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Chandan S, Canakis A, Deliwala S, Frohlinger M, Khan SR, Mohan BP, Dahiya DS, Ramai D, Facciorusso A, Sharma NR, Adler DG, Kochhar GS. Prophylactic pancreatic duct stenting to reduce the risk of post-ampullectomy pancreatitis: a comprehensive review and meta-analysis of 1858 patients. Surg Endosc 2024:10.1007/s00464-024-11019-y. [PMID: 39030415 DOI: 10.1007/s00464-024-11019-y] [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: 03/02/2024] [Accepted: 06/30/2024] [Indexed: 07/21/2024]
Abstract
BACKGROUND The effectiveness of prophylactic pancreatic duct stenting (PPDS) in preventing post-ampullectomy pancreatitis (PAP) at the time of endoscopic ampullectomy (EA) has been reported, however, results are conflicting. We conducted a systematic review and meta-analysis looking at the use of PPDS in reducing PAP as well as overall post-ampullectomy complications. METHODS Multiple databases were searched through May 2023 for studies reporting on EA. Meta-analysis was performed to determine pooled proportions and relative risk (RR) with 95% confidence intervals (CI) of PAP, with and without PPDS. Pooled rates of adverse events including perforation, delayed bleeding, cholangitis, and procedure related mortality were assessed. Random effects model was used for our meta-analysis and heterogeneity was assessed using the I2 statistics. RESULTS Thirty-four studies (14 case series, 18 cohort studies and 2 randomized controlled trials) with 1868 patients were included. The overall pooled rate of PAP was 12.3% (CI 10.3-14.5). We found no statistically significant difference in rates of PAP among patients with PPDS, 11.9% (CI 8.9-15.7) and without PPDS, 16.6% (CI 13.4-20.4), RR 0.8 (CI 0.51-1.28), p = 0.4. In terms of severe PAP, we found no difference between the two groups. The overall pooled rates of successful en-bloc and piecemeal resection were 74.8% (CI 67.3-81.1) and 25.1% (CI 19-32.4). Additionally, pooled rates of ampullary stenosis, post procedural bleeding, perforation, cholangitis, and procedure related mortality were 3.6%, 11.1%, 4.2%, 3.5%, and 1.3%, respectively. CONCLUSIONS Our analysis shows that PPDS at the time of EA does not offer a significant protective effect against PAP. While the incidence of PAP was higher among the no PPDS group, it is plausible that this is more likely due to variation among studies in terms of lesion size, length/size of pancreatic stent used and etiology of ampullary lesions. Future well-designed randomized controlled trials are needed to validate our findings.
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Affiliation(s)
- Saurabh Chandan
- Center for Interventional Endoscopy (CIE), Advent Health, 601 E Rollins St, Orlando, FL, 32803-1248, USA.
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Smit Deliwala
- Division of Digestive Diseases, Emory University, Atlanta, GA, USA
| | - Michael Frohlinger
- Department of Medicine, George Washington University School of Medicine, Washington, DC, USA
| | - Shahab R Khan
- Department of Medicine, Brigham and Women Hospital, Boston, MA, USA
| | | | - Dushyant S Dahiya
- Division of Gastroenterology Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Daryl Ramai
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Neil R Sharma
- Interventional Oncology & Surgical Endoscopy (IOSE), Peak Gastroenterology Associates, PC, Colorado Springs, CO, USA
| | - Douglas G Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, CO, USA
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
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Lee J, Oh D, Seo DW, Song TJ, Park DH, Lee SK, Hong SM. Long-term Outcomes of Ampullary Adenoma According to Resected Margin Status after Endoscopic Papillectomy. Gut Liver 2024; 18:747-755. [PMID: 38715439 PMCID: PMC11249933 DOI: 10.5009/gnl230451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/15/2024] [Accepted: 01/22/2024] [Indexed: 07/16/2024] Open
Abstract
Background/Aims : Endoscopic papillectomy (EP) is increasingly used as an alternative to surgery for managing benign ampullary neoplasms. However, post-EP resection margins are often positive or indeterminate, and there is no consensus on the management of ampullary adenomas with positive or indeterminate margins after EP. This study was designed to compare the long-term outcomes between resected margin-negative (RMN) and resected margin-positive/indeterminate (RMPI) groups and to identify factors associated with clinical outcomes. Methods : This retrospective analysis included patients with ampullary adenoma without evidence of adenocarcinoma who underwent EP between 2004 and 2016. The RMN and RMPI groups were compared for recurrence rates and recurrence-free duration during a mean follow-up duration of 71.7±39.8 months. Factors related to clinical outcomes were identified using multivariate analysis. Results : Of the 129 patients who underwent EP, 82 were in the RMN group and 47 were in the RMPI group. The RMPI group exhibited a higher recurrence rate compared to the RMN group (14.6% vs 34.0%, p=0.019). However, the recurrence-free duration was not significantly different between the groups (34.7±32.6 months vs 36.2±27.4 months, p=0.900). Endoscopic treatment successfully managed recurrence in both groups (75% vs 75%). Submucosal injection was a significant risk factor for residual lesions (hazard ratio, 4.11; p=0.009) and recurrence (hazard ratio, 2.57; p=0.021). Conclusions : Although ampullary adenomas with positive or indeterminate margins after EP showed a higher rate of recurrence at long-term follow-up, endoscopic treatment was effective with favorable long-term outcomes. Submucosal injection prior to resection was associated with increased risk of recurrence and residual lesions.
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Affiliation(s)
- Junghwan Lee
- Division of Gastroenterology, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Dongwook Oh
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wan Seo
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Departments of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Mo Hong
- Departments of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Singh AD, Burke CA, Draganov PV, Bapaye J, Nishimura M, Ngamruengphong S, Kushnir V, Sharma N, Kaul V, Singh A, Bapaye A, Banerjee D, Bayudan A, De Leon MR, Singh RR, Mony S, Gandhi A, Hollander T, Bittner K, Beauvais J, Lyu R, Liska D, Stevens T, Walsh M, Bhatt A. Incidence and risk factors for recurrence of ampullary adenomas after endoscopic papillectomy: Comparative analysis of familial adenomatous polyposis and sporadic ampullary adenomas in an international multicenter cohort. Dig Endosc 2024; 36:834-842. [PMID: 37985239 DOI: 10.1111/den.14725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/16/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVES Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA. METHODS We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease. RESULTS In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence. CONCLUSION Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients.
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Affiliation(s)
- Achintya D Singh
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
- Department of Gastroenterology and Hepatology, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Carol A Burke
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Peter V Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
| | - Jay Bapaye
- Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Makoto Nishimura
- Division of Gastroenterology, Hepatology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Saowanee Ngamruengphong
- Department of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Vladimir Kushnir
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Neil Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, IN, USA
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Aparajita Singh
- Department of Gastroenterology, University of California, San Francisco, CA, USA
| | - Amol Bapaye
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Debdeep Banerjee
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL, USA
| | - Alexis Bayudan
- Department of Gastroenterology, University of California, San Francisco, CA, USA
| | - Mariajose Rojas De Leon
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, IN, USA
| | - Ritu R Singh
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Cancer Institute, Fort Wayne, IN, USA
| | - Shruti Mony
- Department of Gastroenterology and Hepatology, The Johns Hopkins Hospital, Baltimore, MD, USA
- Department of Gastroenterology and Hepatology, University of Oklahoma, Norman, OK, USA
| | - Ashish Gandhi
- Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune, India
| | - Thomas Hollander
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA
| | - Krystle Bittner
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY, USA
| | - Jacques Beauvais
- Division of Gastroenterology, Hepatology and Nutrition Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ruishen Lyu
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - David Liska
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Tyler Stevens
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Walsh
- Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Amit Bhatt
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
- Sanford R. Weiss MD Center for Hereditary Colorectal Neoplasia, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
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Wang Y, Khizar H, Zhou H, Jin H, Lou Q, Zhang X, Yang J. Endoscopic treatment for early duodenal papillary carcinoma: long-term outcomes. J Gastroenterol Hepatol 2024; 39:1367-1373. [PMID: 38528742 DOI: 10.1111/jgh.16546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/24/2024] [Accepted: 03/03/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND AND AIM This study aims to determine whether endoscopic papillectomy (EP) is a safe and effective treatment for early duodenal papillary carcinoma with long-term follow-up. METHODS From June 2012 to September 2022, 48 patients with early duodenal papilloma carcinoma who received endoscopic treatment were included. The histological types, percentage of complete resections, postoperative residuals, adverse events, and recurrences were evaluated. RESULTS EP was successful in all patients; 46 were lumped, and two were fragmented, with a 95.8% intact removal rate (46/48). The preoperative biopsy pathological positive rate was 70.8% (34/48). The incidence of early postoperative adverse events (within 1 month after EP) were 16.7% (8/48), including four cases of acute pancreatitis, three cases of delayed bleeding, and one case of acute cholangitis. In addition, 4.2% (2/48) of the late adverse events were bile duct stenosis. After 6 months, the postoperative residual rate was 0%. The median time to recurrence was 17.5 months, and the postoperative recurrence rate was 16.7% (8/48) in patients treated with radiofrequency ablation. The median progression-free survival was 18.6 months (95% CI, 12.1-25.1), and the median overall survival was 121.5 months (95% CI, 105.6-120.9). CONCLUSIONS EP is a safe and efficient alternative therapy for early duodenal papillary carcinoma. Endoscopic follow-up and treatment are essential because of the potential for recurrence.
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Affiliation(s)
- Yingyu Wang
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
- Department of Gastroenterology, Yuhang First People's Hospital, Hangzhou, Zhejiang, China
| | - Hayat Khizar
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
- Department of Oncology, The Fourth Affiliated Hospital, International Institute of Medicine, Zhejiang University School of Medicine, Hangzhou, China
| | - Haibin Zhou
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Hangbin Jin
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Qifeng Lou
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Xiaofeng Zhang
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
| | - Jianfeng Yang
- Department of Gastroenterology, Hangzhou First People's Hospital, Hangzhou, Zhejiang, China
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Hangzhou, Zhejiang, China
- Key Laboratory of Integrated Traditional Chinese and Western Medicine for Biliary and Pancreatic Diseases of Zhejiang Province, Hangzhou, Zhejiang, China
- Hangzhou Institute of Digestive Diseases, Hangzhou, Zhejiang, China
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Lee J, Park YB, Han SY, Joo DC, Hong SM, Yi K, Kim DU. New Method of Papillectomy May Decrease Recurrence: Anchoring Method versus Conventional Method. J Clin Med 2024; 13:3226. [PMID: 38892937 PMCID: PMC11172506 DOI: 10.3390/jcm13113226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/16/2024] [Accepted: 05/27/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: Endoscopic papillectomy (EP) is the preferred treatment for ampullary tumors because it has fewer side effects than surgical removal. This study retrospectively compared a new anchoring EP method (A-EP) with the conventional (C-EP) approach. Methods: Ninety-nine patients who underwent EP at a single medical institution between 2009 and 2021 were retrospectively reviewed. In all patients, the indications for EP were pathological adenoma with <10 mm of biliary invasion and a tumor diameter <30 mm on endoscopic ultrasonography. The exclusion criteria were antiplatelet/anticoagulant use, previous upper GI surgery, or prior biliary/pancreatic endoscopic therapy. One expert endoscopist performed the two types of EPs, A-EP and C-EP. Results: Sixty-two patients underwent A-EP, and 37 underwent C-EP. There were no significant differences in baseline characteristics, such as sex, age, tumor size, and ductal invasion on endoscopic ultrasound. The A-EP group had higher en bloc resection rates (95.2% vs. 78.4%, p = 0.010). Although the difference was not statistically significant, it tended towards fewer incidences of pancreatitis (p = 0.081) and duct stricture (p = 0.081). The recurrence rate was lower in the A-EP group (8.1% vs. 37.8%, p = 0.000). There were no significant differences between the two groups regarding the follow-up period (A-EP vs. C-EP, 725 vs. 1045 days, p = 0.109) or the days of recurrence (A-EP vs. C-EP, 341 vs. 562 days, p = 0.551). Conclusions: A-EP showed better outcomes than C-EP in terms of en bloc resection and recurrence rates, providing evidence for the efficacy of this novel EP method.
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Affiliation(s)
- Jonghyun Lee
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Yong Bo Park
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
| | - Sung Yong Han
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Dong Chan Joo
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Seung Min Hong
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Kiyoun Yi
- Division of Gastroenterology, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea; (J.L.); (Y.B.P.); (S.Y.H.); (D.C.J.); (S.M.H.); (K.Y.)
- Department of Internal Medicine, College of Medicine, Pusan National University, Yangsan 50612, Republic of Korea
| | - Dong Uk Kim
- Department of Internal Medicine, CHA Gumi Medical Center, CHA University, Gumi-si 39295, Republic of Korea
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Lemos Garcia J, Rosa I, Pereira da Silva J, Lage P, Claro I. Endoscopic Approach to Duodenal Adenomas in Familial Adenomatous Polyposis: A Retrospective Cohort. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:430-436. [PMID: 38476155 PMCID: PMC10928868 DOI: 10.1159/000527209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 08/17/2022] [Indexed: 03/14/2024]
Abstract
Introduction Over 90% of the patients with familial adenomatous polyposis (FAP) will develop duodenal adenomas. Aim The aim of this study was to evaluate the effectiveness and safety of endoscopic excision of large duodenal adenomas in FAP patients. Methods All FAP patients from a familial risk clinic submitted to endoscopic therapy for duodenal adenomas ≥10 mm between January 2010 and February 2021 were included. Results From 151 FAP families, 22 patients (50 lesions) were included: 54.5% female; median follow-up 8.5 (IQR: 5.8-12.3) years after the first endoscopy. First therapeutic endoscopy occurred at a median age of 41.0 years (IQR: 33.0-58.2). Repeat therapeutic endoscopy was required in 54.5% of patients. Median size of the largest adenoma was 15 mm (IQR: 10-18 mm); resection was piecemeal in 63.1% and en bloc in the remaining. In 2 cases, the resection was incomplete (fibrosis due to previous resection and difficult positioning). Complications occurred in 6.3% of the resected lesions (4 patients): 2 immediate (bleeding, perforation); 4 in the first week (1 bleeding, 2 mild pancreatitis, 1 perforation requiring surgery; the latter two after ampullectomy). Histology revealed low-grade dysplasia adenomas in 90.1%; no adenocarcinomas were found. One patient with Spigelman stage IV disease not amenable to endoscopic control underwent elective duodenopancreatectomy (without duodenal cancer). Conclusion Endoscopic surveillance and treatment of duodenal adenomas in FAP patients was safe and effective in the prevention of duodenal cancer.
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Affiliation(s)
- Joana Lemos Garcia
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Isadora Rosa
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - João Pereira da Silva
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Pedro Lage
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
| | - Isabel Claro
- Gastroenterology Department, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
- Familial Risk Clinic, Instituto Português de Oncologia de Lisboa Francisco Gentil E.P.E., Lisboa, Portugal
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Wang Y, Zhang X, Yang Z, Wang T, Zhu D, Gao J, Zhang PP, Wang P, Shi X. Long-term follow-up of endoscopic papillectomy and the value of preventive pancreatic stent placement (with videos). Gastroenterol Rep (Oxf) 2023; 11:goad050. [PMID: 37867926 PMCID: PMC10585593 DOI: 10.1093/gastro/goad050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 07/29/2023] [Accepted: 08/07/2023] [Indexed: 10/24/2023] Open
Abstract
Background Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management. Hence, this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy (EP). Methods In this study, 115 patients who underwent EP at Changhai Hospital (Shanghai, China) between January 2012 and December 2018 were retrospectively analysed. Endoscopy was performed at 1, 3, 6, and 12 months after EP. Data were statistically analysed using the t-test or the Mann-Whitney U test. Results A total of 107 patients were included in this study and the follow-up period was 75 ± 43 months. The average age of the 107 patients was 54.6 years and the average tumor size was 17 mm. The average age of the patients (53.7 ± 10.7 years vs 55.2 ± 10.5 years, P = 0.482), minimum tumor size (13 vs 19 mm, P = 0.063), and complete resection rate (84.78% vs 85.25%, P = 0.947) did not differ significantly between the stent placement and non-stent placement groups. Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48% and 4.35%, respectively. The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis, but not in multivariate analysis. The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis. Moreover, delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up. Conclusions EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.
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Affiliation(s)
- Yuling Wang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Xiaoqing Zhang
- Department of Emergency, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Zhenhua Yang
- Department of Nephrology, Gongli Hospital, Pudong New Area, Shanghai, P. R. China
| | - Teng Wang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Dongqing Zhu
- Department of Radiology, Changzheng Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Jie Gao
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Peiqin Wang
- Department of Gastroenterology, Changzheng Hospital, Naval Military Medical University, Shanghai, P. R. China
| | - Xingang Shi
- Department of Gastroenterology, Changhai Hospital, Naval Military Medical University, Shanghai, P. R. China
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Maselli R, de Sire R, Fugazza A, Spadaccini M, Colombo M, Capogreco A, Beyna T, Repici A. Updates on the Management of Ampullary Neoplastic Lesions. Diagnostics (Basel) 2023; 13:3138. [PMID: 37835881 PMCID: PMC10572979 DOI: 10.3390/diagnostics13193138] [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: 09/08/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Ampullary neoplastic lesions (ANLs) represent a rare cancer, accounting for about 0.6-0.8% of all gastrointestinal malignancies, and about 6-17% of periampullary tumors. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis (FAP). Usually, noninvasive ANLs are asymptomatic and detected accidentally during esophagogastroduodenoscopy (EGD). When symptomatic, ANLs can manifest differently with jaundice, pain, pancreatitis, cholangitis, and melaena. Endoscopy with a side-viewing duodenoscopy, endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP) play a crucial role in the ANL evaluation, providing an accurate assessment of the size, location, and characteristics of the lesions, including the staging of the depth of tumor invasion into the surrounding tissues and the involvement of local lymph nodes. Endoscopic papillectomy (EP) has been recognized as an effective treatment for ANLs in selected patients, providing an alternative to traditional surgical methods. Originally, EP was recommended for benign lesions and patients unfit for surgery. However, advancements in endoscopic techniques have broadened its indications to comprise early ampullary carcinoma, giant laterally spreading lesions, and ANLs with intraductal extension. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of ampullary neoplastic lesions.
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Affiliation(s)
- Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University Federico II of Naples, 80126 Naples, Italy
| | - Alessandro Fugazza
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Marco Spadaccini
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Matteo Colombo
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus, 40217 Düsseldorf, Germany;
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
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9
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Cho SH, Oh D, Song TJ, Park DH, Seo DW, Lee SK, Kim MH, Lee SS. Long-term Outcomes of Endoscopic Intraductal Radiofrequency Ablation for Ampullary Adenoma with Intraductal Extension after Endoscopic Snare Papillectomy. Gut Liver 2023; 17:638-646. [PMID: 36472069 PMCID: PMC10352061 DOI: 10.5009/gnl220201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/10/2022] [Accepted: 09/29/2022] [Indexed: 07/20/2023] Open
Abstract
Background/Aims There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Methods Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. Results A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of ID-RFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Conclusions Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.
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Affiliation(s)
- Sung Hyun Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dongwook Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Do Hyun Park
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Koo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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10
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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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11
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Qin XZ, Zhou CH, Zhang BY, Zhang L, Gong TT, Zhang MM, Wang D, Zou DW. Recurrent acute pancreatitis caused by duodenal papillary adenoma: A case report and literature review. J Dig Dis 2023; 24:60-66. [PMID: 36790293 DOI: 10.1111/1751-2980.13160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 02/10/2023] [Accepted: 02/12/2023] [Indexed: 02/16/2023]
Affiliation(s)
- Xian Zheng Qin
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chun Hua Zhou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ben Yan Zhang
- Department of Pathology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ling Zhang
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ting Ting Gong
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Min Zhang
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Duo Wu Zou
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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12
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Cho KB. Endoscopic Papillectomy for Ampullary Tumors. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2022. [DOI: 10.7704/kjhugr.2022.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ampullary tumors originate from the ampulla of Vater and are often discovered incidentally during an upper endoscopy. These tumors usually occur sporadically and may be benign or malignant in nature. Tumor growth clinically presents with cholestasis, pancreatitis, and bleeding. Patients with ampullary adenomas are often asymptomatic; however, removal of these lesions is recommended in view of their malignant potential. Following advances in endoscopic techniques and the accumulation of experience, considering high recurrence, mortality, and morbidity rates associated with surgery, endoscopic papillectomy may be useful as first-line treatment for adenomatous lesions with ambiguous malignant changes or focal intraepithelial carcinoma. Although it is relatively safe and easy to perform, the operation is a high-level procedure that may be associated with serious complications. It should be performed by an experienced endoscopist at a well-equipped hospital/center with emergency facilities and support personnel. Accurate resection is associated with high treatment success rates. Most complications are mild and can be treated medically. Pancreatitis is the most common complication, and pancreatic duct stenting is useful for prophylaxis. Recurrence may occur, and is more frequently observed during segmental resection; therefore, close periodic follow-up is essential. Although there are no unified indications or guidelines for endoscopic papillectomy, endoscopic papillectomy may be safe and effective for management of ampullary adenomas. Careful patient selection and follow-up are mandatory.
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13
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Cui TT, Chai NL, Cai FC, Li MY, Wang XD, Xiao NJ, Wang ZK, Liu F, Ling-Hu EQ, Li W. Analysis of risk factors for post-endoscopic papillectomy bleeding. Scand J Gastroenterol 2022; 57:1367-1373. [PMID: 35705372 DOI: 10.1080/00365521.2022.2085058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic papillectomy (EP) is an effective treatment for ampullary lesions but technically challenging because of anatomical specificities concerning the high rate of adverse events. Bleeding is one of the most feared complications and can be potentially life-threatening. AIM To study the risk factors for bleeding after EP are presented with the goal of establishing preventive measures. METHODS A total of 173 consecutive patients with ampullary lesions undergone EP from January 2006 to October 2020 were enrolled in this study. They were divided into a bleeding group and a non-bleeding group depending on whether postoperative bleeding occurred. Related factors were analyzed by univariate and multivariate logistics regression. RESULTS Postoperative bleeding was experienced in 33 patients (19.07%). Multivariate analysis also identified intraoperative bleeding (OR: 4.38, 95% CI: 1.87-11.15, p = .001) and endoscopic closure (OR: 0.25, 95% CI: 0.10-0.58, p = .001) as independent factors significantly associated with bleeding after EP. Lesion size (≥3 cm) was shown as an independent factor significantly associated with intraoperative bleeding (OR: 4.25, 95% CI: 1.21-16.44, p = .028). CONCLUSIONS This retrospective evaluation found that endoscopic closure was associated with reduced risk and intraoperative bleeding with increased risk of bleeding after EP. Lesion size may indirectly influence the risk of postoperative bleeding by increasing the risk of intraoperative bleeding.
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Affiliation(s)
- Ting-Ting Cui
- Department of Gastroenterology and Hepatology, Medical School of Chinese PLA, Beijing, China.,Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ning-Li Chai
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Feng-Chun Cai
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ming-Yang Li
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xiang-Dong Wang
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Nian-Jun Xiao
- Department of Gastroenterology and Hepatology, Medical School of Chinese PLA, Beijing, China.,Department of Gastroenterology, Air Force Medical Center, Beijing, China
| | - Zi-Kai Wang
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Fang Liu
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - En-Qiang Ling-Hu
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese PLA General Hospital, Beijing, China
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14
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Liu SZ, Chai NL, Li HK, Feng XX, Zhai YQ, Wang NJ, Gao Y, Gao F, Wang SS, Linghu EQ. Prospective single-center feasible study of innovative autorelease bile duct supporter to delay adverse events after endoscopic papillectomy. World J Clin Cases 2022; 10:7785-7793. [PMID: 36158476 PMCID: PMC9372830 DOI: 10.12998/wjcc.v10.i22.7785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Revised: 04/18/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Conventional endoscopic papillectomy (EP) is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions. As reported by some existing studies, temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.
AIM To evaluate the usefulness, convenience, safety, and short-term results of a novel autorelease bile duct supporter after EP procedure, especially the effectiveness in preventing EP.
METHODS A single-center comparison study was conducted to verify the feasibility of the novel method. After EP, a metallic endoclip and human fibrin sealant kit were applied for protection. The autorelease bile duct supporter fell into the duct segment and the intestinal segment. Specifically, the intestinal segment was extended by nearly 5 cm as a bent coil. The bile was isolated from the pancreatic juice using an autorelease bile duct supporter, which protected the wound surface. The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.
RESULTS En bloc endoscopic resection was performed in 6/8 patients (75%), and piecemeal resection was performed in 2/8 of patients (25%). None of the above patients were positive for neoplastic lymph nodes or distant metastasis. No cases of mortality, hemorrhage, delayed perforation, pancreatitis, cholangitis or duct stenosis with the conventional medical treatment were reported. The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation. One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy. No recurrence was identified during the 8-mo (ranging from 6-9 mo) follow-up period.
CONCLUSION In brief, it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction. Secure closure of the resection wound with clips and fibrin glue were indicated to be promising and important for the use of autorelease bile duct supporters. Well-designed larger-scale comparative studies are required to confirm the findings of this study.
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Affiliation(s)
- Sheng-Zhen Liu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Hui-Kai Li
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Xiu-Xue Feng
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ya-Qi Zhai
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Nan-Jun Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ying Gao
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Fei Gao
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - Sha-Sha Wang
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
| | - En-Qiang Linghu
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing 100853, China
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15
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Park SW, Song TJ, Park JS, Jun JH, Park TY, Oh DW, Lee SS, Kim MH. Effect of prophylactic endoscopic clipping for prevention of delayed bleeding after endoscopic papillectomy for ampullary neoplasm: a multicenter randomized trial. Endoscopy 2022; 54:787-794. [PMID: 35148541 DOI: 10.1055/a-1737-3843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND : Endoscopic clip placement is technically challenging using a duodenoscope, limiting their application for treatment of bleeding after endoscopic papillectomy. This study evaluated the efficacy of newly designed clips to prevent bleeding after endoscopic papillectomy. METHODS : Patients (n = 80) with suspected benign adenomas on the major papilla who were scheduled for endoscopic papillectomy with or without clipping were randomized. A new duodenoscope-compatible clip capable of being rotated, reopened, and repeatedly repositioned was used. The primary end point was incidence of delayed bleeding. RESULTS : The clipping procedure was successful in all patients. The incidence of delayed bleeding was nonsignificantly higher in the no-clipping group than in the clipping group (31.6 % [95 % confidence interval (CI) 19.1-47.5] vs. 15.0 % [95 %CI 7.1-29.1]). The incidence of post-endoscopic retrograde cholangiopancreatography pancreatitis did not differ significantly between the groups (clipping vs. no-clipping: 17.5 % [95 %CI 8.7-31.9] vs. 5.3 % [95 %CI 1.5-17.3]), and all cases were mild. CONCLUSIONS : Placement of the newly designed rotatable clip was technically feasible and tended to have a protective effect by preventing delayed bleeding after endoscopic papillectomy, although statistical significance was not reached.
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Affiliation(s)
- Se Woo Park
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong-si, Korea
| | - Tae Jun Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Seok Park
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jae Hyuk Jun
- Department of Gastroenterology, Eulji University College of Medicine, Daejeon, Korea
| | - Tae Young Park
- Department of Internal Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Dong Wook Oh
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Soo Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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16
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Abstract
Most ampullary lesions (ALs) are sporadic, involve the major papilla, and are premalignant (adenomas). They are often diagnosed as an incidental finding during endoscopy or imaging procedures. Diagnosis and staging of ALs include endoscopic, histologic, and radiological evaluations. Currently, endoscopic papillectomy is the preferred treatment for ALs in most situations. In this article, we will describe the diagnostic work-up and focus on the endoscopic treatment, including indications, technique, outcomes, complications, and follow-up.
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Affiliation(s)
- Sara Teles de Campos
- Department of Gastroenterology, Digestive Unit, Champalimaud Foundation, Avenida de Brasília, Lisbon 1400-038, Portugal
| | - Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Dr. Molewaterplein 40, Rotterdam 3015 GD, the Netherlands.
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17
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Choi SJ, Lee HS, Kim J, Choe JW, Lee JM, Hyun JJ, Yoon JH, Kim HJ, Kim JS, Choi HS. Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study. World J Gastroenterol 2022; 28:1845-1859. [PMID: 35633905 PMCID: PMC9099193 DOI: 10.3748/wjg.v28.i17.1845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/26/2021] [Accepted: 03/27/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ampullary adenoma is a rare premalignant lesion, but its incidence is increasing. Endoscopic papillectomy has become the first treatment of choice for ampullary adenomas due to its safety and effectiveness, thereby replacing surgical resection. However, recurrence rates and adverse events after endoscopic papillectomy were reported in up to 30% of cases.
AIM To review the long-term outcomes of endoscopic papillectomy and investigate the factors that affect these outcomes.
METHODS We retrospectively analyzed the data of patients who underwent endoscopic papillectomy for ampullary adenoma at five tertiary hospitals between 2013 and 2020. We evaluated clinical outcomes and their risk factors. The definitions of outcomes were as follow: (1) curative resection: complete endoscopic resection without recurrence; (2) endoscopic success: treatment of ampullary adenoma with endoscopy without surgical intervention; (3) early recurrence: reconfirmed adenoma at the first endoscopic surveillance; and (4) late recurrence: reconfirmed adenoma after the first endoscopic surveillance.
RESULTS A total of 106 patients were included for analysis. Of the included patients, 81 (76.4%) underwent curative resection, 99 (93.4%) had endoscopic success, showing that most patients with non-curative resection were successfully managed with endoscopy. Sixteen patients (15.1%) had piecemeal resection, 22 patients (20.8%) had shown positive/uncertain resection margin, 11 patients (16.1%) had an early recurrence, 13 patients (10.4%) had a late recurrence, and 6 patients (5.7%) had a re-recurrence. In multivariate analysis, a positive/uncertain margin [Odds ratio (OR) = 4.023, P = 0.048] and piecemeal resection (OR = 6.610, P = 0.005) were significant risk factors for early and late recurrence, respectively. Piecemeal resection was also a significant risk factor for non-curative resection (OR = 5.424, P = 0.007). Twenty-six patients experienced adverse events (24.5%).
CONCLUSION Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas. Careful selection and follow-up of patients is mandatory, particularly in cases with positive/uncertain margin and piecemeal resection.
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Affiliation(s)
- Seong Ji Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
| | - Hong Sik Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jiyeong Kim
- Lab of Biostatistical Consulting and Research, Medical Research Collaborating Center, Industry-University Cooperation Foundation, Hanyang University, Seoul 04763, South Korea
| | - Jung Wan Choe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jai Hoon Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
| | - Hyo Jung Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Jae Seon Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul 02841, South Korea
| | - Ho Soon Choi
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, South Korea
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Takada Y, Kawashima H, Ohno E, Ishikawa T, Mizutani Y, Iida T, Yamamura T, Kakushima N, Furukawa K, Nakamura M, Honda T, Ishigami M, Ito A, Hirooka Y. The impact of the age-adjusted Charlson comorbidity index as a prognostic factor for endoscopic papillectomy in ampullary tumors. J Gastroenterol 2022; 57:199-207. [PMID: 35098349 DOI: 10.1007/s00535-022-01853-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognostic nutritional index (PNI) and Charlson comorbidity index (CCI) have been useful for predicting the prognosis based on nutritional condition and comorbidities in surgery and endoscopic mucosal dissection. The age-adjusted CCI (ACCI) has also been reported to be useful in surgery, but it has not been applied to endoscopic treatment. We therefore clarified the prognostic factors associated with ampullary tumors treated with endoscopic papillectomy (EP). METHODS From January 2003 to December 2020, 236 patients who underwent EP for sporadic ampullary tumors at Nagoya University Hospital were included in this study. The 5-year survival and ability to predict the prognosis were evaluated in terms of the sex, PNI, ACCI, final pathological diagnosis, and intraductal extension. RESULTS During a median follow-up period of 1558 days, 17 patients died. No patient died of the primary disease. The 5-year survival rate was 91.1%. In a univariate analysis, only a high ACCI (≥ 5) was extracted as a significant prognostic factor (Odds ratio, 12.2; 95% confidence interval, 3.81-39.3; p < 0.001). The 5-year survival rates for a low ACCI (≤ 4) and high ACCI were 96.6% and 73.5%, respectively (p < 0.001). CONCLUSIONS A high ACCI is an important prognostic factor associated with the 5-year survival and a risk of death from other illness. Ampullary tumors suitable for EP are less likely to be a prognostic factor, and treatment-free follow-up may be acceptable in patients with a high ACCI.
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Affiliation(s)
- Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan. .,Department of Endoscopy, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8560, Japan.
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Ito
- Nishinoho Ito Medical Clinic, Kitanagoya, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Japan
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19
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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: 16] [Impact Index Per Article: 8.0] [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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20
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Li SL, Li W, Yin J, Wang ZK. Endoscopic papillectomy for ampullary adenomatous lesions: A literature review. World J Gastrointest Oncol 2021; 13:1466-1474. [PMID: 34721778 PMCID: PMC8529916 DOI: 10.4251/wjgo.v13.i10.1466] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 06/02/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Ampullary adenomatous lesions of the gastrointestinal tract are rare and can be asymptomatic. Therefore, ampullary adenomas with malignant potential require prompt removal, regardless of whether they are adenomatous or carcinomatous lesions. Endoscopic papillectomy is a safe and effective alternative therapy to surgery to treat duodenal papillary lesions in selected patients. Accurate preoperative diagnosis and staging of ampullary adenomatous lesions are critical for predicting prognosis and determining the most appropriate therapeutic approach. Furthermore, the management and prevention of adverse events and endoscopic treatment for remnant or recurrent lesions and surveillance are essential for successful endoscopic management of ampullary adenomatous lesions. This literature review was based on PubMed and MEDLINE and focused on recent advancements in the endoscopic papillectomy technique to provide a comprehensive view of endoscopic papillectomy to treat ampullary adenomatous lesions.
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Affiliation(s)
- Shu-Ling Li
- Department of Gastroenterology and Hepatology, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jian Yin
- Department of Gastroenterology and Hepatology, The Fourth Medical Center, Chinese PLA General Hospital, Beijing 100048, China
| | - Zi-Kai Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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21
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Kawashima H, Ohno E, Ishikawa T, Iida T, Tanaka H, Furukawa K, Nakamura M, Honda T, Hashimoto S, Itoh A, Ishigami M, Hirooka Y, Fujishiro M. Endoscopic papillectomy for ampullary adenoma and early adenocarcinoma: Analysis of factors related to treatment outcome and long-term prognosis. Dig Endosc 2021; 33:858-869. [PMID: 33107134 DOI: 10.1111/den.13881] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 10/18/2020] [Accepted: 10/21/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES There are few reports on the long-term prognosis of papillary tumors after endoscopic papillectomy. Here, we report a retrospective study of the therapeutic effects, long-term prognosis, and affecting factors. METHODS The inclusion criteria were papillary adenoma with/without an adenocarcinoma component on biopsy results and ≤10 mm intraductal extension, and the exclusion criteria were moderate to poorly differentiated adenocarcinoma on biopsy results. If no residual lesion was confirmed ≥6 months after the last endoscopic treatment, remission was defined. Subsequently, follow-up endoscopy was scheduled once a year. Surgery was required in the case of adenocarcinoma recurrence or intraductal lesions >10 mm. The rates of adverse events, remission, recurrence, and need for surgery were examined. The affecting factors were calculated. RESULTS There were a total of 253 subjects, including 65 with adenocarcinoma. Pancreatitis (7.5%), bleeding (9.1%) and perforation (2.8%) were observed as adverse events. Among 221 subjects with ≥6 months of follow-up, 212 (95.9%) were in remission. The cumulative recurrence rate using the Kaplan-Meier analysis at 5 years was 16.9% (22 cases), with the need for surgery in 5.9% (5 cases). Intraductal extension on preoperative diagnosis was the only significant risk factor for both recurrence (P < 0.001) and the need for surgery (P = 0.005). The presence of adenocarcinoma had no significant effect. CONCLUSION Although remission was achieved in more than 95% of our patients, we observed a high rate of recurrence at the long-term follow-up, which was significantly associated with intraductal extension but not with the presence of adenocarcinoma.
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Affiliation(s)
- Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Aichi, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Hiroyuki Tanaka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Aichi, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Senju Hashimoto
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Aichi, Japan
| | | | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Gastroenterological Oncology, Fujita Health University, Aichi, Japan
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Aichi, Japan
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22
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Tringali A, Matteo MV, Orlandini B, Barbaro F, Perri V, Zhang Q, Ricci R, Costamagna G. Radiofrequency ablation for intraductal extension of ampullary adenomatous lesions: proposal for a standardized protocol. Endosc Int Open 2021; 9:E749-E755. [PMID: 33937517 PMCID: PMC8062240 DOI: 10.1055/a-1387-7880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/20/2021] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Intraductal extension of ampullary adenoma represents a challenging endoscopic issue. Intraductal radiofrequency ablation (RFA) has been recently suggested, but evidence and standardization of this technique are still lacking. This study aimed to provide a long-term evaluation of clinical efficacy and safety of intraductal RFA ablation with a standardized algorithm of treatment. Patients and methods Data were prospectively collected from consecutive patients with intraductal extension of adenomatous ampullary lesions from January 2016 to November 2018. Endpoints of the study were clinical success evaluated on histology results at the last follow-up, technical success, and adverse events assessment. Results Nine patients with intraductal (biliary ± pancreatic) extension of ampullary adenomas were treated with RFA during the study period. Histology on the papillectomy specimen confirmed intraductal involvement with low-grade dysplasia (LGD) in five cases (56 %), high-grade dysplasia (HGD) in three (33 %), and HGD with intramucosal adenocarcinoma in one patient (11 %). Additional argon plasma coagulation to ablate the adenoma on the duodenal mucosa was applied in five patients (56 %). Technical success was 100 %. One patient (11 %) with failed pancreatic stenting, developing acute pancreatitis after RFA, recovered with medical therapy. After a median follow-up of 21 months (IQR 20-31), six patients (67 %) achieved clinical success being free of recurrence, whereas one was diagnosed with persistence of adenocarcinoma, one with recurrent HGD, and one with recurrent LGD. Conclusions In our experience, intraductal RFA achieved acceptable results after a 2-year follow-up. Further studies are required to confirm our results and to select those patients most likely to respond.
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Affiliation(s)
- Andrea Tringali
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Valeria Matteo
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Beatrice Orlandini
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Federico Barbaro
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Perri
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Qianqian Zhang
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Ricci
- Pathology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Department of Pathology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy,Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
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23
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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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24
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Choi YH, Yoon SB, Chang JH, Lee IS. The Safety of Radiofrequency Ablation Using a Novel Temperature-Controlled Probe for the Treatment of Residual Intraductal Lesions after Endoscopic Papillectomy. Gut Liver 2021; 15:307-314. [PMID: 32616684 PMCID: PMC7960966 DOI: 10.5009/gnl20043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 04/17/2020] [Accepted: 04/23/2020] [Indexed: 12/18/2022] Open
Abstract
Background/Aims Treatment of residual intraductal lesions after endoscopic papillectomy for ampullary adenomas is relatively difficult. Few studies have been conducted using intraductal radiofrequency ablation (RFA) in the treatment of such lesions, and no study has aimed to reduce the side effects of excessive heat caused by RFA. Recently, a temperature-controlled RFA probe was developed to avoid excessive heat. This study aimed to investigate the safety of this new RFA probe in the treatment of intraductal lesions of ampullary adenoma. Methods Patients who received RFA for residual intraductal lesions after endoscopic papillectomy between November 2017 and June 2019 were retrospectively reviewed. A novel temperature- controlled probe (ELRA) was used for intraductal RFA, and clinical data including adverse events were collected. Results Ten patients were included in this study. Intraductal adenomas showed low-grade dysplasia in eight patients and high-grade dysplasia in two patients. The median diameter of intraductal adenomas was 9 mm (range, 5 to 10 mm) in the common bile duct and 5 mm (range, 4 to 11 mm) in the pancreatic duct. Adverse events occurred in three patients (30.0%), of which two were mild pancreatitis and one was asymptomatic biliary stricture. Over a median follow-up period of 253 days, only one patient underwent additional surgery, as the remainder showed no adenomatous lesions on follow-up biopsies. Conclusions The new temperature-controlled RFA probe can be used with acceptable safety for the treatment of residual intraductal lesions after endoscopic papillectomy. Further evaluation through future prospective studies is needed.
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Affiliation(s)
- Young Hoon Choi
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyuck Chang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - In Seok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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25
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Okano N, Igarashi Y, Ito K, Mizutani S, Nakagawa H, Watanabe K, Yamada Y, Yoshimoto K, Kimura Y, Iwasaki S, Takuma K, Hara S, Kishimoto Y. Efficacy of Hypertonic Saline-Epinephrine Local Injection Around the Anal Side before Endoscopic Papillectomy for Ampullary Tumors. Clin Endosc 2021; 54:706-712. [PMID: 33687856 PMCID: PMC8505187 DOI: 10.5946/ce.2020.208] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022] Open
Abstract
Background/Aims Bleeding is a complication of endoscopic snare papillectomy for ampullary tumors. This study aimed to investigate the clinical efficacy of hypertonic saline-epinephrine (HSE) local injection before endoscopic papillectomy for prevention of bleeding.
Methods We retrospectively reviewed the data of 107 consecutive patients with ampullary tumors who underwent endoscopic papillectomy. The rates of en bloc resection, pathological resection margins, and prevention of immediate or delayed bleeding in the simple snaring resection group (Group A) and the HSE injection group (Group B) were compared.
Results A total of 44 and 63 patients were enrolled in Groups A and B, respectively. The total complete resection rate was 89.7% (96/107); the clinical complete resection rates in Group A and Group B were 86.3% (38/44) and 92.1% (58/63), respectively (p=0.354). Post-papillectomy bleeding occurred in 22 patients. In Groups A and B, the immediate bleeding rates were 20.5% (9/44) and 4.8% (3/63), respectively (p=0.0255), while the delayed bleeding rates were 7% (3/44) and 11% (7/63), respectively (p=0.52). The rates of positive horizontal and vertical pathological margin in both groups were 27% and 16%, respectively.
Conclusions HSE local injection was effective in preventing immediate bleeding and was useful for safely performing endoscopic papillectomy for ampullary tumors.
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Affiliation(s)
- Naoki Okano
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yoshinori Igarashi
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ken Ito
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Saori Mizutani
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Hiroki Nakagawa
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kouji Watanabe
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuuto Yamada
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Yoshimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuusuke Kimura
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Susumu Iwasaki
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Kensuke Takuma
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Seiichi Hara
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
| | - Yuui Kishimoto
- Division of Gastroenterology and Hepatology, Toho University Omori Medical Center, Tokyo, Japan
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26
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Cecinato P, Parmeggiani F, Braglia L, Carlinfante G, Zecchini R, Decembrino F, Iori V, Sereni G, Tioli C, Cavina M, Camellini L, Azzolini F, Ponz de Leon M, Sassatelli R. Endoscopic Papillectomy for Ampullary Adenomas: Different Outcomes in Sporadic Tumors and Those Associated with Familial Adenomatous Polyposis. J Gastrointest Surg 2021; 25:457-466. [PMID: 31898110 DOI: 10.1007/s11605-019-04500-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/11/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Ampullary adenomas are rare and potentially malignant. Surgery was the standard treatment but endoscopic papillectomy (EP) is a possible alternative. AIM We retrospectively evaluated the principal clinical outcomes of EP in all patients referred to our unit also dividing sporadic ampullary adenoma (SAA) from familial adenomatous polyposis (FAP)-associated adenomas. METHODS All consecutive patients who underwent endoscopic papillectomy because of ampullary adenoma were considered. The primary outcome was the technical success of EP. Secondary outcomes included the number of procedures, the adverse event rate, the recurrence rate, the concordance of histology pre- and post-EP, and the evaluation of factors related to technical success. RESULTS Between January 2001 and December 2015, sixty-two patients were included (21 FAP and 41 SAA). Technical success was achieved in 75.8% and was different in the two groups (FAP 95.2%, SAA 65.8%, p 0.025). Intraductal invasion was negatively associated with technical success (41.7% vs. 84.0%; p 0.005). The intestinal subtype was predictive of success (79.7% vs. 0%; p 0.012) as well as en bloc resection (90.3% vs. 61.3%; p 0.016). Adverse events were reported in 14 patients (22.6%). CONCLUSIONS EP is an effective and safe procedure and is a viable alternative to surgery. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03494543.
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Affiliation(s)
- Paolo Cecinato
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy.
| | - Francesca Parmeggiani
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Luca Braglia
- Research and Statistics Infrastructure, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Ramona Zecchini
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Francesco Decembrino
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Veronica Iori
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Giuliana Sereni
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Cristiana Tioli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | - Maurizio Cavina
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
| | | | - Francesco Azzolini
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita Salute San Raffaele University, Milan, Italy
| | - Maurizio Ponz de Leon
- Diagnostic Medicine Department, Clinic and Public Health, University of Modena and Reggio Emilia, Modena, Italy
| | - Romano Sassatelli
- Unit of Gastroenterology and Digestive Endoscopy, Azienda USL-IRCCS di Reggio Emilia, 42123, Reggio Emilia, Italy
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Wu L, Liu F, Zhang N, Wang XP, Li W. Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy: A pilot study. World J Gastroenterol 2020; 26:7036-7045. [PMID: 33311948 PMCID: PMC7701946 DOI: 10.3748/wjg.v26.i44.7036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/24/2020] [Accepted: 10/13/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.
AIM To evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.
METHODS This is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an endoscopic nasobiliary drainage tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.
RESULTS EP and overlength stents placement were technically feasible in all five patients (63 ± 12 years), with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), four achieved en bloc excision and curative resection. The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.
CONCLUSION For patients with exposure or injury of the muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.
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Affiliation(s)
- Liang Wu
- International Center for Diagnosis and Treatment of Liver Diseases, The Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China
| | - Fang Liu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Nan Zhang
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
| | - Xiao-Peng Wang
- Department of Gastroenterology and Hepatology, Chinese PLA 305 Hospital, Beijing 100017, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese PLA General Hospital, Beijing 100853, China
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Heise C, Abou Ali E, Hasenclever D, Auriemma F, Gulla A, Regner S, Gaujoux S, Hollenbach M. Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions. J Clin Med 2020; 9:E3622. [PMID: 33182806 PMCID: PMC7696506 DOI: 10.3390/jcm9113622] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/15/2022] Open
Abstract
Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8-81.4%, I2 = 91.38%) for EA, 96.4% (93.6-99.2%, I2 = 37.8%) for SA and 98.9% (98.0-99.7%, I2 = 0%) for PD. AEs were 24.7% (19.8-29.6%, I2 = 86.4%), 28.3% (19.0-37.7%, I2 = 76.8%) and 44.7% (37.9-51.4%, I2 = 0%), respectively. Recurrences were registered in 13.0% (10.2-15.6%, I2 = 91.3%), 9.4% (4.8-14%, I2 = 57.3%) and 14.2% (9.5-18.9%, I2 = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.
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Affiliation(s)
- Christian Heise
- Department of Medicine I—Gastroenterology, Pulmonology, Martin-Luther University Halle-Wittenberg, 06097 Halle, Germany;
| | - Einas Abou Ali
- Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Paris Descartes University, 75014 Paris, France;
| | - Dirk Hasenclever
- Institute for Medical Informatics, Statistics and Epidemiology (IMISE), University of Leipzig, 04103 Leipzig, Germany;
| | - Francesco Auriemma
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital, Rozzano, 20089 Milan, Italy;
| | - Aiste Gulla
- Department of Abdominal Surgery, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, 01513 Vilnius, Lithuania;
- General Surgery, MedStar Georgetown University Hospital, Washington, DC 20007, USA
| | - Sara Regner
- Department of Clinical Sciences Malmö, Section for Surgery, Lund University, 221 00 Lund, Sweden;
| | - Sébastien Gaujoux
- Department of Pancreatic and Endocrine Surgery, Pitié-Salpetriere Hospital, Médecine Sorbonne Université, 75000 Paris, France;
| | - Marcus Hollenbach
- Medical Department II, Division of Gastroenterology, University of Leipzig Medical Center, 04103 Leipzig, Germany
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Fritzsche JA, Klein A, Beekman MJ, van Hooft JE, Sidhu M, Schoeman S, Fockens P, Bourke MJ, Voermans RP. Endoscopic papillectomy; a retrospective international multicenter cohort study with long-term follow-up. Surg Endosc 2020; 35:6259-6267. [PMID: 33159297 PMCID: PMC8523407 DOI: 10.1007/s00464-020-08126-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
Background Endoscopic papillectomy (EP) is considered a relatively safe and minimally invasive treatment for papillary adenomas. In the literature a significant risk for local recurrence is described. The aim of this study was to evaluate long-term recurrence rates and time-to-recurrence. Additionally, risk factors for recurrence, malignancy and adverse events were studied. Methods This is a retrospective study in consecutive patients with papillary adenomas who underwent EP in two tertiary referral hospitals between 2001 and 2018. Primary outcome was recurrence in patients with at least 1-year endoscopic follow-up. Secondary outcomes were surgery free survival, adverse events, and mortality within 30 days after the index procedure. Results A total of 259 patients were found eligible [median age 66 years, 130 male (50.2%)]. Forty-three patients were known with familial adenomatous polyposis (FAP) (16.6%). At least 1-year endoscopic follow-up was available in 154 patients with a total follow-up of 586 person-years and median of 40 months [interquartile range (IQR) 25–75]. Recurrence occurred in 24 cases (15.6%) of which 8 were known with FAP, leading to a recurrence incidence rate of 4.1 per 100 person-years with a median time-to-recurrence of 29 months (IQR 14.75–59.5). Fifty-three patients underwent at least 5-year follow-up, in 6 (11.3%) of them recurrence was encountered after 5 years of which four were known with FAP. No risk factors for recurrence could be identified. Adverse events occurred in 50/259 patients (19.3%). One patient died within 30 days after the procedure. Papillary stenosis occurred in 19/259 (7.3%) of the patients. There were no cases of malignant degeneration during follow-up. Conclusions Recurrence after EP occurs in a significant proportion of patients and occurs even 5 years after EP. This emphasizes the need for long-term follow-up. We advise to consider at least 5-year follow-up in case of a sporadic adenoma, unless comorbidity makes follow-up clinically irrelevant. Electronic supplementary material The online version of this article (10.1007/s00464-020-08126-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeska A. Fritzsche
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Maarten J. Beekman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jeanin E. van Hooft
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Michael J. Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
- Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Yasuda I, Kobayashi S, Takahashi K, Nanjo S, Mihara H, Kajiura S, Ando T, Tajiri K, Fujinami H. Management of Remnant or Recurrent Lesions after Endoscopic Papillectomy. Clin Endosc 2020; 53:659-662. [PMID: 31794653 PMCID: PMC7719432 DOI: 10.5946/ce.2019.171] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 09/17/2019] [Indexed: 02/05/2023] Open
Abstract
Endoscopic papillectomy (EP) for ampullary adenomas achieves cure rates ranging from 76% to 90%, and recurrence rates are as high as 33%. If remnant or recurrent lesions after prior EP are endoscopically visible and are not suspected of intraductal extension into the biliary or pancreatic duct, repeated snaring and cutting can be performed until all visible lesions are completely resected. However, endoscopic ablative therapies, particularly argon plasma coagulation, can be attempted for tiny or uncertain remnant and recurrent lesions. In addition, intraductal radiofrequency ablation has recently been attempted for residual intraductal lesions after EP at several institutions. Although still under investigation, it has shown some promise. It might be offered as an alternative to surgery, particularly in patients who are unfit for surgery or those who refuse to undergo surgery.
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Affiliation(s)
- Ichiro Yasuda
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
- Correspondence: Ichiro Yasuda Third Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan Tel: +81-76-434-7300, Fax: +81-76-434-5027, E-mail:
| | - Saito Kobayashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kosuke Takahashi
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Sohachi Nanjo
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Mihara
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shinya Kajiura
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Takayuki Ando
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Kazuto Tajiri
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Haruka Fujinami
- Third Department of Internal Medicine, University of Toyama, Toyama, Japan
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A Comparison of Clinical Outcomes between Endoscopic Resection and Surgical Resection in Ampullary Tumors. ACTA ACUST UNITED AC 2020; 56:medicina56100546. [PMID: 33080957 PMCID: PMC7603234 DOI: 10.3390/medicina56100546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/05/2020] [Accepted: 10/16/2020] [Indexed: 12/07/2022]
Abstract
Background and objectives: This study aimed to elucidate the clinical outcomes of endoscopic resection (ER) through comparison with surgical resection (SR) through a meta-analysis. Materials and Methods: This meta-analysis was performed using 32 studies. The complete resection and recurrence rates of treatment for ampullary tumors were investigated and compared between ER and SR. In addition, complications, including pancreatitis, cholangitis, cholecystitis, perforation, and papillary stenosis, and mortality of ER and SR, respectively, were estimated. Results: The rates of complete resection were 0.812 (95% confidence interval, CI, 0.758–0.856) and 0.929 (95% CI 0.739–0.984) in ER and SR, respectively. Recurrence rates were 0.145 (95% CI 0.107–0.193) and 0.126 (95% CI 0.057–0.257) in ER and SR, respectively. There were no significant differences in complete resection and recurrence rates between ER and SR in the meta-regression tests (p = 0.164 and p = 0.844, respectively). The estimated rates of pancreatitis, cholangitis/cholecystitis, perforation, and papillary stenosis were 12.8%, 4.4%, 5.2%, and 4.3% in ER and 9.9%, 5.6%, 2.3%, and 5.6% in SR, respectively. There was no significant difference in complications between ER and SR. The mortality rate of SR was slightly higher than that of ER (0.041, 95% CI 0.015–0.107 vs. 0.031, 95% CI 0.005–0.162). Our results show that ER had no significant differences in terms of complete resection and recurrence rates compared to SR, regardless of tumor behaviors. Conclusions: By comparing the complication and mortality rates between ER and SR, the safety of ER was proven.
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Endoscopic snare papillectomy for adenoma of the ampulla of vater: Long-term results in 135 consecutive patients. Dig Liver Dis 2020; 52:1033-1038. [PMID: 32532606 DOI: 10.1016/j.dld.2020.05.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/17/2020] [Accepted: 05/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND The premalignant nature of ampullary adenomas justifies their radical excision. AIMS Aim of this study is to evaluate the long-term results of endoscopic snare papillectomy in a consecutive series of patients with ampullary adenomas. METHODS Patients who underwent endoscopic snare papillectomy between October 1999 and October 2017 were identified from an electronic database. Endoscopic snare papillectomy was performed en bloc, when possible; a pancreatic stent or a nasopancreatic drainage were inserted. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly. RESULTS Endoscopic snare papillectomy was performed in 135 patients (70 M, mean age 60.5 years) by en bloc (83%) or piecemeal (17%) resection. Delayed bleeding occurred in 16 patients (11.8%), infected retroperitoneal collections in 6 patients (4.4%), pancreatitis in 4 patients (3%). One patient died (0.7%). Follow-up was available in 103/114 (90.3%) patients. In case of residual (24.3%) and recurrent (23.3%), adenomas endoscopic retreatment was successful in 42/49 cases (85.7%). After a mean follow-up of 40 months, 93.2% (96/103) of the patients were disease free CONCLUSION: Endoscopic snare papillectomy of ampullary adenomas is effective with favorable long-term outcomes. Compliance to the scheduled follow-up is important for the early detection and re-treatment of recurrences.
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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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Abstract
INTRODUCTION Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP. AREA COVERED This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions. EXPERT OPINION The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine , Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
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Hollenbach M, Ali EA, Auriemma F, Gulla A, Heise C, Regnér S, Gaujoux S. Study Protocol of the ESAP Study: Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for Ampullary Neoplasm-A Pancreas2000/EPC Study. Front Med (Lausanne) 2020; 7:152. [PMID: 32435644 PMCID: PMC7218136 DOI: 10.3389/fmed.2020.00152] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 04/07/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Lesions of the Ampulla of Vater are a rare condition and represent <10% of peri-ampullary neoplasms. Nevertheless, ampullary adenomas have the potential for malignant transformation to ampullary carcinomas by an adenoma-to-carcinoma sequence. Thus, adequate patient selection and complete resection (R0) of non-invasive ampullary lesions either by endoscopic papillectomy (EP), surgical ampullectomy (SA), or pancreaticoduodenectomy (PD) is essential. Although PD was traditionally performed, recent studies reported considerable efficacy and fewer complications following EP and SA. Since consistent comparative data are lacking, the Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodectomy (ESAP) study will provide evidence for a therapeutic standard and post procedure morbidity in ampullary lesions. Methods: International multicenter retrospective study. Adult patients (>18 years of age) who underwent SA or PD for ampullary neoplasm between 2004 and 2018 or EP between 2007 and 2018 will be evaluated. Main inclusion criteria are ampullary lesions strictly located to the ampulla. This includes adenoma, adenocarcinoma (T1 and T2), neuroendocrine tumors, gastrointestinal stroma tumors and other rare conditions. Exclusion criteria are peri-ampullary lesions, e.g., from the duodenal wall or the head of the pancreas, and interventions for tumor stages higher than T2. The main objective of this study is to analyze rates of complete resection (R0), recurrence and necessity for complementary interventions following EP, SA, and PD. Treatment-quality for each procedure will be defined by morbidity, mortality and complication rates and will be compared between EP, SA, and PD. Secondary objectives include outcome for patients with incomplete resection or initially understated tumors, lesions of the minor papilla, hereditary syndromes, neuroendocrine tumors, mesenchymal lesions, and other rare conditions. Additionally, we will analyze therapy by argon plasma coagulation and radiofrequency ablation. Furthermore, outcome in curative and palliative interventions can be distinguished. Conclusion: The ESAP study will provide evidence for therapeutic algorithms and data for the implementation of guidelines in the treatment of different types of ampullary tumors, including recurrent, or incomplete resected lesions.
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Affiliation(s)
- Marcus Hollenbach
- Medical Department II—Gastroenterology, Hepatology, Infectious Diseases, Pulmonology, University of Leipzig Medical Center, Leipzig, Germany
| | - Einas Abou Ali
- Department of Gastroenterology, Digestive Oncology and Endoscopy, Cochin Hospital, Paris Descartes University, Paris, France
| | - Francesco Auriemma
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Hospital, Rozzano, Italy
| | - Aiste Gulla
- Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
- Center of Abdominal Surgery, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
- Department of Surgery, Georgetown University University Hospital, Washington, DC, United States
| | - Christian Heise
- Department of Medicine I—Gastroenterology, Pulmonology, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Sara Regnér
- Section for Surgery, Department of Clinical Sciences Malmö, Lund University, Skane University Hospital, Malmö, Sweden
| | - Sébastien Gaujoux
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
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Endoscopic ampullectomy for non-invasive ampullary lesions: a single-center 10-year retrospective cohort study. Surg Endosc 2020; 35:684-692. [PMID: 32215745 DOI: 10.1007/s00464-020-07433-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lesions involving the ampulla of Vater have traditionally been managed by surgical resection, albeit with high rates of morbidity and mortality. Endoscopic ampullectomy is increasingly recognized as an efficacious and safer treatment option. This study aims to evaluate the safety and efficacy of endoscopic ampullectomy for non-invasive ampullary lesions in a single tertiary referral center. METHODS Patients with non-invasive ampullary lesions, with or without familial adenomatous polyposis (FAP), were identified using pathology and endoscopy databases. The study included all patients who underwent the index ampullectomy between January 2007 and January 2017. Outcome parameters included accuracy of forceps biopsies, adverse events, success of endoscopic resection, and rate of recurrence. RESULTS A total of 53 patients underwent endoscopic ampullectomy over the 10-year period. Histological upstaging was seen in 37.8% of cases at ampullectomy compared to biopsy, including 5 cases (9.4%) of invasive adenocarcinoma. Adverse events occurred in 10 patients (18.9%) consisting of bleeding (11.3%), benign papillary stenosis (3.8%), acute pancreatitis (1.9%), and duodenal perforation (1.9%). Recurrence occurred in 32.7% over a median follow-up of 30 months (range 6-104 months), with the majority (18.4%) occurring at the first surveillance endoscopy. Nonetheless, 75% of recurrences were able to be cleared endoscopically. Endoscopic resection was successful in 91.1% of patients. CONCLUSIONS Endoscopic ampullectomy is an effective and safer therapeutic modality for non-invasive ampullary lesions, in addition to being a valuable diagnostic and staging tool. Nevertheless, careful patient selection and a commitment to endoscopic follow-up are of primary importance to achieve an optimal therapeutic outcome.
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Analysis of risk factors associated with acute pancreatitis after endoscopic papillectomy. Sci Rep 2020; 10:4132. [PMID: 32139734 PMCID: PMC7057991 DOI: 10.1038/s41598-020-60941-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/19/2020] [Indexed: 02/07/2023] Open
Abstract
Acute pancreatitis (AP) is a common adverse event (AE) of endoscopic papillectomy (EP). Prophylactic plastic pancreatic stent (PPS) placement appears to prevent AP. We evaluated factors associated with post-EP AP by a retrospective analysis of patients with tumors of the duodenal papilla who underwent EP from January 2008 to November 2016 at 2 tertiary care centers. Clinical, laboratory, endoscopic ultrasound parameters, and PPS placement were evaluated. Seventy-two patients underwent EP (37 men), with mean age of 60.3 (31–88) years. Mean main pancreatic duct (MPD) diameter was 0.44 (0.18–1.8) cm. Mean tumor size was 1.8 (0.5–9.6) cm. Tumors were staged as uT1N0, uT2N0, and uT1N1 in 87.5%, 11.1%, and 1.4%. Thirty-eight AEs occurred in 33 (45.8%) patients, with no mortality. Total bilirubin, tumor size, MPD diameter, and PPS placement had odds ratios (ORs) of 0.82, 0.14, 0.00, and 6.43 for AP. Multivariate analysis (PPS placement × MPD diameter) showed ORs of 4.62 (95%CI, 1.03–21.32; p = 0.049) and 0.000 (95%CI, 0.00–0.74; p = 0.042) for AP. In conclusion, patients with jaundice, large tumors, and dilated MPD seem less likely to have post-EP AP. PPS placement was associated with a higher risk of AP, which may question its use.
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Kim NH, Kim HJ. Unsolved problems in endoscopic papillectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nam Hee Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Joo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Poley JW, Campos S. Methods and outcome of the endoscopic treatment of ampullary tumors. Ther Adv Gastrointest Endosc 2020; 13:2631774519899786. [PMID: 32030370 PMCID: PMC6977234 DOI: 10.1177/2631774519899786] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/18/2019] [Indexed: 12/16/2022] Open
Abstract
Ampullary tumors are rare neoplasms but increasingly encountered due to an increase in diagnostic procedures, mainly upper gastrointestinal endoscopy. Diagnosis, staging, and treatment of these tumors are described and recommendations given based on the most recent literature.
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Affiliation(s)
- Jan-Werner Poley
- Gastroenterology & Hepatology, Erasmus MC, Dr Molewaterplein 40, 3000 CA Rotterdam, The Netherlands
| | - Sara Campos
- Gastroenterology & Hepatology, Erasmus MC, Rotterdam, The Netherlands
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Endoscopic Papillectomy in the Treatment of Adenomas of the Papilla of Vater: Excision Is Exclusively for Experienced Experts. Dig Dis Sci 2020; 65:9-10. [PMID: 31754991 DOI: 10.1007/s10620-019-05942-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Iwasaki E, Minami K, Itoi T, Yamamoto K, Tsuji S, Sofuni A, Tsuchiya T, Tanaka R, Tonozuka R, Machida Y, Takimoto Y, Tamagawa H, Katayama T, Kawasaki S, Seino T, Horibe M, Fukuhara S, Kitago M, Ogata H, Kanai T. Impact of electrical pulse cut mode during endoscopic papillectomy: Pilot randomized clinical trial. Dig Endosc 2020; 32:127-135. [PMID: 31222794 DOI: 10.1111/den.13468] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/16/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic papillectomy is increasingly being used for ampullary adenoma treatment. However, it remains challenging despite increased safety with treatment advances. The ideal power output and electrosurgical current mode for mucosal resection are not established. We aimed to identify the ideal electrical pulse for use during resection. METHODS This pilot randomized, single-blind, prospective, multicenter trial, recruited patients with ampullary adenomas and conventional anatomy who were scheduled to undergo endoscopic papillectomy. Endoscopic treatment was performed using a standardized algorithm and patients were randomized for endoscopic papillectomy with Endocut or Autocut. The primary outcome was the incidence of delayed bleeding. Incidence of procedure-related pancreatitis, successful complete resection, pathological findings, and other adverse events were secondary endpoints. RESULTS Sixty patients were enrolled over a 2-year period. The incidences of delayed bleeding (13.3% vs. 16.7%, P = 1.00) and pancreatitis (27% vs. 30%, P = 0.77) were similar between both groups. The rate of crush artifacts was higher in the Endocut than in the Autocut group (27% vs. 3.3%, P = 0.03). Immediate bleeding when resecting tumors greater than 14 mm in diameter was more common in the Autocut than in the Endocut group (88% vs. 46%, P = 0.04). CONCLUSIONS The Autocut and Endocut modes have similar efficacy and safety for endoscopic papillectomy. The Endocut mode may prevent immediate bleeding in cases with large tumor sizes, although it causes more frequent crush artifacts. REGISTRY AND THE REGISTRATION NUMBER The Japanese UMIN Clinical Trials Registry (UMIN-CTR: 000021382).
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Affiliation(s)
- Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Abstract
BACKGROUND Data on the endoscopic resection of duodenal and papillary lesions less than 15 mm in size have been well supported by systematic studies. However, for large sessile lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite significant morbidity and mortality. This study aimed to compare the outcomes and costs between endoscopic and surgical resection of such lesions. METHODS Patients who underwent endoscopic or surgical resection of LSL-D/P at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University from 2013 to 2017 were retrospectively analyzed. Endoscopic and surgical outcomes and costs were compared. RESULTS A total of 68 lesions were evaluated (47.1% of patients were male; mean lesion size 25 mm); 46 were treated by endoscopic resection, and 22 were managed by surgical resection. At the initial procedure, complete resection was achieved in 93.4%. Major complications (perforation, delayed bleeding, pancreatitis, infections and admission to the ICU) occurred in 15.3% of the endoscopic group and 22.6% of the surgical group. For recurrence at the first surveillance endoscopic examination, there was a 12.1% recurrence rate in the endoscopic group and a 5.3% recurrence rate in the surgical group (P = 0.654). Compared with surgical resection, regardless of lesion location, endoscopic resection had a shorter procedural time and hospital stay, a lower morbidity rate and was less costly. CONCLUSION In centers specialized in complex endoscopic resection, patients with LSL-D/P would likely benefit from advanced endoscopic management, which offers a lower morbidity profile and reduced costs.
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Minami K, Iwasaki E, Kawasaki S, Fukuhara S, Seino T, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Horibe M, Kitago M, Ogata H, Kanai T. A long (7 cm) prophylactic pancreatic stent decreases incidence of post-endoscopic papillectomy pancreatitis: a retrospective study. Endosc Int Open 2019; 7:E1663-E1670. [PMID: 31788550 PMCID: PMC6877413 DOI: 10.1055/a-1010-5581] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic papillectomy (EP) is a minimally invasive treatment for ampullary neoplasms and is recognized as an alternative treatment to surgical resection; however, there are few reports on a suitable pancreatic stent (PS) after EP for preventing pancreatitis. The aim of this study was to evaluate the efficacy of a long PS after EP. Patients and methods In this retrospective single-center study, 39 patients with pathologically proven ampullary neoplasms who underwent EP between March 2012 and August 2018 were enrolled. The study participants were divided into two subgroups according to the PS length: those with a PS shorter than 5 cm (short PS group, n = 17) and those with a PS of 7 cm (long PS group, n = 22). The incidence of adverse events and risk factors for pancreatitis were evaluated. Results The diameter of all PSs was 5 Fr. Post-EP pancreatitis occurred in nine patients (23.1 %), with two cases of severe pancreatitis (5.1 %). Pancreatitis occurred more frequently in the short PS group (7/17, 41.2 %) than in the long PS group (2/22, 9.1 %) ( P = 0.026). There were no significant differences between the two groups in terms of other adverse events. Univariate and multivariate analyses showed that a long PS was the only factor associated with a decreased incidence of post-EP pancreatitis ( P = 0.042; odds ratio, 0.16; 95 % confidence interval, 0.027-0.94). Conclusion A long (7 cm) PS significantly decreased incidence of pancreatitis after EP. Prospective randomized studies with a larger number of patients and wider range of PS lengths are required.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,Corresponding author Takanori Kanai MD, PhD Chief Professor, Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of Medicine35 ShinanomachiShinjuku-ku, Tokyo 160-8582Japan+81-(0)3-3353-6247
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44
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Minami K, Iwasaki E, Fukuhara S, Horibe M, Seino T, Kawasaki S, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Kanai T, Itoi T. Electric Endocut and Autocut Resection for Endoscopic Papillectomy: A Systematic Review. Intern Med 2019; 58:2767-2772. [PMID: 31243201 PMCID: PMC6815892 DOI: 10.2169/internalmedicine.2720-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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
Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Youichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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45
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Jang S. Endoscopic management of ampullary neoplasm. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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Spadaccini M, Fugazza A, Frazzoni L, Leo MD, Auriemma F, Carrara S, Maselli R, Galtieri PA, Chandrasekar VT, Fuccio L, Aljahdli E, Hassan C, Sharma P, Anderloni A, Repici A. Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis. United European Gastroenterol J 2019; 8:44-51. [PMID: 32213054 DOI: 10.1177/2050640619868367] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Endoscopic papillectomy (EP) is a viable therapy in ampullary lesions (AL). Many series have reported low morbidity and acceptable outcomes. We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for AL. Electronic databases (Medline, Scopus and EMBASE) were searched up to September 2018. Studies that included patients with endoscopically resected AL were eligible. The rate of adverse events (AEs; primary outcome) and the rates of both technical and clinical efficacy outcomes were pooled by means of a random- or fixed-effects model to obtain a proportion with a 95% confidence interval (CI). Twenty-nine studies were included (1751 patients). The overall AE rate was 24.9%. The post-procedural pancreatitis rate was 11.9%, with the only factor affecting this outcome being prophylactic pancreatic stenting. The complete resection rate was 94.2%, with a rate of oncologically curative resection of 87.1%. The recurrence rate was 11.8% (follow-up: 9.6-84.5 months). EP is a relatively safe and effective option for AL. Our study might definitively suggest the protective role of prophylactic pancreatic stenting against post-procedural pancreatitis.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Leonardo Frazzoni
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Francesco Auriemma
- Gastrointestinal Endoscopy Unit, Humanitas Mater Domini, Castellanza, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Roberta Maselli
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | | | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Emad Aljahdli
- Gastroenterology Unit, King Abdul Aziz University Hospital, Jeddah, Saudi Arabia
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Prateek Sharma
- School of Medicine, University of Kansas, Kansas City, USA.,Veteran Affairs Medical Center, Kansas City, USA
| | - Andrea Anderloni
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
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Peng CY, Lv Y, Shen SS, Wang L, Ding XW, Zou XP. The impact of endoscopic ultrasound in preoperative evaluation for ampullary adenomas. J Dig Dis 2019; 20:248-255. [PMID: 30834717 DOI: 10.1111/1751-2980.12719] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Revised: 12/13/2018] [Accepted: 02/25/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in assessing locoregionally and determining therapeutic options for ampullary adenomas and the related factors. METHODS Patients undergoing EUS and surgical or endoscopic resection for biopsy-proven ampullary adenomas between 2009 and 2016 were retrospectively analyzed. The depth of tumor invasion, intraductal extension, and regional lymph node staging evaluated by EUS were compared with post-treatment pathological findings. RESULTS Altogether 120 patients were enrolled in this study. The overall accuracy for EUS in T staging was 81.7%. The sensitivity and specificity of EUS for T staging were 93.9%, 45.5% for adenoma and T1, 50.0% and 96.5% for T2, 66.7% and 97.4% for T3, 50.0% and 97.5% for T4 lesions, respectively. The sensitivity, specificity, and accuracy of EUS for the diagnosis of any intraductal extension were 89.5%, 86.1%, and 86.7%, respectively. The overall accuracy of EUS for regional lymph node staging was 75.0%. The sensitivity and specificity of EUS for diagnosing N1 were 62.5% and 87.5%. By multivariate analysis no factors were found to be independently associated with EUS accuracy for tumor invasive depth. However, small lesion size (≤15 mm) and dilated duct were associated with an overestimation in intraductal extension. CONCLUSION EUS may be a useful diagnostic tool for selecting endoscopic or surgical treatment for ampullary adenomas.
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Affiliation(s)
- Chun Yan Peng
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Shan Shan Shen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xi Wei Ding
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
| | - Xiao Ping Zou
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu Province, China
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Idiopathic acute pancreatitis: a review on etiology and diagnostic work-up. Clin J Gastroenterol 2019; 12:511-524. [DOI: 10.1007/s12328-019-00987-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/19/2019] [Indexed: 12/17/2022]
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49
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Sakai A, Tsujimae M, Masuda A, Iemoto T, Ashina S, Yamakawa K, Tanaka T, Tanaka S, Yamada Y, Nakano R, Sato Y, Kurosawa M, Ikegawa T, Fujigaki S, Kobayashi T, Shiomi H, Arisaka Y, Itoh T, Kodama Y. Clinical outcomes of ampullary neoplasms in resected margin positive or uncertain cases after endoscopic papillectomy. World J Gastroenterol 2019; 25:1387-1397. [PMID: 30918431 PMCID: PMC6429348 DOI: 10.3748/wjg.v25.i11.1387] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 02/06/2019] [Accepted: 02/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Endoscopic papillectomy (EP) for benign ampullary neoplasms could be a less-invasive alternative to pancreatoduodenectomy (PD). There are some problems and limitations with EP. The post-EP resection margins of ampullary tumors are often positive or uncertain because of the burning effect of EP. The clinical outcomes of resected margin positive or uncertain cases after EP remain unknown.
AIM To investigate the clinical outcomes of resected margin positive or uncertain cases after EP.
METHODS Between January 2007 and October 2018, all patients with ampullary tumors who underwent EP at Kobe University Hospital were included in this study. The indications for EP were as follows: adenoma, as determined by preoperative endoscopic biopsy, without bile/pancreatic duct extension, according to endoscopic ultrasound or intraductal ultrasound. The clinical outcomes of resected margin positive or uncertain cases after EP were retrospectively investigated.
RESULTS Of the 45 patients, 29 were male, and 16 were female. The mean age of the patients was 65 years old. Forty-one patients (89.5%) underwent en bloc resection, and 4 patients (10.5%) underwent piecemeal resection. After EP, 33 tumors were histopathologically diagnosed as adenoma, and 12 were diagnosed as adenocarcinoma. The resected margins were positive or uncertain in 24 patients (53.3%). Of these cases, 15 and 9 were diagnosed as adenoma and adenocarcinoma, respectively. Follow-up observation was selected for all adenomas and 5 adenocarcinomas. In the remaining 4 adenocarcinoma cases, additional PD was performed. Additional PD was performed in 4 cases, and residual carcinoma was found after the additional PD in 1 of these cases. In the follow-up period, local tumor recurrence was detected in 3 cases. Two of these cases involved primary EP-diagnosed adenoma. The recurrent tumors were also adenomas detected by biopsy. The remaining case involved primary EP-diagnosed adenocarcinoma. The recurrent tumor was also an adenocarcinoma. All of the recurrent tumors were successfully treated with argon plasma coagulation (APC). There was no local or lymph node recurrence after the APC. The post-APC follow-up periods lasted for 57.1 to 133.8 mo. No ampullary tumor-related deaths occurred in all patients.
CONCLUSION Resected margin positive or uncertain cases after EP could be managed by endoscopic treatment including APC, even in cases of adenocarcinoma. EP could become an effective less-invasive first-line treatment for early stage ampullary tumors.
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Affiliation(s)
- Arata Sakai
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Masahiro Tsujimae
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Atsuhiro Masuda
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Takao Iemoto
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Department of Gastroenterology, Kita-Harima Medical Center, Ono, Hyogo 675-1392, Japan
| | - Shigeto Ashina
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Kohei Yamakawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Takeshi Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Shunta Tanaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yasutaka Yamada
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Ryota Nakano
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yu Sato
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Manabu Kurosawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Takuya Ikegawa
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Seiji Fujigaki
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Takashi Kobayashi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Hideyuki Shiomi
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yoshifumi Arisaka
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
- Department of Gastroenterology, Nippon Life Hospital, Osaka 550-0006, Japan
| | - Tomoo Itoh
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
| | - Yuzo Kodama
- Division of Gastroenterology, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe 650-0017, Japan
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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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