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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; 38:4798-4813. [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] [MESH Headings] [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, 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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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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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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Lee KJ, Lee TH, Cho JH, Hyun JJ, Jang SI, Jeong S, Park JS, Yang JK, Lee DH, Lee DK, Park SH. Efficacy analysis of hemostatic spray following endoscopic papillectomy: A multicenter comparative study. J Gastroenterol Hepatol 2022; 37:2138-2144. [PMID: 36126648 DOI: 10.1111/jgh.16004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND AIM Endoscopic post-papillectomy bleeding is a serious adverse event with a prevalence ranging from 2% to 45.3%. Conventional hemostatic methods, including diluted epinephrine injection before papillectomy or argon plasma coagulation after papillectomy, did not show a preventive role in reducing immediate or delayed post-papillectomy bleeding. Therefore, we aimed to assess the efficacy and safety of a hemostatic powder spray for post-papillectomy bleeding and compare with those of conventional modalities. METHODS Patients who underwent endoscopic papillectomy were enrolled in five tertiary hospitals. The group was divided into hemostatic spray and conventional control groups according to the bleeding control methods. The main outcome measurements were delayed bleeding rate and any adverse events related to the procedures. RESULTS A total of 40 patients who received a hemostatic spray (n = 18) or conventional hemostatic methods (n = 22) after endoscopic papillectomy were included. The prevalence of delayed bleeding was not different in the two groups: 27.8% and 36.4% in hemostatic spray and conventional control groups (P = 0.564), respectively. The adverse events such as post-papillectomy pancreatitis and cholangitis were not different in the two groups. There were no procedure-related mortalities. CONCLUSION Hemostatic spray is technically feasible and safe for the prevention or management of post-papillectomy bleeding. Hemostatic spray can be one of the options for post-papillectomy bleeding control methods owing to its convenient use.
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Affiliation(s)
- Kyong Joo Lee
- Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Don Haeng Lee
- Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Heum Park
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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Takagi T, Sugimoto M, Suzuki R, Konno N, Asama H, Sato Y, Irie H, Nakamura J, Takasumi M, Hashimoto M, Kato T, Kobashi R, Yanagita T, Hashimoto Y, Marubashi S, Hikichi T, Ohira H. Screening for hilar biliary invasion in ampullary cancer patients. World J Gastrointest Endosc 2022; 14:536-546. [PMID: 36186943 PMCID: PMC9516475 DOI: 10.4253/wjge.v14.i9.536] [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: 01/05/2022] [Revised: 06/28/2022] [Accepted: 08/07/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The treatment for ampullary cancer is pancreatoduodenectomy or local ampullectomy. However, effective methods for the preoperative investigation of hilar biliary invasion in ampullary cancer patients have not yet been identified.
AIM To determine the necessity of and an appropriate method for investigating hilar biliary invasion of ampullary cancer.
METHODS Among 43 ampullary cancer patients, 34 underwent endoscopic treatment (n = 9) or surgery (n = 25). The use of imaging findings (thickening and enhancement of the bile duct wall on contrast-enhanced computed tomography, irregularity on endoscopic retrograde cholangiography, thickening of the entire bile duct wall on intraductal ultrasonography (IDUS), and partial thickening of the bile duct wall on IDUS) and biliary biopsy results for diagnosing hilar biliary invasion of ampullary cancer was compared.
RESULTS Hilar invasion was not observed in every patient. Among the patients who did not undergo biliary stent insertion, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results showed the highest accuracy (100%) for diagnosing hilar biliary invasion. However, each imaging method and biliary biopsy yielded some false-positive results.
CONCLUSION Although some false-positive results were obtained with each method, the combination of partial thickening of the bile duct wall on IDUS and biliary biopsy results was useful for diagnosing hilar biliary invasion of ampullary cancer. However, hilar invasion of ampullary cancer is rare; therefore, the investigation of hilar biliary invasion of ampullary cancer might be unnecessary.
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Affiliation(s)
- Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Mitsuru Sugimoto
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Rei Suzuki
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Naoki Konno
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Hiroyuki Asama
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Yuki Sato
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Hiroki Irie
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Jun Nakamura
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1295, Japan
| | - Mika Takasumi
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Minami Hashimoto
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1295, Japan
| | - Tsunetaka Kato
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1295, Japan
| | - Ryoichiro Kobashi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1295, Japan
| | - Takumi Yanagita
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Yuko Hashimoto
- Department of Pathological Diagnosis, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Shigeru Marubashi
- Department of Hepato-Biliary-Pancreatic and Transplant Surgery, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Takuto Hikichi
- Department of Endoscopy, Fukushima Medical University Hospital, Fukushima 960-1295, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University, Fukushima 960-1295, Japan
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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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Khalyfa AA, Ahsan N, Inam M, Ayub K. Endoscopic management of tumors of minor ampulla: a multicenter study. Endosc Int Open 2022; 10:E978-E981. [PMID: 35845025 PMCID: PMC9286768 DOI: 10.1055/a-1839-5401] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 04/20/2022] [Indexed: 11/26/2022] Open
Abstract
Background and study aims Papillary and duodenal carcinoma are aggressive cancers with poor 5-year survival rates. Papillectomy is a well-established treatment for early-stage carcinoma of the major papilla. Tumors arising in the minor papilla are relatively rare and there is little research available on the endoscopic management of these tumors. Patients and methods The purpose of this study was to establish the safety and efficacy of endoscopic papillectomy in the management of minor papillary tumors. A total of six patients undergoing ERCP for papillectomy for minor papillary tumor at four hospitals were included in this study over a period of 5 years. Results Papillectomy was technically successful in all six patients. Pathology revealed adenoma in three patients, adenoma with high-grade dysplasia in one patient, carcinoma in one patient, and carcinoid tumor in one patient. For follow-up, one patient had an additional tumor identified at 2 years which was found to be a recurrence of the original adenoma. This patient was treated with repeat papillectomy with no further evidence of recurrence. Conclusions In our pilot study, we demonstrate that endoscopic papillectomy appears safe and effective in the management of minor papillary tumors.
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Affiliation(s)
- Ahamed A. Khalyfa
- Franciscan Saint James Health Olympia Fields Campus, Gastroenterology
| | - Nayab Ahsan
- Southwest Gastroenterology, Gastroenterology
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Itoi T, Ryozawa S, Katanuma A, Kawashima H, Iwasaki E, Hashimoto S, Yamamoto K, Ueki T, Igarashi Y, Inui K, Fujita N, Fujimoto K. Clinical practice guidelines for endoscopic papillectomy. Dig Endosc 2022; 34:394-411. [PMID: 35000226 DOI: 10.1111/den.14233] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 12/24/2022]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the "Clinical Practice Guidelines for Endoscopic Papillectomy (EP)" as a fundamental guideline using scientific approach. EP is a recently spreading therapeutic modality for ampullary tumors ranked as high risk endoscopic technique. Because of the paucity of high level of evidence, strength of recommendations had to be determined by a consensus among specialists. These guidelines, shed light on the following five issues: Indications, Preoperative/intraoperative preparations and techniques, Early adverse events, Therapeutic outcomes and remnants/recurrences, and Follow-up and late adverse events, to guide current clinical practice on EP.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Eisuke Iwasaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Toshiharu Ueki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Kazuo Inui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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10
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Hwang JS, So H, Oh D, Song TJ, Park DH, Seo DW, Lee SK, Kim MH, Hong SM, Yang J, Lee SS. Long-term outcomes of endoscopic papillectomy for early-stage cancer in duodenal ampullary adenoma: Comparison to surgical treatment. J Gastroenterol Hepatol 2021; 36:2315-2323. [PMID: 33604986 DOI: 10.1111/jgh.15462] [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: 08/27/2020] [Revised: 11/25/2020] [Accepted: 02/11/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM While recent evidences support endoscopic resection as curative in ampullary tumors with high-grade intraepithelial neoplasia, only small case series have reported endoscopic management of early-stage ampullary cancer; thus, radical surgery remains the only accepted treatment modality. We evaluated the long-term outcomes of early ampullary adenocarcinoma administered endoscopic management. METHODS We retrospectively reviewed electronic medical records of 715 patients undergoing endoscopic papillectomy (EP) in a single tertiary medical center in Korea in 2004-2016. We included patients incidentally diagnosed with early-stage adenocarcinoma (Tis and T1a, American Joint Committee on Cancer 8th edition) after EP and with >2 years of follow-up data and analyzed their demographics, histopathologic data, and clinical outcomes. RESULTS Among 70 total patients in the EP-alone (n = 42) and subsequent surgery (n = 28) groups, we observed no significant differences in demographics or tumor size (2.0 ± 0.6 vs 1.9 ± 0.5 cm, P = 0.532), histologic grade (P = 0.077), tumor extent (P = 1.000), lymphovascular invasion (2.4% vs 10.7%, P = 0.344), or complete resection rates (57.1% vs 57.1%, P = 1.000) between groups. Adenocarcinoma lesions were larger in the subsequent surgery group (0.7 ± 0.5 vs 1.1 ± 0.7 cm, P = 0.002). The EP-alone group received more additional ablative treatment (42.9% vs 14.3%, P = 0.024). The 5-year disease-free and cancer-free survival rates were 79.1% vs 87.4% (P = 0.111) and 93.5% versus 87.4% (P = 0.726), respectively, and did not differ significantly between groups. CONCLUSIONS Endoscopic papillectomy followed by endoscopic surveillance showed long-term outcomes comparable with surgical resection for early ampullary cancer and maybe curable alternative to surgery for incidentally found early-stage ampullary cancer, especially in patients unfit for or refusing radical surgery.
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Affiliation(s)
- Jun Seong Hwang
- Department of Internal Medicine, Inje University College of Medicine, Haeundae Paik Hospital, Busan, South Korea
| | - Hoonsub So
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dongwook Oh
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Tae Jun Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Do Hyun Park
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Dong-Wan Seo
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sung Koo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Myung-Hwan Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Seung-Mo Hong
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jungho Yang
- Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Sang Soo Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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11
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The Long-Term Outcomes of Endoscopic Papillectomy and Management of Cases of Incomplete Resection: A Single-Center Study. J Gastrointest Surg 2021; 25:1247-1252. [PMID: 32583320 DOI: 10.1007/s11605-020-04532-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/26/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic papillectomy is increasingly performed as an alternative to surgery for early ampullary tumors. AIM This retrospective study aimed to evaluate the long-term results of endoscopic papillectomy, the management of cases with incomplete endoscopic resection, and the long-term recurrence rates. METHODS All 46 patients who underwent endoscopic papillectomy for ampullary tumors between November 2003 and March 2018 were retrospectively evaluated. RESULTS The final pathological diagnoses were adenoma (n = 44) and adenocarcinoma (n = 2). Histopathological evaluations after endoscopic papillectomy revealed that complete resection was achieved in 19 patients (19/46, 41.3%). Among the 27 patients with incomplete resection, the margin was histopathologically positive in 14 patients and difficult to evaluate in 13. Additional surgery was performed for 2 of the 14 patients with positive margins. Excluding 2 patients who received additional surgery, 7 of the 25 patients with incomplete resection had recurrence, and 18 had no recurrence during the follow-up period. Ten (77%) of the 13 patients in whom the margin was difficult to evaluate had no recurrence. CONCLUSION Approximately 80% of the patients in whom the histopathological evaluation of the resected margin was difficult had no recurrence even after approximately 5 years of follow-up. Thus, careful observation may be considered for these patients.
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12
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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: 59] [Impact Index Per Article: 19.7] [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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13
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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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14
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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: 4] [Impact Index Per Article: 1.3] [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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15
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Yang JK, Hyun JJ, Lee TH, Choi JH, Lee YN, Choe JW, Park JS, Kwon CI, Jeong S, Kim HJ, Moon JH, Park SH. Can prophylactic argon plasma coagulation reduce delayed post-papillectomy bleeding? A prospective multicenter trial. J Gastroenterol Hepatol 2021; 36:467-473. [PMID: 32677716 DOI: 10.1111/jgh.15186] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/03/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Endoscopic post-papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post-papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. METHODS In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow-up duodenoscopy to identify post-papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post-papillectomy bleeding rate and the tumor persistence rate. RESULTS The delayed post-papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non-APC group (P = 0.434). The post-procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure-related mortalities or serious complications. CONCLUSION Prophylactic APC may not be effective in reducing delayed post-papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration-cris.nih.go.kr; KCT0001955).
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Affiliation(s)
- Jae Kook Yang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Tae Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jun-Ho Choi
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Yun Nah Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Jung Wan Choe
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Jin-Seok Park
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Chang-Il Kwon
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Seok Jeong
- Department of Internal Medicine, Inha University School of Medicine, Incheon, Republic of Korea
| | - Hong Ja Kim
- Department of Internal Medicine, College of Medicine, Dankook University, Cheonan, Republic of Korea
| | - Jong Ho Moon
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
| | - Sang-Heum Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Soonchunhyang University, Cheonan, Republic of Korea
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16
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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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17
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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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Jiang L, Ling-Hu EQ, Chai NL, Li W, Cai FC, Li MY, Guo X, Meng JY, Wang XD, Tang P, Zhu J, Du H, Wang HB. Novel endoscopic papillectomy for reducing postoperative adverse events (with videos). World J Gastroenterol 2020; 26:6250-6259. [PMID: 33177797 PMCID: PMC7596639 DOI: 10.3748/wjg.v26.i40.6250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/04/2020] [Accepted: 09/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic adenoma can potentially transform into adenocarcinoma, so it is recommended to be resected surgically or endoscopically. Endoscopic papillectomy is one of the main treatments for papillary adenoma, and bleeding, perforation, and pancreatitis are the most frequent and critical adverse events that restrict its wider use. There is no standard procedure for endoscopic papillectomy yet. The procedure is relevant to postoperative adverse events.
AIM To reduce the postoperative adverse event rates and improve patients’ postoperative condition, we developed a standard novel procedure for endoscopic papillectomy.
METHODS The novel endoscopic papillectomy had two main modifications based on the conventional method: The isolation of bile from pancreatic juice with a bile duct stent and wound surface protection with metal clips and fibrin glue. We performed a single-center retrospective comparison study on the novel and conventional methods to examine the feasibility of the novel method for reducing postoperative adverse events.
RESULTS A total of 76 patients, of whom 23 underwent the novel procedure and 53 underwent the conventional procedure, were retrospectively evaluated in this study. The postoperative bleeding and pancreatitis rates of the novel method were significantly lower than those of the conventional method (0 vs 20.75%, P = 0.028, and 17.4% vs 41.5%, P = 0.042, respectively). After applying the novel method, the most critical adverse event, perforation, was entirely prevented, compared to a prevalence of 5.66% with the conventional method. Several postoperative symptoms, including fever, rapid pulse, and decrease in hemoglobin level, were significantly less frequent in the novel group (P = 0.042, 0.049, and 0.014, respectively). Overall, the total adverse event rate of the novel method was lower (0 vs 24.5%, P = 0.007) than that of the conventional method.
CONCLUSION Patients who underwent the novel procedure had lower postoperative adverse event rates. This study demonstrates the potential efficacy and safety of the novel endoscopic papillectomy in reducing postoperative adverse events.
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Affiliation(s)
- Lei Jiang
- School of Medicine, Nankai University, Tianjin 300071, China
| | - En-Qiang Ling-Hu
- School of Medicine, Nankai University, Tianjin 300071, China
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Ning-Li Chai
- School of Medicine, Nankai University, Tianjin 300071, China
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Wen Li
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Feng-Chun Cai
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Ming-Yang Li
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Xu Guo
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jiang-Yun Meng
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Xiang-Dong Wang
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Ping Tang
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Jing Zhu
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Hong Du
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
| | - Hong-Bin Wang
- Department of Gastroenterology and Hepatology, Chinese People's Liberation Army General Hospital, Beijing 100853, China
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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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Cathcart NS, Souza RCAD, Noda RW, Taglieri E, Ardengh JC, Bonin EA. ENDOSCOPIC PAPILLECTOMY FOR EARLY AMPULLARY NEOPLASTIC LESIONS - A CASE SERIES ANALYSIS. ARQUIVOS DE GASTROENTEROLOGIA 2020; 57:300-305. [PMID: 32935746 DOI: 10.1590/s0004-2803.202000000-55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 06/11/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Endoscopic papillectomy has been conceived as a less invasive therapeutic option for treatment of early neoplastic lesions located at the major duodenal papilla. OBJECTIVE Evaluating patients with early ampullary lesions who underwent curative intent endoscopic papillectomy related to technical success (histopathological tumor margin assessment) and safety (adverse event rate). METHODS A retrospective study including consecutive patients who underwent curative intent endoscopic papillectomy for demographic, histopathological and pre-/post-procedural clinical assessment. Endpoints were technical success (histopathological residual tumor assessment) and adverse events rates. RESULTS A total of 21 medical records patients with a female predominance (13 cases, 61.9%) were included. The tumor was incidental in 8 (38%) cases. Negative residual tumor resection margin rate was 72% (15 cases); three of these cases confirmed high-grade dysplasia in the resected specimen, and six cases were invasive neoplasia. Tumoral recurrence was seen in two cases, and median follow-up time was 12 months, with a 23% loss rate (five patients). Six (28.5%) patients had adverse events, all of them early (bleeding and pancreatitis); none of them required surgical intervention and there was no mortality. CONCLUSION Endoscopic papillectomy allowed for technical successful procedure with complete removal of ampullary neoplastic lesions in the majority of cases with acceptable adverse event rates. Recurrence rate should be carefully assessed in further studies. There was a recent increase in the number of procedures. There was also a low correlation between pre- and post-histopathological assessment regarding the presence of invasive carcinoma and adenoma with high grade dysplasia, with a predominance of superficial neoplastic adenomatous lesions.
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Affiliation(s)
- Nelson Silveira Cathcart
- Universidade Federal do Paraná, Hospital de Clinicas, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil
| | - Raquel Canzi Almada de Souza
- Universidade Federal do Paraná, Hospital de Clinicas, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil.,Hospital São Vicente, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil
| | - Rafael William Noda
- Hospital Nossa Senhora das Graças, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil
| | - Eloy Taglieri
- Hospital 9 de Julho, Setor de Endoscopia, São Paulo, SP, Brasil
| | - José Celso Ardengh
- Hospital 9 de Julho, Setor de Endoscopia, São Paulo, SP, Brasil.,Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo (HCFMRP-USP), Setor de Endoscopia, Ribeirão Preto, SP, Brasil.,Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Diagnóstico por Imagem, São Paulo, Brasil
| | - Eduardo Aimore Bonin
- Universidade Federal do Paraná, Hospital de Clinicas, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil.,Hospital Nossa Senhora das Graças, Serviço de Endoscopia Digestiva, Curitiba, PR, Brasil
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Outcome of a novel modified endoscopic papillectomy for duodenal major papilla adenoma. Surg Endosc 2020; 34:5160-5167. [PMID: 32666256 PMCID: PMC7572334 DOI: 10.1007/s00464-020-07715-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
Background and aims In recent years, with the development of endoscopic techniques, endoscopic resection is widely used for duodenal papillary adenomas, but conventional endoscopic resection has a high rate of incomplete resection and recurrence. On this basis, we have employed a novel modified endoscopic papillectomy (ESP). In this study, we evaluated the feasibility and advantages of this ESP for the treatment of duodenal major papilla adenoma. Methods A total of 56 patients with duodenal major papilla adenoma confirmed by endoscopic ultrasonography, intraluminal ultrasound and gastroscopic biopsy from October 2007 to June 2017 were collected in the Department of Gastroenterology, Nanjing Drum Tower Hospital. The diameter of the adenoma ranged from 1.41 to 2.02 cm. 16 cases were given the conventional method and 40 cases underwent the modified ESP procedure in which a small incision was made by cutting current when anchoring the snare tip on the distal side of the adenoma. Results En bloc resection rate was significantly higher in the modified group (100%, 40/40) than that in the conventional group (81.3%, 13/16; P = 0.02). However, no significance was seen between the modified group and the conventional group in complete resection rate (92.5%, 37/40 vs 93.8%, 15/16; P = 1.00). There was no significant difference in the number and difficulty of postoperative pancreatic and biliary stents placement between the two groups (P = 0.20). Total bleeding occurrence was much lower in the modified group (37.5%, 15/40 vs 87.5%, 14/16; P = 0.001), and no significant differences were found in other short-term complications and the 3, 6, 12 and 24 months recurrences rate between the conventional and modified ESP groups. Conclusions The modified ESP improves the treatment outcome of duodenal major papilla adenoma with higher en bloc resection rate and lowering bleeding rate. Electronic supplementary material The online version of this article (10.1007/s00464-020-07715-0) contains supplementary material, which is available to authorized users.
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22
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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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Mathur A, Paul H, Ross S, Luberice K, Hernandez J, Vice M, Rosemurgy AS. Transduodenal Ampullectomy for Ampullary Adenomas: A Safe and Effective Procedure with Long-term Salutary Outcomes. Am Surg 2020. [DOI: 10.1177/000313481408000229] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
With widespread use of endoscopy, ampullary adenomas are more frequently identified, many of which are not amenable to endoscopic resection. Pancreatoduodenctomy is curative for these lesions but carries high morbidity. The purpose of this study was to determine the safety and efficacy of transduodenal ampullectomy for these lesions. Data were collected on 32 patients who underwent transduodenal ampullectomy from 2002 to 2010. The median age of patients was 64 years. Adenomas were found because of abdominal pain in 34 per cent, jaundice in 22 per cent, and incidentally on endoscopic screening in 16 per cent and on computed tomography scan of the abdomen in 9 per cent. All patients had a preoperative diagnosis of premalignant disease; 6 per cent required intraoperative conversion to pancreaticoduodenectomy after frozen section evaluation documented carcinoma. Of ampullectomies, 97 per cent had clear margins. Follow-up was 28 months. Four (13%) patients developed recurrent disease at 4 years, 2 years, 1.5 years, and 4 months; all had clear margins at ampullectomy and underwent subsequent pancreaticoduodenectomy with invasive malignancy in a single patient. After preoperative biopsy documenting premalignant disease, malignancy at ampullectomy is unusual. Recurrence is uncommon but occurs even with clear margins necessitating diligent follow-up; even with diligent follow-up, recurrence can be malignant.
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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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Lü S, Jiang M, Liu F, Tang H, Yang Y, Zhang W, Zhang M, Jin Z, Li Z. Endoscopic papillectomy of benign papillary tumors: A single-center experience. Medicine (Baltimore) 2020; 99:e20414. [PMID: 32481436 DOI: 10.1097/md.0000000000020414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Endoscopic treatment of duodenal papillary tumors is well described. This study aims to provide new evidence for the treatment of benign papillary tumors through comparisons between endoscopic snare papillectomy (ESP) and endoscopic mucosal resection (EMR).Between May 2010 and December 2017, 72 patients were enrolled. Diagnosis and treatment procedures were ESP and EMR. Endoscopic follow-up evaluation was done periodically as a surveillance measurement for recurrence.Seventy-two patients with ampullary tumors were enrolled, of which 66 had adenomas including 9 high-grade intraepithelial neoplasias and 2 carcinomas in adenoma. Complete resections with tumor-free lateral and basal margins were achieved in all patients. Postoperative complications were bleeding (9.5% in EMR vs 10% in ESP) and pancreatitis (2.4% in EMR and 3.3% in ESP), with no occurrence of perforation, cholangitis or papillary stenosis. Adenoma recurrence was found in 7 patients (14.3% in EMR vs 3.3% in ESP) at 1 year.The ESP procedure is safe and effective for benign ampullary adenoma, high-grade intraepithelial neoplasias, and noninvasive cancer without intraductal tumor growth, which has a shorter procedural duration, as well as lower complication, recurrence rates and hospitalization costs.
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Affiliation(s)
- Shunli Lü
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Mengni Jiang
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Feng Liu
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Hailing Tang
- Department of Gastroenterology, Xi'an Central Hospital, Xi'
| | - Yuan Yang
- Department of Gastroenterology, Affiliated Hospital of Zunyi Medical College, Zunyi, P.R. China
| | | | - Minmin Zhang
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Zhendong Jin
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Changhai Road 168, Shanghai
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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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Long-Term Outcomes of Endoscopic Papillectomy for Ampullary Adenomas. Dig Dis Sci 2020; 65:260-268. [PMID: 31463668 DOI: 10.1007/s10620-019-05812-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/20/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas and has mostly replaced surgical local resection. Recent data have discussed the role of endoscopic removal of laterally spreading adenomas associated with ampullary adenomas. We evaluated our long-term results of endoscopic papillectomy for ampullary adenomas. METHODS We retrospectively analyzed patients who underwent endoscopic papillectomy of biopsy-proven adenomas at our tertiary center between 1994 and 2017. Clinical success was defined as complete excision of an adenoma with no evidence of recurrence during follow-up, no evidence of cancer, and without the need for surgery. RESULTS A total of 161 patients (73M/88F) with a mean age of 61 (range 19-93) were included. Mean adenoma size was 20 mm (range 5-70). In total, 114/161 patients continued endoscopic surveillance for a minimum of 6 months with a median follow-up of 30 months (range 6-283). Recurrent adenomas were diagnosed in 8 patients (7%) after a median of 36 months (range 12-138). Clinical success was 83%; 35 laterally spreading adenomas were treated, which were larger than adenomas confined to the papilla (mean size 38 mm vs 15 mm, P < 0.05) and required more piecemeal resections (77% vs 15%, P < 0.05). However, no difference was found in recurrence rates between the two groups (8% vs 4%, P = 0.26); 24/161 (15%) of patients had adverse events including bleeding (6%) and pancreatitis (7%). CONCLUSIONS Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas, including laterally spreading ones. Long-term surveillance demonstrates low recurrence rates at expert centers.
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Campos FG, Martinez CAR, Sulbaran M, Bustamante-Lopez LA, Safatle-Ribeiro AV. Upper gastrointestinal neoplasia in familial adenomatous polyposis: prevalence, endoscopic features and management. J Gastrointest Oncol 2019; 10:734-744. [PMID: 31392054 DOI: 10.21037/jgo.2019.03.06] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background To evaluate the prevalence of upper gastrointestinal (GI) polyps in familial adenomatous polyposis (FAP), and to discuss current therapeutic recommendations. Methods Clinical, endoscopic, histological and treatment data were retrieved from charts of 102 patients [1958-2016]. Duodenal adenomatosis was classified according to Spigelman stages. Results this series comprised 59 women (57.8%) and 43 men (42.1%) with a median age of 32.3 years. Patients underwent 184 endoscopic procedures, the first at a median age of 35.9 years (range, 13-75 years). Fundic gastric polyps (n=31; 30.4%) prevailed in the stomach. While only 5 adenomas were found in the stomach, 33 patients (32.4%) presented duodenal ones. Advanced lesions (n=13; 12.7%) were detected in the stomach (n=2) and duodenum (n=11). During follow-up, Spigelman stages improved in 6 (12.2%) patients, remained unchanged in 25 (51.0%) and worsened in 18 (36.7%). Carcinomas were diagnosed in the stomach and duodenum (4 lesions each, 3.9%), at median ages of 50.2 and 55.0 years, respectively. Advanced lesions and carcinomas were managed through local or surgical resections. Severe complications occurred in only 2 patients (one death). Enteroscopy in 21 patients revealed jejunal adenomas in 12, 11 of whom also presented duodenal adenomas. Conclusions There is a high prevalence of upper GI adenomas and cancer in FAP. There were diagnosed fundic gastric polyps (30.4%), duodenal (32.4%) and jejunal adenomas (11.8%), respectively. One third of duodenal polyps progressed slowly throughout the study. The rates of advanced gastroduodenal lesions (12.7%) and cancer (7.8%) raise the need for continuous surveillance during follow-up.
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Affiliation(s)
- Fábio Guilherme Campos
- Colorectal Surgery Division, Gastroenterology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Carlos Augusto Real Martinez
- Colorectal Surgery Division, Gastroenterology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Marianny Sulbaran
- Colorectal Surgery Division, Gastroenterology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Leonardo Alfonso Bustamante-Lopez
- Colorectal Surgery Division, Gastroenterology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Adriana Vaz Safatle-Ribeiro
- Colorectal Surgery Division, Gastroenterology Department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, SP, Brazil
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Nedoluzhko IY, Khon EI, Shishin KV. Endoscopic papillectomy for tumors of the major duodenal papilla. ACTA ACUST UNITED AC 2019. [DOI: 10.16931/1995-5464.2019136-42] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aim.To evaluate an effectiveness of endoscopic papillectomy (EA) for benign ampullary tumors.Material and methods.There were 45 patients with ampullary tumors who underwent endoscopic papillectomy in 2014–2018. Mean dimension of tumor was 2.25 ± 1.75 cm.Results.Papillectomy was successfully performed in all cases. En-bloc resection was completed in 24 cases (53%), while 21 (47%) patients had a piecemeal resection. Pancreatic duct stenting was carried out in 30 (67%) cases. Postoperative complication rate was 31%. Postoperative bleeding occurred in 8 (18%) cases, perforation in 4 (8.9%) cases, acute pancreatitis in 2 (4.4%) cases. Mortality was 4.4 % (n= 2). Local recurrence rate within 4-year period was 2.2% (n= 1). Mean length of hospital-stay was 13 days (13 ± 11) considering prolonged treatment of patients with complicated postoperative period.Conclusion.Endoscopic papillectomy is effective minimally invasive treatment of benign ampullary tumors. Regardless considerable morbidity rate, all of them may be effectively managed by medication or endoscopic procedure. EP can be considered as a first-line treatment of benign ampullary tumors.
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Affiliation(s)
- I. Yu. Nedoluzhko
- Loginov Moscow Clinical Scientific Center, Department of Health of Moscow
| | - E. I. Khon
- Loginov Moscow Clinical Scientific Center, Department of Health of Moscow
| | - K. V. Shishin
- Loginov Moscow Clinical Scientific Center, Department of Health of Moscow
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Yamamoto K, Sofuni A, Tsuchiya T, Ishii K, Tsuji S, Tanaka R, Tonozuka R, Honjo M, Mukai S, Fujita M, Asai Y, Matsunami Y, Nagakawa Y, Yamaguchi H, Itoi T. Clinical Impact of Piecemeal Resection Concerning the Lateral Spread of Ampullary Adenomas. Intern Med 2019; 58:901-906. [PMID: 30568115 PMCID: PMC6478995 DOI: 10.2169/internalmedicine.1147-18] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Endoscopic papillectomy (EP) has been recognized to be a safe and reliable treatment modality for ampullary adenomas. The purpose of this study was to determine the safety and efficacy of endoscopic piecemeal resection for laterally spreading ampullary adenomas and to compare these findings with a control population of smaller conventional ampullary tumors treated in the same time period. Methods Between May 1999 and September 2015, 136 patients underwent EP at Tokyo Medical University hospital. A total of 125 patients underwent en bloc resection, and 11 patients underwent piecemeal resection. Results The final pathological diagnoses were 103 adenomas, 14 carcinomas in adenomas, 4 carcinomas, and 4 hyperplasia in the en bloc resection group, versus 7 adenomas, 3 carcinomas in adenoma, and 1 carcinomas in the piecemeal resection group. A single treatment session was possible in 104 (83.2%) of the 125 patients in the en bloc resection group and in 8 (72.7%) of the 11 in the piecemeal resection group. The total resection rate including additional treatments was 98.4% in the en bloc resection group and 100% in the piecemeal resection group. Conclusion Piecemeal resection for laterally spreading ampullary adenomas was sufficiently performed compared with en bloc resection.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Kentaro Ishii
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Mitsuyoshi Honjo
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Shuntaro Mukai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Mitsuru Fujita
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Yasutsugu Asai
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Yukitoshi Matsunami
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
| | - Yuichi Nagakawa
- Third Department of Surgery, Tokyo Medical University, Japan
| | | | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 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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Affiliation(s)
- Jennis Kandler
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany.
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study. Surg Endosc 2018; 33:1180-1188. [PMID: 30167949 PMCID: PMC6430826 DOI: 10.1007/s00464-018-6392-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/20/2018] [Indexed: 12/13/2022]
Abstract
Background Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions. Methods All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence. Results We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733). Conclusion Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.
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Maguire A, Sheahan K. Primary small bowel adenomas and adenocarcinomas-recent advances. Virchows Arch 2018; 473:265-273. [PMID: 29998424 DOI: 10.1007/s00428-018-2400-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/11/2022]
Abstract
The small intestine represents 75% of the length and 90% of the absorptive surface area of the gastrointestinal tract (GIT), yet only 2% of digestive system cancers occur at this site. Adenocarcinoma accounts for half of small bowel malignancies. There have been a number of important recent advances in our understanding, classification and treatment of small bowel tumours. Over recent years, ampullary tumours have become recognised as a form of small bowel carcinoma, distinct from head of pancreas and lower biliary tract tumours. This is reflected in separate TNM systems and increasing interest in separating intestinal from pancreatobiliary subtypes. The recognition of the importance of microsatellite (MSI) status and the advent of molecular pathology has also changed our approach to these neoplasms.
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Affiliation(s)
- Aoife Maguire
- Histopathology Department, St. James's Hospital, Dublin 2, Ireland
| | - Kieran Sheahan
- Pathology Department, & Centre for Colorectal Disease, UCD Medical School, St. Vincent's University Hospital, Dublin, Ireland.
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Nam K, Song TJ, Kim RE, Cho DH, Cho MK, Oh D, Park DH, Lee SS, Seo DW, Lee SK, Kim MH, Baek S. Usefulness of argon plasma coagulation ablation subsequent to endoscopic snare papillectomy for ampullary adenoma. Dig Endosc 2018; 30:485-492. [PMID: 29288506 DOI: 10.1111/den.13008] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 12/25/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Endoscopic snare papillectomy (ESP) is an effective treatment for ampullary adenoma. Argon plasma coagulation (APC) is widely used as an additional method to control bleeding or ablate the residual tumor. However, the efficacy of this procedure has not yet been fully evaluated. This study aimed to evaluate the usefulness of APC as an additional method to ESP. METHODS Patients who underwent ESP for ampullary adenoma between September 2005 and September 2015 were retrospectively reviewed. Using propensity score matching, we compared short- and long-term outcomes between the ESP-with-additional-APC group (ESP + APC group) and the ESP-only group. Primary outcome was early post-ESP adverse events (AE), and secondary outcomes were late AE and recurrence. RESULTS Among 109 patients, additional APC was carried out in 59 (54.1%) patients. After matching, 41 patients were included in both groups, respectively. Bleeding rate was significantly lower in the ESP + APC group than in the ESP-only group (7.3% vs 31.7%, odds ratio = 0.180, P < 0.01). However, there were no significant differences in other procedure-related early AE such as pancreatitis (12.2% vs 19.5%, P = 0.365), cholangitis (2.4% vs 9.8%, P = 0.198), and perforation (2.4% vs 2.4%, P = 1.000) between the ESP + APC group and the ESP-only group. During the follow-up period (mean 904 ± 868 days), papillary stricture (9.8% vs 4.9%, P = 0.405) and recurrence rates (24.4% vs 24.4%, P = 0.797) were not significantly different between the ESP + APC group and the ESP-only group. CONCLUSION Additional APC during ESP may have a beneficial effect by decreasing bleeding rate without harmful effects.
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Affiliation(s)
- Kwangwoo Nam
- Division of Gastroenterology, Department of Internal Medicine, Dankook University Hospital, Dankook University College of Medicine, Cheonan, South Korea
| | - Tae Jun Song
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Raymond E Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Dong Hui Cho
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Min Keun Cho
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dongwook Oh
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hyun Park
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sang Soo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Dong-Wan Seo
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Sung Koo Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Myung-Hwan Kim
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seunghee Baek
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Kim AL, Choi YI. Safety of duodenal ampullectomy for benign periampullary tumors. Ann Hepatobiliary Pancreat Surg 2017; 21:146-150. [PMID: 28990001 PMCID: PMC5620475 DOI: 10.14701/ahbps.2017.21.3.146] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 07/05/2017] [Accepted: 08/07/2017] [Indexed: 12/18/2022] Open
Abstract
Backgrounds/Aims Surgical resection, such as pancreaticoduodenectomy (PD), is used for treatment of benign periampullary tumors, but high morbidity and mortality resulting from PD can be a huddle. The aim of this study is to suggest a safe and less invasive procedure for treatment of benign periampullary tumors. Methods From January 2001 to September 2016, 31 patients with ampulla of Vater (AOV) tumors were reviewed retrospectively. Patients who were confirmed with malignancy through biopsy were excluded, except for one patient with malignancy and multiple underlying diseases. To investigate the safety and availability of transduodenal ampullectomy (TDA), TDA and endoscopic papillectomy (EP) were compared. Results There was no significant difference in the occurrence of complications between the TDA group and EP group (p=0.145), and the resection margins were negative in both groups. There was no recurrence in patients who had TDA, while one patient had a recurrence after EP. Conclusions This study suggests that TDA is as safe as EP for treating benign periampullary tumors.
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Affiliation(s)
- Alvin Lyle Kim
- Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
| | - Young Il Choi
- Department of Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea
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Espinel J, Pinedo E, Ojeda V, Guerra Del Río M. Endoscopic ampullectomy: a technical review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:271-8. [PMID: 27187501 DOI: 10.17235/reed.2016.3867/2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges. METHODS We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques. RESULTS Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy. CONCLUSIONS Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.
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Affiliation(s)
| | | | - Vanesa Ojeda
- Digestivo, Hospital Universitario Dr. Negrín. Las Palmas de Gran Canaria, España
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A prospective multicenter study of submucosal injection to improve endoscopic snare papillectomy for ampullary adenoma. Gastrointest Endosc 2017; 85:746-755. [PMID: 27566056 DOI: 10.1016/j.gie.2016.08.013] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 08/02/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Whether or not submucosal injection of a diluted epinephrine solution should be used to lift ampullary tumors during endoscopic snare papillectomy is unclear. This study aimed to investigate the clinical efficacy of a simple snaring method versus submucosal injection for papillectomy. METHODS A prospective multicenter study was performed at 4 tertiary referral centers. Patients with papillary lesions were randomized to undergo either simple snare papillectomy (SSP) or submucosal injection papillectomy (SIP) using 1:10,000 diluted epinephrine. The main outcome measures were complete resection rate and post-papillectomy adverse events. RESULTS A total of 50 patients with biopsy-proven papillary adenomas were enrolled. Complete resection rates in the SSP and SIP groups were 80.8% (21/26) and 50.0% (12/24), respectively (P = .02). However, tumor persistence at 1 month (15.4% vs 8.3%, P = .62) and recurrence at 12 months (12.0% vs 9.5%, P = .58) did not differ despite initial differences in the prevalence of a positive resection margin. The mean tumor size was 12 mm in the SSP group and 9.29 mm in the SIP group. Post-papillectomy bleeding developed in 42.3% (11/26) and 45.8% (11/24) of patients, respectively (P = .80). Delayed bleeding (>12 h) occurred in 27.3% (3/11) and 36.4% (4/11) of patients, respectively (P = .50). Post-procedure pancreatitis occurred in 15.4% (4/26) and 25% (6/24) of patients, respectively (P = .49). Pancreatitis severity did not differ between the groups, and there were no procedure-related mortalities. CONCLUSIONS Although the recurrence rate was similar between the SSP and SIP groups, SIP showed no advantage over SSP in terms of achieving complete resection or decreasing the frequency of post-papillectomy adverse events, such as bleeding. SSP may thus be a simpler and primarily recommendable technique. (Clinical trial registration number: NCT02165852.).
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Dacha S, Chawla S, Lee JE, Keilin SA, Cai Q, Willingham FF. Endoscopic retrograde cholangiopancreatography with ampullary biopsy vs ERCP alone: a matched-pairs controlled evaluation of outcomes and complications. Gastroenterol Rep (Oxf) 2017; 5:277-281. [PMID: 28065885 PMCID: PMC5691614 DOI: 10.1093/gastro/gow044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/11/2016] [Accepted: 11/21/2016] [Indexed: 11/13/2022] Open
Abstract
Background and aims Biopsy of the ampulla of Vater may be performed to evaluate for ampullary adenomas, suspected ampullary tumors and immunohistological staining for autoimmune pancreatitis. Ampullary biopsies are commonly performed at the time of endoscopic retrograde cholangiopancreatography (ERCP). Due to the well-established complication rate following ERCP, the contribution of ampullary biopsy as a potential independent risk factor would require a controlled comparison. Methods A matched-pairs, case-control analysis was performed for patients undergoing ERCP with or without ampullary biopsy. The analysis involved a retrospective review of adult patients at a tertiary-care center who underwent ampullary biopsies during ERCP compared (via procedural complexity) with a matched control group who underwent ERCP without ampullary biopsies. Results Of 159 procedures involving ampullary biopsy, 54 ERCPs that met the inclusion criteria were performed with ampullary biopsy and included in the analysis cohort. This cohort was compared with 54 patients undergoing ERCP without ampullary biopsy, matched by American Society for Gastrointestinal Endoscopy (ASGE) grade of procedural complexity. There were no patients with sphincter of Oddi dysfunction. Ampullary biopsies suggested a diagnosis in 75.9% of the procedures including 12 adenomas, 5 adenocarcinomas and 1 intraductal papillary mucinous neoplasm. Including major and minor complications, the overall complication rate with biopsy (9.3%) was equivalent to the complication rate in the control group without ampullary biopsy (9.3%, P>0.99). The incidence of post-procedure pancreatitis was not significantly different between the two groups (5.6% vs 3.7%, P=0.6). Age and pancreatic duct manipulation, but not ampullary biopsy, were associated with complications on multivariate analysis in the study population. Conclusions Ampullary biopsy performed during ERCP had a high diagnostic yield and was not associated with an increased rate of post-procedure complications or pancreatitis when compared with ERCP alone.
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Affiliation(s)
- Sunil Dacha
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Saurabh Chawla
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Jai Eun Lee
- Department of Medicine, Division of Gastroenterology, Georgia Regents University, Augusta, GA, USA
| | - Steven A Keilin
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Field F Willingham
- Department of Medicine, Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015; 82:773-81. [PMID: 26260385 DOI: 10.1016/j.gie.2015.06.027] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 02/08/2023]
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Espinel J, Pinedo E, Ojeda V, Rio MGD. Endoscopic management of adenomatous ampullary lesions. World J Methodol 2015; 5:127-135. [PMID: 26413485 PMCID: PMC4572025 DOI: 10.5662/wjm.v5.i3.127] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/30/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.
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Ardengh JC, Kemp R, Lima-Filho &ER, Santos JSD. Endoscopic papillectomy: The limits of the indication, technique and results. World J Gastrointest Endosc 2015; 7:987-994. [PMID: 26265992 PMCID: PMC4530332 DOI: 10.4253/wjge.v7.i10.987] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/31/2014] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy (EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.
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Yang D, Reinhard MK, Wagh MS. Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model. World J Gastrointest Endosc 2015; 7:728-735. [PMID: 26140100 PMCID: PMC4482832 DOI: 10.4253/wjge.v7.i7.728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/27/2015] [Accepted: 04/02/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model.
METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle (4 cycles/session). Survival animals (n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day (POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury.
RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6 (100%) animals. Cryospray with liquid nitrogen (four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean procedural time was 54.5 min (range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis (depth of injury) was limited to the mucosa on full-thickness specimen evaluation.
CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.
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Gluck N, Strul H, Rozner G, Leshno M, Santo E. Endoscopy and EUS are key for effective surveillance and management of duodenal adenomas in familial adenomatous polyposis. Gastrointest Endosc 2015; 81:960-6. [PMID: 25440680 DOI: 10.1016/j.gie.2014.08.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 08/26/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) are prone to developing duodenal adenoma and cancer. Optimal surveillance and management of these adenomas are not well established. OBJECTIVE We assessed the outcome of FAP patients undergoing intense multimodal surveillance and subsequent endoscopic resection of advanced lesions. PATIENTS Eighty consecutive FAP patients enrolled during 2001 to 2011 from the Familial Cancer Clinic of a tertiary hospital as part of routine surveillance. DESIGN Case series, prospective in years 2006 to 2011 and retrospective in years 2001 to 2006. SETTING AND INTERVENTION Patients were followed by annual forward-view and/or side-view upper endoscopy. A biopsy sample was obtained from visible lesions and normal papillae. Ampullary adenomas were further assessed by EUS to determine dimensions and resectability. Advanced adenomas (size ≥ 10 mm, villous type, high-grade dysplasia) underwent endoscopic ampullectomy or polypectomy and continued surveillance. MAIN OUTCOME MEASUREMENTS Detection of advanced adenomas by endoscopy and EUS, endoscopic maintenance of duodenum free of advanced adenoma and cancer. RESULTS Patients (38 men and 42 women, mean age 32.68 ± 13.60) were followed 7.2 years and underwent 5.36 diagnostic studies on average. Thirty-eight patients had ampullary adenomas. Advanced adenoma was diagnosed by endoscopy in 10 patients. Importantly, EUS upstaged 9 additional patients to advanced adenoma and downstaged 1, thus altering the treatment course in 36% of patients performing EUS. Endoscopic ampullectomy was performed in 15 patients. Adenoma recurred in 10. Five remained nonadvanced and 5 in advanced stages: 3 were successfully retreated endoscopically and 2 ultimately required surgery for residual adenoma. Advanced nonampullary adenomas were successfully resected endoscopically in 23 patients. No patient had duodenal cancer during the study period. LIMITATIONS Limited follow-up period, young age group, uncontrolled study. CONCLUSIONS In an intense surveillance program for FAP patients, both endoscopy and EUS were key in accurate selection of advanced adenomas for endoscopic resection. During a 10-year period, only 2 patients required elective surgery and no cancer was observed.
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Affiliation(s)
- Nathan Gluck
- Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hana Strul
- Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rozner
- Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Moshe Leshno
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Erwin Santo
- Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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De Palma GD, Luglio G, Maione F, Esposito D, Siciliano S, Gennarelli N, Cassese G, Persico M, Forestieri P. Endoscopic snare papillectomy: a single institutional experience of a standardized technique. A retrospective cohort study. Int J Surg 2015; 13:180-183. [PMID: 25498490 DOI: 10.1016/j.ijsu.2014.11.045] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Revised: 11/09/2014] [Accepted: 11/27/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND Indications for endoscopic snare papillectomy (ESP) remain controversial. Main concerns with ESP are related to the incomplete removal of the lesion, high recurrence rates and inadequate oncological resection. Aim of the study is to report short and long term outcomes after endoscopic papillectomy in a single institutional series with strict inclusion criteria and a standardized technique. METHODS Patients with ampullary tumors who underwent endoscopic papillectomy over a 5 year period were reviewed. Inclusion criteria for endoscopic resection were: tumor diameter less than 3 cm, no endoscopic evidence of malignancy, absence of infiltration of biliary and pancreatic duct at pre-operative ERCP and tumor confined to the submucosa at EUS. An en-block resection was attempted in all cases, followed by a pancreatic stent insertion whenever possible. RESULTS Twenty-seven patients (10 female, mean age 68 y) have been identified. Ampullectomy was successfully performed in all the cases. En bloc resection was completed in 24 patients (88.8%), while 3 patients had a piecemeal resection. A pancreatic stent was successfully placed in all the patients. Five patients experienced complications, including bleeding (2 cases, 7.4%) and acute pancreatitis (3 cases, 11.1%). There was no procedure-related mortality. Histology revealed a poor prognosis in two patients, which were subsequently treated by duodenopancreatectomy. Over a long-term follow-up (median 18 months), one patient developed local recurrence, which was successfully treated with further endoscopic resection. Overall curative resection rate was 92.6%. CONCLUSIONS Endoscopic ampullectomy allows resection of benign tumors and in situ carcinoma. Strict indications and a proper standardized technique seem to be key factors in order to achieve excellent short and long-term results.
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Affiliation(s)
- Giovanni D De Palma
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Gaetano Luglio
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Francesco Maione
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Dario Esposito
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Saverio Siciliano
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Nicola Gennarelli
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Marcello Persico
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
| | - Pietro Forestieri
- Department of Clinical Medicine and Surgery, Center of Excellence for Technical Innovation in Surgery (CEITC), University of Naples Federico II, School of Medicine, Naples, Italy.
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Han J, Lee DW, Kim HG. Recent advances in endoscopic papillectomy for ampulla of vater tumors: endoscopic ultrasonography, intraductal ultrasonography, and pancreatic stent placement. Clin Endosc 2015; 48:24-30. [PMID: 25674523 PMCID: PMC4323428 DOI: 10.5946/ce.2015.48.1.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/27/2014] [Accepted: 12/27/2014] [Indexed: 12/16/2022] Open
Abstract
Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.
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Affiliation(s)
- Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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48
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Moon JH, Choi HJ, Lee YN. Current status of endoscopic papillectomy for ampullary tumors. Gut Liver 2014; 8:598-604. [PMID: 25368746 PMCID: PMC4215444 DOI: 10.5009/gnl14099] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Accepted: 07/03/2014] [Indexed: 12/14/2022] Open
Abstract
Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.
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Affiliation(s)
- Jong Ho Moon
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Hyun Jong Choi
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
| | - Yun Nah Lee
- Digestive Disease Center and Research Institute, Department of Internal Medicine, SoonChunHyang University Bucheon Hospital, SoonChunHyang University School of Medicine, Bucheon, Korea
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Moussata D, Napoleon B, Lepilliez V, Klich A, Ecochard R, Lapalus MG, Nancey S, Cenni JC, Ponchon T, Chayvialle JA, Saurin JC. Endoscopic treatment of severe duodenal polyposis as an alternative to surgery for patients with familial adenomatous polyposis. Gastrointest Endosc 2014; 80:817-25. [PMID: 24814771 DOI: 10.1016/j.gie.2014.03.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 03/05/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with familial adenomatous polyposis (FAP) and severe (stage IV) duodenal polyposis are candidates for pancreaticoduodenectomy, which has high morbidity. Little information is available about the feasibility of therapeutic endoscopy for these patients. OBJECTIVE To evaluate the long-term efficiency and risks of endoscopic therapy. DESIGN Retrospective study. SETTING A 2-referral center long-term cohort study. PATIENTS Thirty-five FAP patients (15 men, mean age 48 years) presenting with stage IV duodenal polyposis were included. Patients had a mean Spigelman classification score of 9.8 points (range 9-12 points) at their first examination. INTERVENTIONS Patients underwent a surveillance endoscopy, including lateral and axial viewing with chromoendoscopy while under sedation, along with 7 ± 4.8 therapeutic endoscopic sessions during a follow-up period of 9 ± 4.5 years (range 1-19 years) after their first endoscopy. MAIN OUTCOME MEASUREMENTS Treatment modalities, adverse events, and efficiency (evolution of the Spigelman score) were reviewed. RESULTS A total of 245 therapeutic endoscopies were performed and 15 adverse events (6%) occurred. During the follow-up period, Spigelman scores decreased in 95% of patients by 6 ± 2.2 points (P = .002). Modeling analysis showed that the mean Spigelman score decreased by 60% after 150 months. LIMITATIONS Retrospective study and the duration of the follow-up, even though this is the longest follow-up reported in medical literature. CONCLUSION Endoscopic treatment of severe duodenal polyposis in patients with FAP produces few adverse events and allows efficient downstaging of the polyposis. Long-term follow-up data did not reveal a high risk of invasive duodenal cancer in these patients.
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Affiliation(s)
- Driffa Moussata
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | | | | | - Amna Klich
- Statistics Department, Lyon Civil Hospital, Lyon, France
| | - René Ecochard
- Statistics Department, Lyon Civil Hospital, Lyon, France
| | | | - Stéphane Nancey
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | - Jean-Claude Cenni
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France
| | - Thierry Ponchon
- Gastroenterology Department, Edouard Herriot Hospital, Lyon, France
| | | | - Jean-Christophe Saurin
- Gastroenterology Department, Lyon Sud Hospital, Pierre Benite, France; Gastroenterology Department, Edouard Herriot Hospital, Lyon, France
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50
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Pancreatic intubation facilitated by methylene blue injection decreases the risk for postpapillectomy acute pancreatitis. Eur J Gastroenterol Hepatol 2014; 26:990-5. [PMID: 25072383 DOI: 10.1097/meg.0000000000000146] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endoscopic snare papillectomy (ESP) is a viable alternative to surgical treatment of ampullary adenomas and T1N0 stage ampullary carcinomas. The main drawback of this technique is the high risk of acute pancreatitis post procedure.The aim of this study was to assess the efficacy, safety, and long-term results of this procedure, and to determine whether routine pancreatic intubation facilitated by intraductal methylene blue (MB) injection reduces the risk for pancreatitis. PATIENTS AND METHODS Between 2004 and 2011, 56 consecutive patients underwent ESP. Before resection, the pancreatic duct was cannulated, and MB was injected intraductally to facilitate stent placement after ampullectomy. RESULTS ESP was performed en bloc in 45 patients with histological findings of low-grade dysplasia (39%), high-grade dysplasia (25%), carcinoma (32.5%), and others (3.5%). The morbidity rate was 19.5%: acute pancreatitis (n=6), bleeding (n=4), perforation (n=1), and sepsis (n=1). Pancreatic intubation was performed in 89% of the patients. Postprocedure pancreatitis occurred significantly less in the patients with a pancreatic stent than in those without: 3/49 versus 3/6, P=0.013. ESP was considered as curative in 39 patients (75%). Of the 12 recurrences (25%), 10 were managed endoscopically, but with higher morbidity (acute pancreatitis=40%). CONCLUSION Endoscopic papillectomy is safe and effective in the hands of experts. Pancreatic-duct stent placement in fewer cannulation attempts could be facilitated by injection of MB before papillectomy, and this decreases the risk for postprocedure pancreatitis. Recurrences can be managed endoscopically, but with a higher risk for pancreatitis.
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