Recurrent pancreatitis caused by ampullary carcinoma and minor papilla adenoma in familial polyposis: report of a case

Endoscopic papillectomy for ampullary lesions of minor papilla

BACKGROUND AND AIMS

Ampullary lesions (ALs) of the minor duodenal papilla are extremely rare. Endoscopic papillectomy (EP) is a routinely used treatment for AL of the major duodenal papilla, but the role of EP for minor AL has not been accurately studied.

METHODS

We identified 20 patients with ALs of minor duodenal papilla in the multicentric database from the Endoscopic Papillectomy vs Surgical Ampullectomy vs Pancreatitcoduodenectomy for Ampullary Neoplasm study, which included 1422 EPs. We used propensity score matching (nearest-neighbor method) to match these cases with ALs of the major duodenal papilla based on age, sex, histologic subtype, and size of the lesion in a 1:2 ratio. Cohorts were compared by means of chi-square or Fisher exact test as well as Mann-Whitney U test.

RESULTS

Propensity score-based matching identified a cohort of 60 (minor papilla 20, major papilla 40) patients with similar baseline characteristics. The most common histologic subtype of lesions of minor papilla was an ampullary adenoma in 12 patients (3 low-grade dysplasia and 9 high-grade dysplasia). Five patients revealed nonneoplastic lesions. Invasive cancer (T1a), adenomyoma, and neuroendocrine neoplasia were each found in 1 case. The rate of complete resection, en-bloc resection, and recurrences were similar between the groups. There were no severe adverse events after EP of lesions of minor papilla. One patient had delayed bleeding that could be treated by endoscopic hemostasis, and 2 patients showed a recurrence in surveillance endoscopy after a median follow-up of 21 months (interquartile range, 12-50 months).

CONCLUSIONS

EP is safe and effective in ALs of the minor duodenal papilla. Such lesions could be managed according to guidelines for EP of major duodenal papilla.

Endoscopic Mucosal Resection of Adenocarcinoma at the Minor Duodenal Papilla: A Case Report and Suggestions for the Optimal Treatment Strategy

We herein report an extremely rare case of adenocarcinoma of the minor duodenal papilla (MiDP) which was successfully treated by endoscopic mucosal resection (EMR). An asymptomatic 84-year-old man underwent upper gastrointestinal endoscopy, which revealed a slightly elevated lesion at the MiDP. The biopsy findings were suggestive of adenocarcinoma. Computed tomography, magnetic resonance images and endoscopic ultrasonography did not reveal pancreatic tumor infiltration nor any apparent distant metastases. Therefore, we treated the lesion using EMR with complete resection. No recurrence or metastasis has been detected at 13 months after EMR. Total resection of the MiDP can thus serve as a relatively safe and simple treatment.

Pancreatoduodenectomy for Periampullary Tumors Presenting with Acute Pancreatitis

Background

Periampullary tumors (PT) may rarely present as acute pancreatitis (AP) or acute recurrent pancreatitis (ARP). Unlike other cases of AP and ARP, these conditions necessitate pancreaticoduodenectomy (PD), and timely diagnosis is crucial. Materials and Methods. A retrospective review of clinical, radiological, surgical, and pathological data was conducted for patients admitted to the Binzhou Medical University Hospital during the period from January 2010 to December 2017, for AP or ARP caused by PT. All patients included in the study group had undergone PD. The perioperative data for these patients was compared with data for patients with PT but without AP or ARP who underwent PD during the same period (control group).

Results

During the study period, 412 patients with AP or ARP were treated; among this group, 15 patients had PT. Compared with controls, patients in the study group were younger in age and had a longer course of disease, more frequent hospitalizations, and more severe derangements in laboratory data (P < 0.05). Operative time and intraoperative blood loss were significantly higher in the study group, but the incidence of postoperative outcomes such as pancreatic/biliary fistula, abdominal infection, postoperative hospital stay, and mortality were similar between groups (P < 0.05). Operative time and intraoperative blood loss were significantly higher in the study group, but the incidence of postoperative outcomes such as pancreatic/biliary fistula, abdominal infection, postoperative hospital stay, and mortality were similar between groups (

Conclusions

Neither AP nor ARP has any adverse impact on the outcomes of PD. However, in the treatment of younger patients suffering from AP or ARP, unexplained pancreatic duct dilation and weight loss should raise the suspicion of PT. EUS and EUS-FNA may be helpful in making the diagnosis.

Endoscopic management of adenomatous ampullary lesions

Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.

Adenocarcinoma of the minor duodenal papilla: report of a case

We report a rare case of adenocarcinoma of the minor papilla of the duodenum treated with transduodenal minor papillectomy. A 64-year-old woman was treated for an asymptomatic duodenal tumor detected on gastroduodenoscopy. Endoscopy showed a 15-mm sessile mass in the descending duodenum proximal to the major papilla. The major papilla was a villous 24-mm-diameter polypoid tumor. Histopathologic examination of the biopsy specimen showed tubular adenoma with moderate epithelial atypia. Transduodenal major and minor papillectomies were performed. The orifice of the duct of Santorini and the pancreatic duct were re-approximated to the duodenal wall to prevent acute pancreatitis caused by scarring and stenosis of the duct orifice. Histological findings were consistent with well-differentiated adenocarcinoma limited to the minor duodenal papilla, without infiltration of the duodenal wall submucosa, and confirmed complete resection. The patient had an uneventful postoperative course and has remained asymptomatic, without evidence of tumor recurrence or stenosis of the pancreatic duct orifice, for 4 years.

Pedunculated early ampullary carcinoma treated by ampullectomy: report of a case

CASE REPORT

A 30-year-old woman was admitted to our hospital for treatment of an ampullary tumor. Upper gastrointestinal endoscopy revealed a pedunculated tumor in the ampulla of Vater with a diameter of 50 mm, which was biopsied and diagnosed as tubulovillous adenoma with moderate atypia. Endoscopic ultrasonography demonstrated a hypoechoic tumor limited to the mucosa and without evidence of lymph node metastasis. Since endoscopic resection was not indicated because of the large size and pedunculated morphology with a long stalk, the patient underwent ampullectomy and papilloplasty. Histological examination revealed well-differentiated tubular adenocarcinoma in tubular adenoma with severe atypia limited to the mucosa. The patient remains well with no evidence of recurrence 10 months after resection.

DISCUSSION

Ampullectomy is an established method for ampullary tumor, but such a tumor with a long stalk is rare.