLUSION

Preventive closure of the frenulum after EP is an effective, safe, rational, and economical method to reduce the incidence of delayed bleeding, without prolonging the procedure time or increasing the risk of post-procedure pancreatitis perforation.

Pancreatic intraductal papillary mucinous neoplasm masquerading as ampullary adenoma: a diagnostic puzzle

Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic lesion, remaining mostly asymptomatic. An atypical presentation of such a lesion, initially thought to be an ampullary adenoma, is presented herein. A 78-year-old white male with painless jaundice was treated in a tertiary hospital. Imaging and endoscopic investigations pointed towards an ampullary adenoma obstructing and causing dilatation of both bile and pancreatic ducts. Endoscopic papillectomy was carried out and histology revealed tubulovillous adenoma. Follow-up duodenoscopy 3 months later showed a recurrent lesion with mucous leaking from the pancreatic duct. Cytology revealed mucin-rich atypical cells, consistent with main-duct IPMN. Pancreatoduodenectomy was performed, finally revealing main-duct IPMN protruding through Vater’s ampulla. Cystic pancreatic lesions are increasingly found and IPMN is the most common of these. On the other hand, the management of ampullary adenomas has been revolutionized by endoscopic treatment and the advent of endoscopic papillectomy, with expanding indications. Meticulous clinical and imaging work up of these patients is essential to avoid suboptimal treatment. IPMN should be included in the differential diagnosis of ampullary adenomas, especially in the presence of a grossly dilated pancreatic duct.

Electric Endocut and Autocut Resection for Endoscopic Papillectomy: A Systematic Review

Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.

Clinical Impact of Piecemeal Resection Concerning the Lateral Spread of Ampullary Adenomas

Objective Endoscopic papillectomy (EP) has been recognized to be a safe and reliable treatment modality for ampullary adenomas. The purpose of this study was to determine the safety and efficacy of endoscopic piecemeal resection for laterally spreading ampullary adenomas and to compare these findings with a control population of smaller conventional ampullary tumors treated in the same time period. Methods Between May 1999 and September 2015, 136 patients underwent EP at Tokyo Medical University hospital. A total of 125 patients underwent en bloc resection, and 11 patients underwent piecemeal resection. Results The final pathological diagnoses were 103 adenomas, 14 carcinomas in adenomas, 4 carcinomas, and 4 hyperplasia in the en bloc resection group, versus 7 adenomas, 3 carcinomas in adenoma, and 1 carcinomas in the piecemeal resection group. A single treatment session was possible in 104 (83.2%) of the 125 patients in the en bloc resection group and in 8 (72.7%) of the 11 in the piecemeal resection group. The total resection rate including additional treatments was 98.4% in the en bloc resection group and 100% in the piecemeal resection group. Conclusion Piecemeal resection for laterally spreading ampullary adenomas was sufficiently performed compared with en bloc resection.

Expanding the indication of endoscopic papillectomy for T1a ampullary carcinoma

BACKGROUND AND AIM

Endoscopic papillectomy (EP) has been attempted not only for benign lesions but also for early ampullary carcinoma (AC). However, there is still no sufficient evidence or consensus regarding the effectiveness of EP for early AC. Herein, we evaluated the expanding indication of EP for early AC.

METHODS

Between May 1999 and December 2016, 177 patients were diagnosed with ampullary tumor before undergoing EP, and their clinical and histopathological data were analyzed retrospectively.

RESULTS

There were 27 Tis-T1a AC patients and four T1b AC patients who underwent EP. Mean tumor size was 14.1 mm for Tis-T1a AC and 17.0 mm for T1b AC. For the histological grade, 50% (2/4) of T1b AC were moderately differentiated, whereas 96.3% (26/27) of Tis-T1a AC were well differentiated and papillary. For lymphovascular invasion, one (25%) occurred in T1b AC but none occurred in Tis-T1a AC. There was no AC recurrence from the date of EP until a maximum of 5 years (Tis-T1a: mean period 48.5 months [5-60]; T1b: mean period 26.5 months [3-60]).

CONCLUSIONS

Endoscopic papillectomy is useful and reliable for the curative treatment of T1a AC. Large-scale prospective studies with long-term follow up are needed.

Gangliocytic Paraganglioma with Carcinoma of the Ampulla of Vater

The patient was a "73" -year-old woman who visited our hospital with the chief complaint of weight loss. Upper gastrointestinal endoscopy revealed an enlarged ampulla of Vater, and a biopsy led to a diagnosis of Group "4" gastric carcinoma; suspicious of adenocarcinoma. There were no findings suggesting invasion into the muscle layer of duodenum, despite tumor mass formation being observed in the sphincter of Oddi. We performed endoscopic papillectomy for both diagnostic and therapeutic purposes. Pathologically, a well-differentiated adenocarcinoma existed in the superficial layer of the mucous membrane of the papilla of Vater, and gangliocytic paraganglioma was present in the deep portion. The resected margins of both lesions were negative.

Endoscopic Resection of Ampullary Neuroendocrine Tumor

We report the case of a 57-year-old man with a 1.0-cm grade 1 neuroendocrine tumor (G1 NET) of the ampulla of Vater (ampullary NET) who underwent endoscopic snare papillectomy. Pancreatitis occurred after endoscopic resection but was cured with conservative therapy. In two years of follow-up, no local recurrence or metastasis occurred. Endoscopic snare papillectomy for small G1 NET of the ampulla of Vater is relatively safe and less invasive than surgical treatment and should be considered as treatment option.

Left Hepatic Artery Pseudoaneurysm Caused by Acute Pancreatitis

OBJECTIVE

The aim of this work was to report a case of left hepatic artery pseudoaneurysm due to acute pancreatitis following endoscopic papillectomy.

CLINICAL PRESENTATION AND INTERVENTION

A 74-year-old female with an ampullary adenoma underwent papillectomy, which was complicated by acute pancreatitis. Computed tomography showed aneurysmal dilatation of the proximal left hepatic artery. An angiography with coli embolization was performed and was successful. The patient was doing well at the 1-year follow-up.

CONCLUSION

This patient with left hepatic artery pseudoaneurysm following severe acute pancreatitis was successfully treated with coil embolization.

Endoscopic wire-guided papillectomy versus conventional papillectomy for ampullary tumors: A prospective comparative pilot study

BACKGROUND AND AIM

A major concern about endoscopic snare papillectomy (ESP) is the risk of procedure-related pancreatitis. To maintain pancreatic duct access for stent placement after ESP, wire-guided ESP (WP) was introduced. The aim of the study was to compare post-procedure pancreatitis rates, the success rate of pancreatic stent insertion, and complete resection rates between WP and conventional ESP (CP) procedures.

METHODS

This was a multi-center, prospective, randomized pilot study. Forty-five patients with ampullary tumors were randomly assigned to a WP group (n = 22) or a CP group (n = 23). In the WP group, a guidewire was placed in the pancreatic duct prior to ESP. A 5-Fr pancreatic stent was passed over the guidewire and placed across the pancreatic duct orifice.

RESULTS

Complete resection was achieved in 20 patients (91%) in the WP group and 18 patients (78%) in the CP group (P = 0.414). A pancreatic stent was placed successfully in all patients in the WP group but in only 15 patients (65%) in the CP group (P = 0.004). Post-papillectomy pancreatitis occurred in four (18%) patients in the WP and three (13%) patients in the CP groups (P = 0.960). In the CP group, three of eight (37.5%) patients without stents developed pancreatitis compared with zero of 15 patients with stents (P = 0.032).

CONCLUSIONS

The WP method is a useful technique used to insert a pancreatic stent after ESP, compared with CP. However, there was no significant difference in the post-procedure pancreatitis or complete resection rates between the two methods.

Clinicopathologic characteristics associated with complications and long-term outcomes of endoscopic papillectomy for adenoma

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.

Treatment of ampullary neuroendocrine tumor by endoscopic snare papillectomy

Patient: Female, 45

Final Diagnosis: Neuroendocrine tumor

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Endoscopic papillectomy into the treatment of neoplastic lesions of vater papilla

Adenomas of the duodenal papilla are rare. The frequency of malignant adenomas is 15-30%. Villous adenoma is a premalignant lesion with the highest rate of transformation. Options for surgical treatment include endoscopic and ablation resection, transduodenal ampullectomy, duodeno-pancreatectomy.

AIM

Evaluation of the efficacy and safety of endoscopic papillectomy for ampullary adenomas.

MATERIAL AND METHOD

12 patients were selected (F:M, 5:7, age range 37 - 68 years) with ampullary adenoma, treated by endoscopic papillectomy. Biliary sphincterotomy was performed in 6 cases; and pancreatic sphincterotomy was performed in 3 cases. Biliary stenting was performed in 2 cases; pancreatic stent was placed in 11 cases.

RESULTS

En bloc resection was performed in 8 cases, and piecemeal resection in 4 cases. Complete resection R0 was noted in 10 cases. Pathology examination has show: tubulo-villous adenoma (5 patients); villous adenoma (4 patients), tubular adenoma (2 cases), adenocarcinoma (one case). Complications were immediate: bleeding (2 cases) and pancreatitis (1 case). Follow-up endoscopy reveals no ductal stenosis or recurrence.

CONCLUSION

Endoscopic papillectomy is a safe and well-tolerated alternative to surgical treatment of ampullary adenoma.