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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] [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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Rosella S, Zorron Cheng Tao Pu L, Ng J, Be KH, Vaughan R, Chandran S, Efthymiou M. Readmission rate and complications following biopsy of the ampulla of Vater—A retrospective data analysis. JGH OPEN 2023; 7:299-304. [PMID: 37125251 PMCID: PMC10134756 DOI: 10.1002/jgh3.12895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/13/2023] [Accepted: 03/18/2023] [Indexed: 03/31/2023]
Abstract
Background and Aim Obtaining endoscopic biopsies from the ampulla of Vater is important for the diagnosis of lesions that are suspicious for neoplasia. The clinical safety profile is not well defined in the literature. Our aim was to evaluate the procedure-related readmission rate and complications from ampullary biopsy in patients undergoing duodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP). Methods A retrospective data analysis was performed on adult patients at Austin Hospital who underwent ampullary biopsies between 1 January 2010 and 1 March 12022. Medical records were identified using pathology databases. The electronic health record was reviewed for baseline characteristics including demographics, date, indication for ampullary biopsy, procedure type (duodenoscopy or ERCP), and procedural associated interventions during ERCP. Readmissions to the Austin Emergency Department within 30 days following the biopsy were identified, and complications were noted. Results A total of 506 records were reviewed and 246 episodes of ampullary biopsy met the inclusion criteria. The procedure-related readmission rate for all episodes was 6.1%, which included pain (3.3%), pancreatitis (2.0%), cholangitis (1.6%), and bleeding (0.8%). Ampullary biopsies with ERCP had a procedure-related readmission rate of 8.4%, whereas ampullary biopsies without ERCP had a rate of 2.2%. Increased readmissions and complications were associated with male sex (P = 0.01 and P = 0.05, respectively). There was no association between the number of biopsies taken and complications. Conclusion Performing an ampullary biopsy without an associated ERCP carries a low rate of clinical complications and procedure-related readmissions. The combination of ERCP and ampullary biopsy increases the risk four-fold.
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Affiliation(s)
- Sam Rosella
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
| | | | - Jonathan Ng
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Kim Hay Be
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Rhys Vaughan
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
| | - Sujievvan Chandran
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
- Department of MedicineMonash University, Peninsula Health CampusFrankstonVictoriaAustralia
| | - Marios Efthymiou
- Medicine, Dentistry and Health SciencesUniversity of MelbourneParkvilleVictoriaAustralia
- Department of Gastroenterology and HepatologyAustin HealthMelbourneVictoriaAustralia
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Itoi T, Ryozawa S, Katanuma A, Kawashima H, Iwasaki E, Hashimoto S, Yamamoto K, Ueki T, Igarashi Y, Inui K, Fujita N, Fujimoto K. Clinical practice guidelines for endoscopic papillectomy. Dig Endosc 2022; 34:394-411. [PMID: 35000226 DOI: 10.1111/den.14233] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Eisuke Iwasaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Toshiharu Ueki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Kazuo Inui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Extended antibiotic prophylaxis after pancreatoduodenectomy reduces postoperative abdominal infection in high-risk patients: Results from a retrospective cohort study. Surgery 2022; 172:205-211. [DOI: 10.1016/j.surg.2021.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/18/2021] [Accepted: 12/23/2021] [Indexed: 11/20/2022]
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Outcome of a novel modified endoscopic papillectomy for duodenal major papilla adenoma. Surg Endosc 2020; 34:5160-5167. [PMID: 32666256 PMCID: PMC7572334 DOI: 10.1007/s00464-020-07715-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
Background and aims In recent years, with the development of endoscopic techniques, endoscopic resection is widely used for duodenal papillary adenomas, but conventional endoscopic resection has a high rate of incomplete resection and recurrence. On this basis, we have employed a novel modified endoscopic papillectomy (ESP). In this study, we evaluated the feasibility and advantages of this ESP for the treatment of duodenal major papilla adenoma. Methods A total of 56 patients with duodenal major papilla adenoma confirmed by endoscopic ultrasonography, intraluminal ultrasound and gastroscopic biopsy from October 2007 to June 2017 were collected in the Department of Gastroenterology, Nanjing Drum Tower Hospital. The diameter of the adenoma ranged from 1.41 to 2.02 cm. 16 cases were given the conventional method and 40 cases underwent the modified ESP procedure in which a small incision was made by cutting current when anchoring the snare tip on the distal side of the adenoma. Results En bloc resection rate was significantly higher in the modified group (100%, 40/40) than that in the conventional group (81.3%, 13/16; P = 0.02). However, no significance was seen between the modified group and the conventional group in complete resection rate (92.5%, 37/40 vs 93.8%, 15/16; P = 1.00). There was no significant difference in the number and difficulty of postoperative pancreatic and biliary stents placement between the two groups (P = 0.20). Total bleeding occurrence was much lower in the modified group (37.5%, 15/40 vs 87.5%, 14/16; P = 0.001), and no significant differences were found in other short-term complications and the 3, 6, 12 and 24 months recurrences rate between the conventional and modified ESP groups. Conclusions The modified ESP improves the treatment outcome of duodenal major papilla adenoma with higher en bloc resection rate and lowering bleeding rate. Electronic supplementary material The online version of this article (10.1007/s00464-020-07715-0) contains supplementary material, which is available to authorized users.
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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] [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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Lü S, Jiang M, Liu F, Tang H, Yang Y, Zhang W, Zhang M, Jin Z, Li Z. Endoscopic papillectomy of benign papillary tumors: A single-center experience. Medicine (Baltimore) 2020; 99:e20414. [PMID: 32481436 DOI: 10.1097/md.0000000000020414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Endoscopic treatment of duodenal papillary tumors is well described. This study aims to provide new evidence for the treatment of benign papillary tumors through comparisons between endoscopic snare papillectomy (ESP) and endoscopic mucosal resection (EMR).Between May 2010 and December 2017, 72 patients were enrolled. Diagnosis and treatment procedures were ESP and EMR. Endoscopic follow-up evaluation was done periodically as a surveillance measurement for recurrence.Seventy-two patients with ampullary tumors were enrolled, of which 66 had adenomas including 9 high-grade intraepithelial neoplasias and 2 carcinomas in adenoma. Complete resections with tumor-free lateral and basal margins were achieved in all patients. Postoperative complications were bleeding (9.5% in EMR vs 10% in ESP) and pancreatitis (2.4% in EMR and 3.3% in ESP), with no occurrence of perforation, cholangitis or papillary stenosis. Adenoma recurrence was found in 7 patients (14.3% in EMR vs 3.3% in ESP) at 1 year.The ESP procedure is safe and effective for benign ampullary adenoma, high-grade intraepithelial neoplasias, and noninvasive cancer without intraductal tumor growth, which has a shorter procedural duration, as well as lower complication, recurrence rates and hospitalization costs.
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Affiliation(s)
- Shunli Lü
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Mengni Jiang
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Feng Liu
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Hailing Tang
- Department of Gastroenterology, Xi'an Central Hospital, Xi'
| | - Yuan Yang
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical College, Zunyi, P.R. China
| | | | - Minmin Zhang
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
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Fernandez Y Viesca M, Arvanitakis M. Early Diagnosis And Management Of Malignant Distal Biliary Obstruction: A Review On Current Recommendations And Guidelines. Clin Exp Gastroenterol 2019; 12:415-432. [PMID: 31807048 PMCID: PMC6842280 DOI: 10.2147/ceg.s195714] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 10/23/2019] [Indexed: 12/13/2022] Open
Abstract
Malignant biliary obstruction is a challenging condition, requiring a multimodal approach for both diagnosis and treatment. Pancreatic adenocarcinoma and cholangiocarcinoma are the leading causes of malignant distal biliary obstruction. Early diagnosis is difficult to establish as biliary obstruction can be the first presentation of the underlying disease, which can already be at an advanced stage. Consequently, the majority of patients (70%) with malignant distal biliary obstruction are unresectable at the time of diagnosis. The association of clinical findings, laboratory tests, imaging, and endoscopic modalities may help in identifying the underlying cause. Novel endoscopic techniques such as cholangioscopy, intraductal ultrasonography, or confocal laser endomicroscopy have been developed with promising results, but are not used in routine clinical practice. As the number of patients with malignant distal biliary obstruction who will undergo curative surgery is limited, endoscopy has a crucial role in palliation, to relieve biliary obstruction. According to the last European guidelines published in the management of biliary obstruction, self-expandable metal stents have a central place in biliary drainage compared to plastic stents. Endoscopic ultrasound has evolved impressively in the last decades. When standard techniques of biliary cannulation by endoscopic retrograde cholangiopancreatography fail, endoscopic ultrasound-guided biliary drainage is a good option compared to percutaneous drainage.
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Affiliation(s)
- Michael Fernandez Y Viesca
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Univertié Libre de Bruxelles (ULB), Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Univertié Libre de Bruxelles (ULB), Brussels, Belgium
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Alali A, Espino A, Moris M, Martel M, Schwartz I, Cirocco M, Streutker C, Mosko J, Kortan P, Barkun A, May GR. Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events. J Can Assoc Gastroenterol 2019; 3:17-25. [PMID: 32010876 PMCID: PMC6985700 DOI: 10.1093/jcag/gwz007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 02/23/2019] [Indexed: 02/06/2023] Open
Abstract
Background The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy. Methods Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data. Results Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically. Conclusion Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.
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Affiliation(s)
- Ali Alali
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Haya Al-Habeeb Gastroenterology and Hepatology Center, Mubarak Al-Kabeer Hospital, Jabriya, Kuwait
| | - Alberto Espino
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Gastroenterology, Pontificia Universidad Católica de Chile, Endoscopy Unit Hospital UC-Christus, Santiago, Chile
| | - Maria Moris
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Myriam Martel
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Ingrid Schwartz
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Maria Cirocco
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Streutker
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jeffrey Mosko
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Kortan
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Quebec, Canada
| | - Gary R May
- The Center for Therapeutic Endoscopy and Endoscopic Oncology, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
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Espinel J, Pinedo E, Ojeda V, Guerra Del Río M. Endoscopic ampullectomy: a technical review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:271-8. [PMID: 27187501 DOI: 10.17235/reed.2016.3867/2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges. METHODS We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques. RESULTS Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy. CONCLUSIONS Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.
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Affiliation(s)
| | | | - Vanesa Ojeda
- Digestivo, Hospital Universitario Dr. Negrín. Las Palmas de Gran Canaria, España
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Schneider L, Contin P, Fritz S, Strobel O, Büchler MW, Hackert T. Surgical ampullectomy: an underestimated operation in the era of endoscopy. HPB (Oxford) 2016; 18:65-71. [PMID: 26776853 PMCID: PMC4750227 DOI: 10.1016/j.hpb.2015.07.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 05/28/2015] [Accepted: 07/10/2015] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Benign neoplastic, inflammatory or functional pathologies of the ampulla of Vater are mainly treated by primary endoscopic interventions. Consequently, transduodenal surgical ampullectomy (TSA) has been abandoned in many centres, although it represents an important tool not only after unsuccessful endoscopic treatment. The aim of the study was to analyse TSA for benign lesions of the ampulla of Vater. PATIENTS AND METHODS All patients who underwent TSA between 2001 and 2014 were included. Patients were analysed in terms of indications, postoperative morbidity and mortality as well as long-term success. RESULTS Eighty-three patients underwent TSA. Indications included adenomas in 44 and inflammatory stenosis in 39 patients. 96% of the patients had undergone endoscopic therapeutic approaches prior to TSA (median no. of interventions n = 3). Postoperative morbidity occurred in 20 patients (24%). There was one procedure-associated death (mortality 1.2%). The mean follow-up was 54 months. Long-term overall success rate for TSA was 83.6%. After TSA for ampullary adenoma, the recurrence rate was 4.5%. CONCLUSION TSA is an underestimated surgical procedure, which can be performed safely with high long-term efficacy. It can be implemented in clinical algorithms for patients with benign pathologies of the ampulla of Vater, particularly after unsuccessful endoscopic treatment.
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Affiliation(s)
- Lutz Schneider
- Correspondence Markus Büchler, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany. Tel.: +49 6221 566110. Fax: +49 6221 56 5450.
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The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015; 82:773-81. [PMID: 26260385 DOI: 10.1016/j.gie.2015.06.027] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 02/08/2023]
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Lee HS, Jang JS, Lee S, Yeon MH, Kim KB, Park JG, Lee JY, Kim MJ, Han JH, Sung R, Park SM. Diagnostic Accuracy of the Initial Endoscopy for Ampullary Tumors. Clin Endosc 2015; 48:239-46. [PMID: 26064825 PMCID: PMC4461669 DOI: 10.5946/ce.2015.48.3.239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Ampullary tumors come in a wide variety of malignant forms. We evaluated the diagnostic accuracy of endoscopy for ampullary tumors, and analyzed the causes of misdiagnosis. Methods We compared endoscopic imaging and biopsy results to final diagnoses. Types of endoscope, numbers of biopsy specimens taken, and final diagnoses were evaluated as possible factors influencing diagnostic accuracy. Results Final diagnoses were 19 adenocarcinomas, 18 normal or papillitis, 11 adenomas, two adenomyomas, one paraganglioma, and one neuroendocrine tumor. The diagnostic accuracy of endoscopic imaging or the initial biopsy was identical (67.3%). At least one test was concordant with the final diagnosis in all except two cases. Compared with the final diagnosis, endoscopic imaging tended to show more advanced tumors, whereas the initial biopsy revealed less advanced lesions. The diagnostic accuracy of the initial biopsy was influenced by the type of endoscope used and the final diagnosis, but not by the number of biopsies taken. Conclusions Endoscopy has limited accuracy in the diagnosis of ampullary tumors. However, most cases with concordant endoscopic imaging and biopsy results are identical to the final diagnosis. Therefore, in cases where both of these tests disagree, re-evaluation with a side-viewing endoscope after resolution of papillitis is required.
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Affiliation(s)
- Hee Seung Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong Soon Jang
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seungho Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Myeong Ho Yeon
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ki Bae Kim
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae Geun Park
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joo Young Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Mi Jin Kim
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Rohyun Sung
- Department of Pathology, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
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Ahmad SR, Adler DG. Cancer of the ampulla of vater: current evaluation and therapy. Hosp Pract (1995) 2015; 42:45-61. [PMID: 25485917 DOI: 10.3810/hp.2014.12.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.
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Affiliation(s)
- Sarah R Ahmad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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Pancreatic intubation facilitated by methylene blue injection decreases the risk for postpapillectomy acute pancreatitis. Eur J Gastroenterol Hepatol 2014; 26:990-5. [PMID: 25072383 DOI: 10.1097/meg.0000000000000146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endoscopic snare papillectomy (ESP) is a viable alternative to surgical treatment of ampullary adenomas and T1N0 stage ampullary carcinomas. The main drawback of this technique is the high risk of acute pancreatitis post procedure.The aim of this study was to assess the efficacy, safety, and long-term results of this procedure, and to determine whether routine pancreatic intubation facilitated by intraductal methylene blue (MB) injection reduces the risk for pancreatitis. PATIENTS AND METHODS Between 2004 and 2011, 56 consecutive patients underwent ESP. Before resection, the pancreatic duct was cannulated, and MB was injected intraductally to facilitate stent placement after ampullectomy. RESULTS ESP was performed en bloc in 45 patients with histological findings of low-grade dysplasia (39%), high-grade dysplasia (25%), carcinoma (32.5%), and others (3.5%). The morbidity rate was 19.5%: acute pancreatitis (n=6), bleeding (n=4), perforation (n=1), and sepsis (n=1). Pancreatic intubation was performed in 89% of the patients. Postprocedure pancreatitis occurred significantly less in the patients with a pancreatic stent than in those without: 3/49 versus 3/6, P=0.013. ESP was considered as curative in 39 patients (75%). Of the 12 recurrences (25%), 10 were managed endoscopically, but with higher morbidity (acute pancreatitis=40%). CONCLUSION Endoscopic papillectomy is safe and effective in the hands of experts. Pancreatic-duct stent placement in fewer cannulation attempts could be facilitated by injection of MB before papillectomy, and this decreases the risk for postprocedure pancreatitis. Recurrences can be managed endoscopically, but with a higher risk for pancreatitis.
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Ogura T, Hara K, Hijioka S, Mizuno N, Imaoka H, Niwa Y, Tajika M, Kondo S, Tanaka T, Shimizu Y, Hosoda W, Yatabe Y, Bhatia V, Higuchi K, Yamao K. Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for tumors of the ampulla of vater? -an initial study. Endosc Ultrasound 2014; 1:84-9. [PMID: 24949343 PMCID: PMC4062218 DOI: 10.7178/eus.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 06/28/2012] [Indexed: 12/11/2022] Open
Abstract
Objective: No previous studies have described endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) only for intra-ampullary lesions of the papilla of Vater. We aimed to examine whether EUS-FNA can be used to diagnose such lesions. Methods: This study included a subset of 10 consecutive patients in whom EUS-FNA targeted the ampulla of Vater. All the patients underwent biopsy and/or brushing cytology under endoscopic retrograde cholangiopancreatography (ERCP) prior to EUS-FNA. The final diagnosis was based on pathological examinations of specimens obtained by surgical resection or clinical follow-up more than 1 year in case of evidence of benign lesions. Results: Tissues from the ampulla of Vater could be obtained by EUS-FNA for all 10 patients. The final diagnosis was papillitis (n = 7) and intra-ampullary carcinoma (n = 3). Carcinoma of the ampulla of Vater showed neither exposure on the duodenal mucosal surface nor invasion to the pancreas. The diagnostic accuracy of surface biopsy with duodenoscopy, and intra-ampullary biopsy and/or brush cytology with ERCP and/or intra-ampullary biopsy after endoscopic sphincterotomy (EST) in distinguishing between benign and malignancy was 70%. The diagnostic accuracy of EUS-FNA was 100%. No complications associated with EUS-FNA were encountered in this study. Conclusion: EUS-FNA for ampulla of Vater may be safely and accurately performed, and should be considered as a diagnostic modality before EST.
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Affiliation(s)
- Takeshi Ogura
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan ; 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinya Kondo
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Waki Hosoda
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), Delhi, India
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Okano K, Oshima M, Yachida S, Kushida Y, Kato K, Kamada H, Wato M, Nishihira T, Fukuda Y, Maeba T, Inoue H, Masaki T, Suzuki Y. Factors predicting survival and pathological subtype in patients with ampullary adenocarcinoma. J Surg Oncol 2014; 110:156-62. [PMID: 24619853 DOI: 10.1002/jso.23600] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 02/17/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Carcinoma of the ampulla of Vater is uncommon. This study aimed to clarify predictors of survival for ampullary adenocarcinoma and to identify characteristics of its two major pathological subtypes. METHODS Medical records were reviewed for 86 patients who underwent curative resection for ampullary adenocarcinoma between 2000 and 2012 at 12 principal hospitals in Kagawa, Japan. RESULTS Resection was most common among 75-79-year-old patients. Actuarial 1-, 3-, and 5-year postoperative survival rates for ampullary adenocarcinoma were 90%, 72.3%, and 69.1%, respectively. Preoperative biliary drainage; serum CA19-9 and total bilirubin levels; pathological grade; perineural, vascular, pancreatic, and duodenal invasion; nodal metastasis; UICC-T stage; and pancreatobiliary subtype were predictors of poor survival. An elevated serum CA19-9 level; an elevated total bilirubin level; lymphatic, vascular, perineural, and pancreatic invasion; and advanced overall tumor stage were more common in patients with pancreatobiliary-type tumors than in patients with intestinal-type tumors. Additionally, pathologic subtype analysis showed that each subtype had distinct prognostic factors. CONCLUSIONS Preoperative elevated serum CA19-9 and total bilirubin levels are prognostic factors for ampullary adenocarcinoma, and are both associated with pancreatobiliary-type tumors. Surgeons should be aware of these factors because pancreatobiliary-type adenocarcinoma is aggressively invasive and is associated with poor survival.
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Affiliation(s)
- Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Kagawa, Japan
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Primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis: report of a case. Surg Today 2014; 45:506-10. [PMID: 24522893 DOI: 10.1007/s00595-014-0860-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 12/16/2013] [Indexed: 10/25/2022]
Abstract
A 70-year-old male was treated for gastric ulcers. Follow-up upper gastrointestinal endoscopy revealed an irregular, elevated tumor in the second portion of the duodenum. Upon pathological inspection of a biopsy specimen, a diagnosis of adenocarcinoma was made, and the patient was admitted to our hospital. Computed tomography showed an irregular mass in the pancreatic head and dilatation of the main pancreatic duct and bile duct. Pancreatic head carcinoma with infiltration of the duodenum was diagnosed, and pylorus-preserving pancreaticoduodenectomy was performed. A histopathological examination of the resected specimen showed moderately differentiated adenocarcinoma in the minor duodenal papilla and chronic pancreatitis in the pancreatic head. Therefore, primary adenocarcinoma of the minor duodenal papilla with mass-forming chronic pancreatitis was diagnosed. Currently, the patient is alive without recurrence 17 months after the surgery. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. We herein report this case, and also provide a review of the literature.
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Soni RC, Puri AS, Garg V, Sachdeva S, Banka A, Tyagi P, Saran RK. Comparative yield of fine needle aspiration cytology, ampullary biopsy, and needle knife assisted biopsy in the diagnosis of nonulcerated periampullary tumors. Indian J Gastroenterol 2013; 32:258-61. [PMID: 23700137 DOI: 10.1007/s12664-013-0333-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 04/12/2013] [Indexed: 02/04/2023]
Abstract
AIM Periampullary tumors (PAT) are defined as tumors arising within 2 cm of the major duodenal papilla. Studies on yield of preoperative biopsy for nonulcerated PAT are scarce. Needle knife papillotomy-assisted biopsy (NKAB) may sample the deeper tissues and thereby increase the histologic yield. We aimed to compare the diagnostic yield of fine needle aspiration cytology (FNAC), surface ampullary biopsy, and NKAB in nonulcerated PAT. METHODS Patients with suspected PAT based on clinical, biochemical, and radiologic investigations were evaluated. Patients with smooth ampullary bulge on side viewing endoscopy (SVE) were included, while those with gastric outlet obstruction or obvious ulceration of ampulla on SVE were excluded. RESULTS Twenty-five of 78 patients with PAT met the inclusion criteria. The median (range) age was 60 (43-75) years, and 13 were male. Serum CA 19.9 was 466 (2-9372) U/mL. Histopathological positivity rate for surface biopsy, FNAC, and NKAB was 10 (40 % and 95 % CI: 21.8 % to 61.1 %), 12 (48 % and 95 % CI: 28.3 % to 68.2 %), and 21 (84 % and 95 % CI: 63.1 % to 94.7 %), respectively. Diagnostic yield of NKAB was significantly better than surface biopsy (p = 0.001) and FNAC (p = 0.007). None of the patients subjected to NKAB had any complications other than self-limited minor ooze. CONCLUSION NKAB was superior to surface biopsy or FNAC to establish preoperative tissue diagnosis of nonulcerated PAT. NKAB is safe and simple in expert hands and may be recommended as standard procedure to obtain histological specimen in these patients.
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Affiliation(s)
- Ram Chandra Soni
- Department of Gastroenterology, G B Pant Hospital, J L Nehru Marg, New Delhi 110 002, India
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20
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Sourrouille I, Gaujoux S, Lacave G, Bert F, Dokmak S, Belghiti J, Paugam-Burtz C, Sauvanet A. Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination. HPB (Oxford) 2013; 15:473-80. [PMID: 23458261 PMCID: PMC3664052 DOI: 10.1111/hpb.12012] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 10/15/2012] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Pancreaticoduodenectomy (PD) is associated with high morbidity, in part as a result of infectious complications increased by preoperative bile contamination. The aim of the present study was to assess the effect on the incidence of infectious complications of short-term antimicrobial therapy (AMT) in high-risk patients. METHODS Patients with a high risk for positive intraoperative bile culture (i.e. those with ampulloma or pancreatic adenocarcinoma with preoperative endoscopic procedures) (high-risk group, n = 99) were compared with low-risk patients (i.e. those with pancreatic adenocarcinoma without preoperative endoscopic procedures) (low-risk group, n = 76). The high-risk group received a 5-day course of perioperative AMT secondarily adapted to the bile antibiogram. The low-risk group received only the usual antimicrobial prophylaxis. RESULTS Positive bile cultures were significantly more frequent in high-risk patients (81% versus 12%; P < 0.001). The overall rate of infectious complications was lower in the high-risk group (29% versus 46%; P = 0.018). The statistically significant decrease in the rate of infectious complications reflected reduced rates of urinary tract infections, pulmonary infections and septicaemia. Rates of wound infection (3% versus 5%; P = 0.639) and intra-abdominal abscess (7% versus 7%; P = 0.886) were similar in the high- and low-risk groups, as was the need for curative AMT. CONCLUSIONS This exploratory study suggests that a postoperative short course of AMT in patients at high risk for biliary contamination reduces the overall rate of infectious complications after PD. The adaptation of perioperative antimicrobial policy to the patient's risk for bile contamination seems promising and should be further evaluated.
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Affiliation(s)
- Isabelle Sourrouille
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Sebastien Gaujoux
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Guillaume Lacave
- Department of Anesthesiology and Critical Care Medicine, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - François Bert
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Safi Dokmak
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy
| | - Jacques Belghiti
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France
| | - Catherine Paugam-Burtz
- Department of Bacteriology, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Unit 773, National Institute of Health and Medical Research (INSERM)Paris, France
| | - Alain Sauvanet
- Department of Hepatobiliary and Pancreatic Surgery, Centre for Digestive System Diseases, Beaujon Hospital AP-HP (Assistance-Publique-Hôpitaux de Paris)Clichy,University Paris DiderotParis, France,Correspondence Alain Sauvanet, Department of Hepatobiliary and Pancreatic Surgery, Hospital Beaujon, 100 Boulevard du Général Leclerc, 92110 Clichy, France. Tel: + 33 1 40 87 58 95. Fax: + 33 1 40 87 17 24. E-mail:
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Kim HK, Lo SK. Endoscopic approach to the patient with benign or malignant ampullary lesions. Gastrointest Endosc Clin N Am 2013; 23:347-83. [PMID: 23540965 DOI: 10.1016/j.giec.2013.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.
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Affiliation(s)
- Hyung-Keun Kim
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Uijeongbu St. Mary's Hospital, Guemo-dong, Uijeongbu, Republic of Korea
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Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg 2013; 257:315-22. [PMID: 23059497 DOI: 10.1097/sla.0b013e318269d010] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). BACKGROUND The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. METHODS Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. RESULTS After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. CONCLUSIONS In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.
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Parc Y, Desaint B, Fléjou JF, Lefèvre JH, Serfaty L, Vienne A, Kotti S, Simon T, Tiret E. The effect of ursodesoxycholic acid on duodenal adenomas in familial adenomatous polyposis: a prospective randomized placebo-control trial. Colorectal Dis 2012; 14:854-60. [PMID: 21899713 DOI: 10.1111/j.1463-1318.2011.02816.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Duodenal adenomas occur in about 90% of patients with familial adenomatous polyposis (FAP) and are the second cause of death of patients who have had a prophylactic proctocolectomy. Studies suggest that biliary acids have a role in the development of duodenal adenomas. The aim of this study was to evaluate the impact of ursodesoxycholic acid (UDCA) on duodenal adenoma formation in patients with FAP. METHOD A randomized, double-blinded, placebo-controlled study was carried out of 71 patients (20-65 years) who already had a restorative proctocolectomy. Subjects received either 10 mg/kg of UDCA orally per day or a placebo tablet for 24 months. The Spigelman severity score was determined after duodenal axial and lateral view endoscopy at 12 and 24 months. RESULTS At 2 years 55 patients had completed the entire period of treatment. At the end of the follow-up period, nine (25%) patients in the UDCA group and seven (20%) in the placebo group had a decrease in the Spigelman score (P = 0.6142). Patients receiving UDCA had no side-effects (0%) compared with four (14%) in the placebo group (P = 0.0392). CONCLUSION UDCA had no effect on the development of duodenal adenomas in FAP patients (NCT: 00134758).
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Affiliation(s)
- Y Parc
- Department of Digestive Surgery, Hôpital Saint-Antoine, AP-HP, Université Pierre et Marie Curie, Paris, France.
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Heinzow HS, Meister T, Domagk D. Endoskopische Papillenresektion: Indikation und Grenzen. Visc Med 2012. [DOI: 10.1159/000345869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Adenome der Papilla Vateri sind selten. Prävalenzen von 0,04–0,12% werden beschrieben. Eine maligne Transformation von benignen Adenomen zu Papillenkarzinomen ist möglich und folgt der Adenom-Karzinom-Sequenz. Die meisten Papillenadenome treten sporadisch auf, können jedoch z.B. bei Patienten mit familiärer adenomatöser Polyposis genetisch häufiger vorkommen. <b><i>Methode: </i></b>Es erfolgte eine aktuelle PubMed-Recherche zum Thema endoskopische Papillenresektion. <b><i>Ergebnisse/Schlussfolgerung: </i></b>Eine endoskopische Papillektomie kann bei Adenomen ohne duktale Infiltration durchgeführt werden, während es in Hinblick auf das papilläre Adenokarzinom noch keinen Konsens gibt. Jedoch konnten neuere Studien zeigen, dass Patienten mit hochgradiger intraepithelialer Neoplasie der Papilla Vateri keine lymphovaskuläre Invasion oder Lymphknotenmetastasen aufweisen, sodass eine endoskopische Papillektomie gerechtfertigt erscheint. Da papilläre Adenome in bis zu 30% der Fälle das Risiko für fokale karzinomatöse Areale beherbergen können, sollte jede Papillektomie «en bloc» durchgeführt werden.
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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] [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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Noor MT, Vaiphei K, Nagi B, Singh K, Kochhar R. Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma. World J Gastrointest Endosc 2011; 3:220-4. [PMID: 22110838 PMCID: PMC3221954 DOI: 10.4253/wjge.v3.i11.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 09/23/2011] [Accepted: 10/18/2011] [Indexed: 02/05/2023] Open
Abstract
AIM: To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.
METHODS: In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.
RESULTS: Between January 2008 and December 2010, 38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients. Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy. There were 8 (61.5%) males and 5 (38.5%) females. The most common presenting symptom was jaundice (100%), followed by fever (46.2%), melena (38.5%), abdominal pain (30.8%) and weight loss (30.8%). All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of (11.2 ± 1.9) mg/dL (normal value < 1 mg%) and the mean ± SD serum alkaline phosphatase was (288.0 ± 94.3) IU/L (normal value < 129 IU/L). Serum CA 19.9 level estimation was done in 11 patients; it was elevated (cut off value > 70.5 IU/L) in all of them with a median of 1200 IU/L (inter quartile range 274-3500). Side viewing endoscopy showed a bulky papilla in all of them. Adequate tissue was obtained in all of the 13 patients for histological evaluation; 12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma. There were no complications from the needle knife papillotomy in any of the patients.
CONCLUSION: Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.
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Affiliation(s)
- Mohd Talha Noor
- Mohd Talha Noor, Kim Vaiphei, Birinder Nagi, Kartar Singh, Rakesh Kochhar, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Parc Y, Mabrut JY, Shields C. Surgical management of the duodenal manifestations of familial adenomatous polyposis. Br J Surg 2011; 98:480-4. [PMID: 21656714 DOI: 10.1002/bjs.7374] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND Duodenal adenomas develop in patients with familial adenomatous polyposis, incurring a risk of carcinoma. When this risk is high, surgery is indicated. The choice of surgical treatment can be difficult as evidence-based data are lacking. METHODS This is a systematic review of the literature on the non-medical management of duodenal lesions arising in the setting of familial adenomatous polyposis. Studies were identified through searching MEDLINE. Studies published between January 1965 and October 2009 were included. Data regarding number of subjects, complications, length of follow-up, recurrence rate and outcome were extracted. RESULTS Transduodenal resection does not differ from an endoscopic approach in terms of recurrence. Ampullectomy has limited application as only papillary lesions are amenable to treatment in this manner. Duodenectomy with pancreas preservation is preferable to pancreaticoduodenectomy unless malignancy is present, or cannot be excluded. CONCLUSION Surgery should be reserved for advanced or malignant polyps.
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Affiliation(s)
- Y Parc
- Department of Digestive Surgery, Hôpital Saint-Antoine, Université Pierre et Marie Curie, Paris, France.
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Chacko A, Dutta AK. Endoscopic resection of ampullary adenomas: novel technique to reduce post procedure pancreatitis. J Gastroenterol Hepatol 2010; 25:1338-9. [PMID: 20659220 DOI: 10.1111/j.1440-1746.2010.06386.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Is blind pancreaticoduodenectomy justified for patients with ampullary neoplasms? J Gastrointest Surg 2009; 13:1666-73. [PMID: 19557483 DOI: 10.1007/s11605-009-0943-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Accepted: 06/03/2009] [Indexed: 01/31/2023]
Abstract
BACKGROUND Many specialists justify pancreaticoduodenectomy (PD) for pancreatic head neoplasms with suspected but unproven malignance (blind-PD). Our aim in this study was to determine whether blind-PD is also justified for ampullary neoplasms. METHODS We retrospectively reviewed the records of all patients with presumed resectable ampullary neoplasms treated at the National Taiwan University Hospital from 1998 to 2008. RESULTS Of the 84 patients without a preoperative tissue diagnosis of malignance, 64 had blind-PD and 20 had ampullectomy (AMP) with intraoperative frozen section. Patients with jaundice, gastrointestinal bleeding, imaging findings showing tumor invasion, and larger tumor size were significantly more frequently treated by blind-PD. Final pathological diagnosis was benign in ten of 64 blind-PD-treated patients. CONCLUSIONS Our data support a selective use of blind-PD because (1) a significant portion (65%) of benign ampullary neoplasms can be safely and effectively treated by AMP, (2) blind-PD does not treat ampullary cancer at earlier stage, and (3) blind-PD is associated with significantly more complications and significantly longer hospital stay than AMP. However, blind-PD is strongly recommended for patients with large ampullary neoplasms (>3 cm in diameter), with jaundice, or with malignant endoscopic appearance.
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Abstract
AIM: To investigate the endoscopic ampullectomy practices of expert biliary endoscopists.
METHODS: An anonymous survey was mailed to 79 expert biliary endoscopists to assess ampullectomy practices.
RESULTS: Forty six (58%) biliary endoscopists returned the questionnaire. Of these, 63% were in academia and in practice for an average of 16.4 years (± 8.6). Endoscopists performed an average of 1.1 (± 0.8) ampullectomies per month. Prior to ampullectomy, endoscopic ultrasound was “always” utilized by 67% of respondents vs“sometimes” in 31% of respondents. Empiric biliary sphincterotomy was not utilized uniformly, only 26% “always” and 37% “sometimes” performed it prior to resection. Fifty three percent reported “never” performing empiric pancreatic sphincterotomy prior to ampullectomy. Practitioners with high endoscopic retrograde cholangiopancreatography volumes were the most likely to perform a pancreatic sphincterotomy (OR = 10.9; P = 0.09). Participants overwhelmingly favored “always” placing a prophylactic pancreatic stent, with 86% placing it after ampullectomy rather than prior to resection (23%). Argon plasma coagulation was the favored adjunct modality (83%) for removal of residual adenomatous tissue. Practitioners uniformly (100%) preferred follow-up examination to be within 6 mo post-ampullectomy.
CONCLUSION: Among biliary experts, there is less variation in ampullectomy practices than is reflected in the literature.
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Kim JH, Kim JH, Han JH, Yoo BM, Kim MW, Kim WH. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol 2009; 16:2547-54. [PMID: 19568817 DOI: 10.1245/s10434-009-0509-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/16/2009] [Accepted: 04/16/2009] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study was designed to provide safe management guidelines for ampullary adenoma by analysis of clinicopathological features. BACKGROUND The treatment of ampullary cancer has been established; however, the indications for treatment of ampullary adenoma remain controversial. METHODS Between July 1997 and July 2008, a total of 33 patients were diagnosed with ampullary adenoma prior to procedures: 20 endoscopic papillectomies (ESP), 5 transduodenal resections (TDR), and 8 pancreatoduodenectomies (PD). RESULTS The false-negative rate of biopsy for cancer was 27.5% (8/29). Coexistence of cancer in patients with pre-high-grade dysplasia (HGD) was 50.0% (5/10), whereas it was 15.7% in pre-low-grade dysplasia (LGD). In addition, the rate of recurrence was 80% (8/10) in patients with pre-HGD. The size of tumor by final pathology was 1.27 +/- 0.89 cm in LGD, 1.81 +/- 0.99 cm in HGD, and 1.98 +/- 1.08 cm in cancer group. There was a significant correlation between size of tumor and final pathology (P = 0.036). According to receiver operating characteristic (ROC) curve, criterion to predict HGD/cancer was tumor size larger than 1.5 cm; sensitivity and specificity were 55.6% and 80.0%, respectively, and likelihood ratio was 2.778. However, size of tumor was not associated with preprocedural pathology. CONCLUSIONS Ampullary adenoma with preprocedural HGD was highly associated with coexistence of cancer and recurrence. Moreover, most of large tumors were treated by surgical procedures and proved to be cancer. Therefore, we suggest that ampullary adenoma with preprocedural HGD or more than 1.5 cm should not be managed with endoscopic papillectomy due to high associated rates of recurrence.
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Affiliation(s)
- Ji Hun Kim
- Departments of Surgery, School of Medicine, Ajou University, Suwon, Korea
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Jung MK, Cho CM, Park SY, Jeon SW, Tak WY, Kweon YO, Kim SK, Choi YH. Endoscopic resection of ampullary neoplasms: a single-center experience. Surg Endosc 2009; 23:2568-74. [PMID: 19360365 DOI: 10.1007/s00464-009-0464-9] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Revised: 03/03/2009] [Accepted: 03/14/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND An ampullary tumor, whether malignant or not, must be completely resected. A benign adenoma has the potential for malignant transformation. Currently, endoscopic papillectomy with curative intent is increasingly performed for benign papillary tumors. This study aimed to evaluate the outcome of endoscopic papillectomy performed for ampullary tumors at a single center. METHODS From July 2003 to June 2008, 22 patients with a diagnosis of ampullary tumors determined by endoscopic retrograde cholangiopancreatography (ERCP) were treated using endoscopic resection of the tumors. Endoscopic resection was performed in a radical fashion analogous to polypectomy for colon adenomas. RESULTS The 22 patients (9 men and 13 women) had an average age of 58 +/- 14 years (range, 19-85 years). The median follow-up period was 169 days (range, 14-903 days). The papillary lesions ranged in size from 8 to 33 mm. The rate of concordance between the endoscopic forceps biopsy and the resected specimen was 50% (9/18) according to the Vienna classification. Complete endoscopic resections were performed for 17 of 22 the cases (77.3%). The median length of hospital stay was 4 days (range, 2-11 days), and there were no readmissions for complications. Endoscopic complications occurred for 5 (22.7%) of the 22 patients: postpapillectomy pancreatitis for 4 patients, bleeding for 1 patient, and retroperitoneal perforation for 1 patient. However, no procedure-related deaths occurred. After the papillectomy, a pathologically incomplete resection was noted in 10 cases, including submucosal invasion of an adenocarcinoma with lateral clean resection margins. CONCLUSIONS The findings showed that an endoscopic papillectomy was safe and effective for benign-appearing adenomas with negative biopsy results for a malignancy. This procedure should be considered as the initial intervention in such cases. The decision whether to perform a pancreatoduodenectomy can be made after the pathology report of the resected specimen is obtained from the endoscopic papillectomy.
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Affiliation(s)
- Min Kyu Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyungpook National University Hospital, 50, Samduk-Dong 2 Ga, Chung-Gu, Daegu, 700-721, South Korea
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Lorenzo-Zúñiga V, Moreno De Vega V, Domènech E, Boix J. [Diagnosis and treatment of ampullary tumors]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:101-8. [PMID: 19231683 DOI: 10.1016/j.gastrohep.2008.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 02/19/2008] [Indexed: 01/04/2023]
Abstract
Tumors of the ampulla of Vater are called ampullary tumors and can arise from any of the three epithelia (duodenal, pancreatic and biliary) that delimit the papilla. These tumors are clinically important and early identification, appropriate staging and proper treatment are essential. The symptoms of these tumors are non-specific and not always evident. All ampullary tumors must be resected but opinions differ on the optimal method of excision. Currently, controlled trials are lacking and consequently the treatment chosen must be individually tailored according to the characteristics of the patient and the tumor. Curative treatment may be endoscopic or surgical. In patients who are not candidates for curative treatment, palliative treatment through drainage can be performed.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD).
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Aiura K, Hibi T, Handa K, Kojima M, Kitagawa Y. ENDOSCOPIC SNARE PAPILLECTOMY FOR TUMORS OF THE MAJOR DUODENAL PAPILLA. Dig Endosc 2008. [DOI: 10.1111/j.1443-1661.2008.00796.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Wakatsuki T, Irisawa A, Takagi T, Koyama Y, Hoshi S, Takenoshita S, Abe M, Ohira H. Primary adenocarcinoma of the minor duodenal papilla. Yonsei Med J 2008; 49:333-6. [PMID: 18452274 PMCID: PMC2615313 DOI: 10.3349/ymj.2008.49.2.333] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 70-year-old man was admitted to our institution due to aggravation of blood-sugar level control and because an abdominal CT showed dilatation of the main pancreatic duct. Upper gastrointestinal endoscopy revealed a flat elevated tumor with central ulceration in the second portion of the duodenum. Subsequent duodenoscopy for a more detailed examination showed that the tumor had originated in the minor duodenal papilla. A biopsy specimen showed moderately differentiated adenocarcinoma. Endoscopic retrograde pancreatography via the major duodenal papilla revealed a slightly dilated main pancreatic duct and obstruction of the accessory pancreatic duct. Endoscopic ultrasonography showed a hypoechoic mass in the minor duodenal papilla with retention of the muscularis propria of the duodenum. These findings suggest that the tumor existed only to a limited extent in the minor duodenal papilla, and that the tumor did not infiltrate into the pancreas. For treatment, pylorus-preserving pancreatoduodenectomy was performed, and histological findings revealed a well-differentiated adenocarcinoma that originated in the minor duodenal papilla. Primary adenocarcinoma of the minor duodenal papilla is extremely rare. Our case is the first report of primary adenocarcinoma of the minor duodenal papilla at an early stage with no infiltration into muscularis propria of the duodenum and pancreas.
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Affiliation(s)
- Takeru Wakatsuki
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Atsushi Irisawa
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tadayuki Takagi
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yoshihisa Koyama
- Department of Surgery 2, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Sayuri Hoshi
- Department of Pathology 1, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Seiichi Takenoshita
- Department of Surgery 2, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Masafumi Abe
- Department of Pathology 1, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Internal Medicine 2, Fukushima Medical University School of Medicine, Fukushima, Japan
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Abstract
Recent advances in understanding of pancreatitis and advances in technology have uncovered the veils of idiopathic pancreatitis to a point where a thorough history and judicious use of diagnostic techniques elucidate the cause in over 80% of cases. This review examines the multitude of etiologies of what were once labeled idiopathic pancreatitis and provides the current evidence on each. This review begins with a background review of the current epidemiology of idiopathic pancreatitis prior to discussion of various etiologies. Etiologies of medications, infections, toxins, autoimmune disorders, vascular causes, and anatomic and functional causes are explored in detail. We conclude with management of true idiopathic pancreatitis and a summary of the various etiologic agents. Throughout this review, areas of controversies are highlighted.
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Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, Takasawa O, Obana T. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc 2007; 66:740-7. [PMID: 17905017 DOI: 10.1016/j.gie.2007.03.1081] [Citation(s) in RCA: 129] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Accepted: 03/26/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic papillectomy is performed in selected patients with ampullary neoplasm, and, thus, accurate preoperative tumor staging is indispensable for its application. DESIGN Prospective and histopathologically controlled study. SETTING Single center. PATIENTS AND INTERVENTIONS EUS and transpapillary intraductal US (IDUS) were performed in 40 patients with ampullary neoplasm before surgery (n = 30) or endoscopic papillectomy (n = 10). Ductal infiltration by a tumor into the bile duct (BD) or the pancreatic duct (PD) was also evaluated. The indication for endoscopic papillectomy was determined by findings obtained by EUS and IDUS. These findings were compared with histologic features of the resected specimens. MAIN OUTCOME MEASUREMENTS AND RESULTS Thirty-three patients had adenocarcinoma (14 pT1, 11 pT2, 8 pT3-4) and 7 had adenoma. Tumor depiction by EUS and IDUS was achieved in 95% and 100% of the patients, respectively. The diagnostic accuracy of EUS and IDUS in T staging was 62% and 86% in adenoma and pT1, 45% and 64% in pT2, and 88% and 75% in pT3-4, respectively. The overall accuracy by EUS and IDUS in T staging was 63% and 78%, respectively (P = .14). In 10 patients who underwent endoscopic papillectomy, the accuracy of IDUS in T staging with EUS and IDUS was 80% and 100%, respectively. Ductal infiltration into the BD and the PD was correctly assessed in 88% and 90% by EUS and in both BD and the PD in 90% by IDUS, respectively. Ductal infiltration was correctly diagnosed by EUS and IDUS in all patients who had a papillectomy. CONCLUSION Although IDUS had a tendency of overestimation in tumor staging for ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for endoscopic papillectomy.
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Affiliation(s)
- Kei Ito
- Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
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Genc H, Haciyanli M, Tavusbay C, Colakoglu O, Aksöz K, Unsal B, Ekinci N. Carcinoma arising from villous adenoma of the ampullary bile duct: Report of a case. Surg Today 2007; 37:165-8. [PMID: 17243040 DOI: 10.1007/s00595-004-3350-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2004] [Accepted: 04/20/2004] [Indexed: 01/27/2023]
Abstract
Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct.
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Affiliation(s)
- Hudai Genc
- Second Department of Surgery, Ataturk Training and Research Hospital, Izmir, Turkey
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Eswaran SL, Sanders M, Bernadino KP, Ansari A, Lawrence C, Stefan A, Mattia A, Howell DA. Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series. Gastrointest Endosc 2006; 64:925-32. [PMID: 17140900 DOI: 10.1016/j.gie.2006.06.018] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2006] [Accepted: 06/05/2006] [Indexed: 12/16/2022]
Abstract
BACKGROUND Increasing reports suggest that endoscopic removal of benign ampullary and duodenal polyps is safe and frequently definitive; however, most reported polyps have been small in size (<3 cm). We have developed experience with endoscopic removal of increasingly large and complex polyps. PATIENTS Fifty-one cases of endoscopic removal were attempted and grouped according to size: group A (n = 22) polyps 1 to 3 cm and group B (n = 29) polyps 3 cm or larger, including 7 cases larger than 5 cm. When the ampulla was involved, biductal sphincterotomy and prophylactic pancreatic duct stent placement was performed first, followed by saline solution-assisted piecemeal polypectomy, argon plasma coagulation, selective endoclip placement, and recovery of all polyp fragments. INTERVENTIONS Endoscopic removal of duodenal and ampullary adenomas. RESULTS The outcomes of small and large adenoma removal include mean number of endoscopic retrograde cholangiopancreatographies required for complete removal (2.09 vs 2.56, P = .392), number of complications (4.5% vs 13.9%, P = .375), discovery of unsuspected cancer (0% vs 10.3%, P = .242), and final definitive resolution (100% vs 86.2%, P = .124). Complete removal was achieved in 92.2% of all patients. LIMITATIONS This was a single center retrospective study. CONCLUSIONS Large (>/=3 cm) ampullary and duodenal polyps comprised 56.9% of our endoscopically treated cases and present special challenges to definitive endoscopic removal. Successful removal of even very large sessile lesions is possible with minimal increase in risk.
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Adler DG, Qureshi W, Davila R, Gan SI, Lichtenstein D, Rajan E, Shen B, Zuckerman MJ, Fanelli RD, Van Guilder T, Baron TH. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2006; 64:849-54. [PMID: 17140885 DOI: 10.1016/j.gie.2006.08.044] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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DeOliveira ML, Triviño T, de Jesus Lopes Filho G. Carcinoma of the papilla of Vater: are endoscopic appearance and endoscopic biopsy discordant? J Gastrointest Surg 2006; 10:1140-3. [PMID: 16966033 DOI: 10.1016/j.gassur.2006.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2006] [Accepted: 05/08/2006] [Indexed: 01/31/2023]
Abstract
Carcinoma of the papilla of Vater is classified as periampullary cancer representing 5% of all gastrointestinal tract malignancies. Early and accurate diagnosis is important for those patients with a tumor of the papilla, as the prognosis is more favorable than in other periampullary neoplasms. Endoscopically obtained biopsies from suspicious papillae can detect an early tumor, although even for skilled pathologists it is often difficult to differentiate carcinomas from noninvasive lesions on the basis of forceps biopsies. The purpose of this study was to assess the preoperative diagnostic accuracy of duodenoscopy appearance and biopsy in all cases with suspicion of tumor. Thirty patients with suspicion of carcinoma of the papilla of Vater and with final diagnosis established by pancreatoduodenectomy were included in this retrospective study. In each case, a comparison was made between endoscopic biopsy and duodenoscopic appearance. Duodenoscopic appearance sensitivity and accuracy for malignancy were 86% and 83%, respectively, whereas endoscopic biopsy sensitivity and accuracy were 65% and 67%, respectively. Although preoperative diagnosis of carcinoma of the papilla of Vater is useful for making therapeutic decisions, the diagnostic value of the endoscopic appearance was superior to endoscopic biopsy in this series.
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Affiliation(s)
- Michelle Lucinda DeOliveira
- Department of Surgery, Division of Gastrointestinal Surgery, University Federal of São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil.
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Uchiyama Y, Imazu H, Kakutani H, Hino S, Sumiyama K, Kuramochi A, Tsukinaga S, Matsunaga K, Nakayoshi T, Goda KI, Saito S, Kaise M, Kawamuara M, Omar S, Tajiri H. New approach to diagnosing ampullary tumors by magnifying endoscopy combined with a narrow-band imaging system. J Gastroenterol 2006; 41:483-90. [PMID: 16799891 DOI: 10.1007/s00535-006-1800-7] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 02/19/2006] [Indexed: 02/04/2023]
Abstract
BACKGROUND A newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors. METHODS Fourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels. RESULTS In 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas. CONCLUSIONS MENBI has the ability and potential to predict histological characteristics of ampullary lesions.
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Affiliation(s)
- Yujiro Uchiyama
- Department of Endoscopy, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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Katsinelos P, Paroutoglou G, Kountouras J, Beltsis A, Papaziogas B, Mimidis K, Zavos C, Dimiropoulos S. Safety and long-term follow-up of endoscopic snare excision of ampullary adenomas. Surg Endosc 2006; 20:608-13. [PMID: 16508819 DOI: 10.1007/s00464-004-2278-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Accepted: 06/10/2005] [Indexed: 12/18/2022]
Abstract
BACKGROUND Adenomas of the duodenal papilla are rare. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection techniques, transduodenal local excision, and pancreaticoduodenectomy. The aim of this retrospective study was to evaluate the safety and outcome of endoscopic snare resection of papillary adenomas in a Greek cohort of patients. METHODS Fourteen patients (six women and eight men; age range, 42-76 years) were referred for endoscopic management of ampullary adenomas. A questionnaire was completed for each patient, which included preoperative and postoperative data points. Presenting symptoms were jaundice (n = 4), cholangitis (n = 1), and pain (n = 2). Seven patients were asymptomatic. If there was no common bile and main pancreatic duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy onto normal duodenal tissue was performed. The adenomas were resected via a diathermy snare, along with the major papilla, after elevation of the lesion by epinephrine plus dextrose 50% (1:10,000) solution. At the discretion of the endoscopist, a biliary or pancreatic stent was inserted as a prophylactic procedure immediately after excision. RESULTS Histopathologically, resected tissue included 11 adenomas and three adenomas with focal malignancy, referred for pancreaticoduodenectomy. Immediate complications were moderate bleeding (n = 1) and mild pancreatitis (n = 1). No procedure-related death occurred. Follow-up was available for 11 patients (mean, 28.36 months; range, 6-72). Pancreatic and biliary stents were placed in four and nine patients, respectively. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in two patients (18%), which was resected endoscopically. CONCLUSION Endoscopic snare resection of adenomas of the major duodenal papilla is a safe, well-tolerated alternative to surgical therapy. In expert hands, complications are mild and may be avoided by pre-resection biductal sphincterotomy, stent placement, and elevation of the lesion by epinephrine plus dextrose 50% solution injection.
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Affiliation(s)
- P Katsinelos
- Department of Endoscopy, Central Hospital, Ethnikis Aminis 41, T.K. 54635, Thessaloniki, Greece.
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44
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Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006; 63:292-301. [PMID: 16427938 DOI: 10.1016/j.gie.2005.07.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Accepted: 07/11/2005] [Indexed: 12/24/2022]
Affiliation(s)
- Jimin Han
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Cortes A, Sauvanet A, Bert F, Janny S, Sockeel P, Kianmanesh R, Ponsot P, Ruszniewski P, Belghiti J. Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor. J Am Coll Surg 2005; 202:93-9. [PMID: 16377502 DOI: 10.1016/j.jamcollsurg.2005.09.006] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Revised: 09/05/2005] [Accepted: 09/07/2005] [Indexed: 02/08/2023]
Abstract
BACKGROUND The influence of preoperative biliary drainage on the postoperative course of patients undergoing pancreaticoduodenectomy (PD) remains controversial. Among drawbacks of biliary drainage, bile contamination and its consequences are incompletely evaluated. This study aimed to compare outcomes after PD in patients with sterile and those with infected bile. STUDY DESIGN Seventy-nine consecutive patients underwent PD for periampullary tumor with routine bile culture and antibiotic prophylaxis with cefazolin. The postoperative course of 35 patients with infected bile (group B+) was compared with that of 44 patients with sterile bile (group B-). RESULTS The distribution of tumors was comparable except for ampullary carcinoma, which was more frequent in group B+ patients (p = 0.001). Interventional biliary endoscopy was performed preoperatively in 80% of patients in group B+ versus 14% in group B- (p < 0.001), including 9 isolated sphincterotomies (20% versus 5%, p < 0.03) and 20 endoprosthesis insertions (57% versus 0%, p < 0.0001). More patients in group B+ were classified as American Society of Anesthesiologists (ASA) 2 (p = 0.04). Operative time and blood loss were similar in both groups. One patient died postoperatively (group B+). Overall morbidity was increased in group B+ (77% versus 59%, p = 0.05). Postoperative infectious complications, all demonstrated bacteriologically, were more frequent in group B+: (65% versus 37%, p = 0.003). In group B+, bile was polybacterial in 54% of patients and isolated microorganisms were resistant to cefazolin in 97%. In patients with infectious complications, the same germ was isolated in bile and another sample in 49%. CONCLUSIONS In patients undergoing PD, bile infection is related to previous interventional biliary endoscopy in 80% of patients and is associated with an increased rate of postoperative infections. During PD for ampullary carcinoma or after interventional biliary endoscopy, a specific antibioprophylaxis should be evaluated.
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Affiliation(s)
- Alexandre Cortes
- Department of Surgery, Hospital Beaujon, Assistance Publique-Hôpitaux de Paris, Université Paris VII, Clichy, France
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Bohnacker S, Seitz U, Nguyen D, Thonke F, Seewald S, deWeerth A, Ponnudurai R, Omar S, Soehendra N. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 2005; 62:551-60. [PMID: 16185970 DOI: 10.1016/j.gie.2005.04.053] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2004] [Accepted: 04/28/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic papillectomy of benign papillary tumor is still not widely practiced. Intraductal growth has been considered a contraindication for endoscopic therapy. This prospective study evaluates endoscopic papillectomy for treatment of benign papillary tumors without and with intraductal growth. METHODS Monofilament snare and monopolar electrocoagulation were used for papillectomy. A 7F stent was placed in the pancreatic duct. Patients with distal intraductal growth underwent sphincterotomy and endoscopic resection after exclusion of more proximal growth. RESULTS Between February 1985 and April 2004, 106 patients (109 lesions), 68 women, 38 men, median age 68 years (range 29-88 years) were included. Median tumor size was 2 cm (range 0.5-6 cm) with one session (range 1-8) required for removal. Nine patients had invasive carcinoma (8%). Surgery for incomplete removal or recurrence was performed in 12% of 75 patients without and 37% of 31 patients with intraductal growth (p < 0.01), respectively. Fifteen patients had recurrence (15%); but, only 4 required surgery. Endoscopic resection was curative (median follow-up, 43 months) in 83% without and 46% with intraductal growth (p < 0.001). CONCLUSIONS Endoscopic papillectomy is safe and effective, and may be feasible in cases of intraductal growth. Surveillance and, if required, re-treatment are mandatory because of the risk of recurrence.
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Affiliation(s)
- Sabine Bohnacker
- Department for Interdisciplinary Endoscopy, Center of Internal Medicine, University Hospital Eppendorf, Hamburg, Germany
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Eickhoff A, Jakobs R, Riemann JF. Papillenadenom/Papillenkarzinom: Endoskopisch-interventionelle Möglichkeiten. Visc Med 2005. [DOI: 10.1159/000083360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
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Moon JH, Cha SW, Cho YD, Ryu CB, Cheon YK, Kwon KW, Kim YS, Kim YS, Lee JS, Lee MS, Shim CS, Kim BS. Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla. Gastrointest Endosc 2005; 61:461-6. [PMID: 15758926 DOI: 10.1016/s0016-5107(04)02649-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis. METHODS Six patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire. RESULTS En bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically. CONCLUSIONS Wire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.
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Affiliation(s)
- Jong Ho Moon
- Department of Internal Medicine, Digestive Disease Center, Institute for Digestive Research, Soon Chun Hyang University College of Medicine, 657 Hannam-Dong, Yongsan-Ku, Seoul 140-743, Korea
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Cheng CL, Sherman S, Fogel EL, McHenry L, Watkins JL, Fukushima T, Howard TJ, Lazzell-Pannell L, Lehman GA. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004; 60:757-64. [PMID: 15557951 DOI: 10.1016/s0016-5107(04)02029-2] [Citation(s) in RCA: 198] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Tumors of the major and the minor duodenal papillae can be malignant or premalignant, and traditionally are treated by surgical excision. This study evaluated the safety and the outcome of endoscopic snare resection of such tumors. METHODS All patients with tumors of the major or the minor papilla treated by endoscopic snare resection over a 10-year period (1994-2003) were identified from an ERCP database. Patients with tumors that had endoscopic features of malignancy and those proven to be cancerous by biopsy were excluded. Papillectomy was performed by electrosurgical snare resection. A pancreatic stent usually was placed before or after excision. Residual tumor was eradicated by repeated procedures. Endoscopic surveillance was at the discretion of the endoscopist. RESULTS Seventy snare resections were performed in 55 patients (mean age 59 years). Histopathologic diagnoses were the following: adenoma (45 patients; 7 with focal high-grade dysplasia, 6 with intraductal extension), adenocarcinoma (5), carcinoid tumor (2), gastric heterotopia (1), and normal histology (2). Fourteen patients had familial adenomatous polyposis. Of the 39 patients with isolated extraductal adenoma per cholangiogram, two underwent surgical resection because of persistent high-grade dysplasia, and 37 were successfully treated by endoscopic papillectomy alone. During follow-up (mean 30 months), 18 of 37 patients (49%) had no recurrence, 7 had recurrent adenoma (mean time interval to recurrence 27 months), two died of unrelated illnesses, and 10 are awaiting follow-up. Of the 6 patients with intraductal adenoma per cholangiogram, two underwent surgical resection, two had intraductal photodynamic therapy, and two had endoscopic snare resection. Intraductal tumor in the 4 latter patients was eliminated, although it recurred in one of the patients who had photodynamic therapy. Of the 7 patients with adenocarcinoma or carcinoid tumor, pancreaticoduodenectomy was performed in 3 and palliative papillectomy was performed in 4 unsuitable for surgery. One patient with carcinoid tumor of the minor papilla is alive, without recurrence, at 5 years after papillectomy. There were 10 procedure-related complications (14.5%), including pancreatitis (5), bleeding (4), and mild perforation (1). There was no procedure-related death. CONCLUSIONS Most adenomas of the duodenal papillae without intraductal extension can be fully resected by snare papillectomy. However, adenoma recurs in about a third of patients. Endoscopic therapy appears to be a reasonable alternative to surgery for management of papillary tumors. Longer follow-up is needed to determine the true recurrence rate and if endoscopic re-treatments are effective.
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Affiliation(s)
- Chi-Liang Cheng
- Division of Gastroenterology/Hepatology, Department of Surgery, Indiana University Medical Center, Indianapolis 46202, USA
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Sauvanet A, Regimbeau JM, Jaeck D. [Technique of surgical ampullectomy]. ACTA ACUST UNITED AC 2004; 129:381-6. [PMID: 15297231 DOI: 10.1016/j.anchir.2004.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2004] [Indexed: 02/08/2023]
Abstract
We describe the technique of surgical ampullectomy, which consists of complete resection of the papilla of Vater, including the sphincter, the distal part of common bile duct and Wirsung duct, and the duodenal wall around the papilla. Limits of resection are assessed by frozen section, particularly on both biliary and pancreatic ducts which are sutured together and reinserted on the duodenal wall. Surgical ampullectomy, combined with frozen section, is associated with a low morbidity, and represents a valid alternative to pancreaticoduodenectomy and endoscopic ampullectomy for presumed-benign ampullomas.
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Affiliation(s)
- A Sauvanet
- Service de chirurgie digestive, hôpital Beaujon, AP-HP, université Paris-VII, 100 boulevard du Général-Leclerc, 92118 Clichy cedex, France.
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