Endoscopic resection of tumors of the ampulla of Vater: how far up and how deep down can we go?

Role of Endoscopy in Management of Upper Gastrointestinal Cancers

Upper gastrointestinal (GI) malignancy is a leading cause of cancer-related morbidity and mortality. Upper endoscopy has an established role in diagnosing and staging upper GI cancers, screening for pre-malignant lesions, and providing palliation in cases of advanced malignancy. New advances in endoscopic techniques and technology have improved diagnostic accuracy and increased the therapeutic potential of upper endoscopy. We aim to describe the different types of endoscopic technology used in cancer diagnosis, summarize the current guidelines for endoscopic diagnosis and treatment of malignant and pre-malignant lesions, and explore new potential roles for endoscopy in cancer therapy.

Long-term outcomes of endoscopic papillectomy for early-stage cancer in duodenal ampullary adenoma: Comparison to surgical treatment

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.

Transduodenal ampullectomy for ampullary tumor

BACKGROUND

Transduodenal ampullectiomy (TDA) is a surgical local excision method that can be performed in patients with ampullary tumors, but it has not been widely used clinically. Recently, TDA is considered as a good alternative surgical technique in patients who are unable to perform the endoscopic ampullectomy (EA) or pancreaticoduodenectomy (PD) for various reasons. The purpose of this study is to evaluate the surgical outcomes of TDA and the clinicopathological significance of pathologic findings in TDA.

METHODS

We reviewed the medical records of 31 patients diagnosed as ampullary tumor and underwent TDA from March 2004 to December 2019 in a single center.

RESULTS

All 31 patients were planned to perform TDA, and 4 of them were converted to PPPD due to the marginal status results of frozen biopsy. Of the 31 patients, 19 were diagnosed with malignancy and 12 were diagnosed with benign. Of the 18 patients who were diagnosed as malignancy in final biopsy, only 9 patients (50%) were diagnosed with malignancy on the preoperative endoscopic biopsy. In 15 patients who underwent only TDA for malignancy, there was no recurrence during the follow-up period (mean: 51.1 months, range: 19-137).

CONCLUSIONS

In benign ampullary tumor, TDA is a choice of treatment for patients who are unsuitable for endoscopic ampullectomy. TDA may be considered as an alternative operation in highly selective patients with early ampullary cancer (Tis and T1). Further studies on consensus of TDA indication for ampullary tumor will be needed in the future.

Trans-duodenal ampullectomy for ampullary neoplasms: early and long-term outcomes in 36 consecutive patients

BACKGROUND

Trans-duodenal ampullectomy (TDA) is a surgical option for the treatment of selected ampullary neoplasms. The aim of this study was to evaluate our experience with TDA for the treatment of ampullary neoplasms, focusing on indications, technical aspects, and short- and long-term outcomes.

METHODS

All TDAs for ampullary neoplasms performed between January 2010 and December 2018 at our institution were retrospectively evaluated. Patients had ampullary neoplasms with low-grade dysplasia or in situ carcinoma (Tis) not suitable for an endoscopic approach, ampullary carcinoma unfit for pancreaticoduodenectomy (PD), or ampullary neuroendocrine G1-tumours.

RESULTS

Thirty-six patients were included in the study: 9 (25.0%) with neoplasms with low-grade dysplasia, 4 (11.1%) with G1 neuroendocrine tumours and 23 (63.9%) with Tis or invasive carcinoma. Mean operative time was 252.5 min. Overall and severe (Clavien-Dindo > IIIa) morbidity rate was 44.4% and 13.9%, respectively. No 90-day mortality was observed. At follow-up, no deaths were observed and local recurrence rate was 11.1% for patients with ampullary adenomas with low-grade dysplasia. Among four patients with neuroendocrine neoplasms, only one developed recurrence (pulmonary). Tis, T1 and T2 lesions were found in 16 (69.6%), 2 (8.7%) and 5 (21.7%) patients, respectively: recurrence occurred in 3 patients with Tis lesions (one malignant), no patients with T1 neoplasms and 2 patients with T2 lesions (3 patients had a survival of > 3 years).

CONCLUSIONS

TDA is a feasible and effective surgical procedure for the treatment of ampullary adenomas with low-grade dysplasia when endoscopic approach is contraindicated or has failed. For lesions with evidence of malignancy, TDA seems to be an oncological safe procedure for Tis ampullary cancer and a good palliative procedure for patients unfit for PD. Moreover, TDA may be appropriate for the treatment of G1 ampullary neuroendocrine neoplasms. A large multicentre study of TDA for early ampullary cancers is needed.

Insights and updates on endoscopic papillectomy

INTRODUCTION

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

AREA COVERED

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

EXPERT OPINION

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

Surgical versus endoscopic resection of large sessile duodenal and papillary lesions

BACKGROUND

Data on the endoscopic resection of duodenal and papillary lesions less than 15 mm in size have been well supported by systematic studies. However, for large sessile lesions of the duodenum or papilla (LSL-D/P), surgery is often performed despite significant morbidity and mortality. This study aimed to compare the outcomes and costs between endoscopic and surgical resection of such lesions.

METHODS

Patients who underwent endoscopic or surgical resection of LSL-D/P at Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University from 2013 to 2017 were retrospectively analyzed. Endoscopic and surgical outcomes and costs were compared.

RESULTS

A total of 68 lesions were evaluated (47.1% of patients were male; mean lesion size 25 mm); 46 were treated by endoscopic resection, and 22 were managed by surgical resection. At the initial procedure, complete resection was achieved in 93.4%. Major complications (perforation, delayed bleeding, pancreatitis, infections and admission to the ICU) occurred in 15.3% of the endoscopic group and 22.6% of the surgical group. For recurrence at the first surveillance endoscopic examination, there was a 12.1% recurrence rate in the endoscopic group and a 5.3% recurrence rate in the surgical group (P = 0.654). Compared with surgical resection, regardless of lesion location, endoscopic resection had a shorter procedural time and hospital stay, a lower morbidity rate and was less costly.

CONCLUSION

In centers specialized in complex endoscopic resection, patients with LSL-D/P would likely benefit from advanced endoscopic management, which offers a lower morbidity profile and reduced costs.

Diagnosis, risk stratification, and management of ampullary dysplasia by DNA flow cytometric analysis of paraffin-embedded tissue

The limited accuracy of endoscopic biopsy in detecting high-grade dysplasia or adenocarcinoma within ampullary adenoma or dysplasia has been reported. The natural history of ampullary dysplasia is also unclear, and there are no established guidelines to determine which patients with ampullary dysplasia require resection versus surveillance endoscopy. DNA flow cytometry was performed on 47 ampullary biopsies with low-grade dysplasia, 18 high-grade dysplasia, and 23 negative for dysplasia, as well as 11 cases of ampullary adenocarcinoma. Abnormal DNA content (aneuploidy or elevated 4N fraction > 6%) was identified in 9 (82%) of adenocarcinoma, 13 (72%) of high-grade dysplasia, 7 (15%) of low-grade dysplasia, and none (0%) of non-dysplastic mucosa. One-, 2-, and 7-year detection rates of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with abnormal DNA content were 57%, 86%, and 88%, respectively, whereas low-grade dysplasia patients in the setting of normal DNA content had 1-, 2-, and 7-year detection rates of 10%, 10%, and 10%, respectively. The univariate and multivariate hazard ratios (HRs) for subsequent detection of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 16.8 (p = <0.01) and 9.8 (p = <0.01), respectively. Among the 13 high-grade dysplasia patients with DNA content abnormality, 5 patients (38%) were subsequently found to have adenocarcinoma within a mean follow-up time of 3 months, whereas only 1 (20%) of the remaining 5 patients in the setting of normal DNA content developed adenocarcinoma in a month (HR = 2.6, p = 0.39). The overall 1- and 2-year detection rates of adenocarcinoma in all high-grade dysplasia patients (regardless of flow cytometric results) were 34% (95% confidence interval = 16-63%) and 47% (95% confidence interval = 23-79%), respectively. In conclusion, the majority of low-grade dysplasia patients (86%) in the setting of abnormal DNA content developed high-grade dysplasia or adenocarcinoma within 2 years and thus may benefit from resection, whereas those with normal DNA content may be followed with surveillance endoscopy. The presence of DNA content abnormality can also confirm a morphologic suspicion of high-grade dysplasia, which should be managed with resection, as nearly 50% of the high-grade dysplasia patients were found to have adenocarcinoma within 2 years.

Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study

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.

Safety of duodenal ampullectomy for benign periampullary tumors

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.

Does ampullary adenoma size predict invasion on EUS? Does invasion on EUS predict presence of malignancy?

Background and study aims: It is common practice to perform ampullectomy without endoscopic ultrasound (EUS) for ampullary lesions < 1 cm but no data exists to support it. No studies have explored whether EUS findings of invasion correlate with malignancy or high-grade dysplasia (HGD) on pathology. We explored the association between adenoma size, pathology results, and invasion on EUS.  Patients and methods: This was a single-center retrospective cohort study at a large tertiary care academic hospital. Chart review was performed for 161 patients with benign ampullary lesions on endoscopic biopsy (identified by pathology records). The primary outcomes were mean size (mm) of adenomas and pathology findings with and without intraductal and/or duodenal wall invasion on EUS.  Results: Invasion was identified by EUS in 41 (34.1 %) of 120 patients who underwent EUS. The mean size of the lesion in these patients was 20.9 mm (± 11.6 mm) compared to 13.9 mm (± 11.3 mm, P = 0.0001) in patients without invasion. A receiver operating characteristic (ROC) curve (AUC 0.73, 95 % CI 0.63 - 0.83) revealed 100 % sensitivity for absence of invasion on EUS in lesions less than 6.5 mm. Invasion on EUS had sensitivity of 63.0 % (95 % CI 47.0 % - 77.0 %) and specificity 88.0 % (95 % CI 78.0 % - 95.0 %) for presence of malignancy, HGD or invasion on pathology. Conclusions: EUS should be considered for ampullary lesions > 6.5 mm. This study provides evidence to support the practice of ampullectomy without EUS for smaller adenomas. EUS evidence of invasion is highly specific for pathologic malignancy, HGD, or invasion (which preclude endoscopic ampullectomy).

Endoscopic resection of advanced and laterally spreading duodenal papillary tumors

Historically, neoplasia of the duodenal papilla has been managed surgically, which may be associated with substantial morbidity and mortality. In the absence of invasive cancer, even lesions with extensive lateral duodenal wall involvement, or limited intraductal extension may be cured endoscopically with a superior safety profile. Endoscopic papillectomy is associated with greater risks of adverse events such as bleeding than resection elsewhere in the gastrointestinal tract. Additionally site-specific complications such as pancreatitis exist. A structured approach to lesion assessment, adherence to technical aspects of resection, endoscopic management of complications and post-resection surveillance is required. Advances have been made in all facets of endoscopic papillary resection since its introduction in the 1980s; extending the boundaries of endoscopic cure, optimizing outcomes and enhancing patient safety. These will be the focus of the present review.

Endoscopic treatment of severe duodenal polyposis as an alternative to surgery for patients with familial adenomatous polyposis

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.

Trends in incidence and management of cancer of the ampulla of Vater

AIM: To provide trends in incidence, management and survival of cancer of the ampulla of Vater in a well-defined French population.

METHODS: Data were obtained from the population-based digestive cancer registry of Burgundy over a 34-year period. Age-standardized incidence rates were computed using the world standard population. Average annual variations in incidence rates were estimated using a poisson regression. A univariate and multivariate relative survival analysis was performed.

RESULTS: Age-standardized incidence rates were 0.46 and 0.30 per 100000 inhabitants for men and women, respectively. Incidence rate increased from 0.26 (1976-1984) to 0.58 (2003-2009) for men and remained stable for women. Resection for cure was performed in 48.3% of cases. This proportion was stable over the study period. Among cases with curative resection, pancreatico-duodenectomy was performed in 94.0% of cases and ampullectomy in 6.0% of cases. A total of 50.8% of cancers of the ampulla of Vater were diagnosed at an advanced stage. Their proportion remained stable throughout the study period. The overall 1- and 5-year relative survival rates were 60.2% and 27.7%, respectively. Relative survival did not vary over time. Treatment and stage at diagnosis were the most important determinants of survival. The 5-year relative survival rate was 41.5% after resection for cure, 9.5% after palliative surgery and 6.7% after symptomatic treatment. In multivariate analysis, only stage at diagnosis significantly influenced the risk of death.

CONCLUSION: Cancer of the ampulla of Vater is still uncommon, but its incidence increased for men in Burgundy. Diagnosis is often made at an advanced stage, dramatically worsening the prognosis.

Prognostic factors for long-term survival in patients with ampullary carcinoma: the results of a 15-year observation period after pancreaticoduodenectomy

Introduction. Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15-year observation period. Methods. From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%) and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). Results. The overall 1-, 5-, 10-, and 15-year survival rates were 79%, 40%, 24%, and 10%, respectively. Within a mean observation period of 30 (0–205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement (P = 0.001), lymphatic vessel invasion (P = 0.0001), intraoperative administration of packed red blood cells (P = 0.03), an elevated CA 19-9 (P = 0.03), jaundice (P = 0.04), and an impaired patient condition (P = 0.01) are strong negative predictors for a reduced patient survival. Conclusions. Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic adenocarcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with this risk constellation.

Endoscopic approach to the patient with benign or malignant ampullary lesions

Adenoma and adenocarcinoma are the most common ampullary lesions. Advances in diagnostic modalities including endoscopic ultrasonography and intraductal ultrasonography have provided useful information that aids in diagnosing and managing ampullary lesions. Endoscopic papillectomy can be a curative therapy for localized ampullary adenoma and have a role in the diagnosis of indeterminate ampullary lesions that may contain a hidden malignancy. However, the consensus on how and when to use endoscopic papillectomy has not been fully established. This article reviews the approach to the patient with benign or malignant ampullary lesion.

Endoskopische Papillenresektion: Indikation und Grenzen

<b><i>Hintergrund: </i></b>Adenome der Papilla Vateri sind selten. Prävalenzen von 0,04–0,12% werden beschrieben. Eine maligne Transformation von benignen Adenomen zu Papillenkarzinomen ist möglich und folgt der Adenom-Karzinom-Sequenz. Die meisten Papillenadenome treten sporadisch auf, können jedoch z.B. bei Patienten mit familiärer adenomatöser Polyposis genetisch häufiger vorkommen. <b><i>Methode: </i></b>Es erfolgte eine aktuelle PubMed-Recherche zum Thema endoskopische Papillenresektion. <b><i>Ergebnisse/Schlussfolgerung: </i></b>Eine endoskopische Papillektomie kann bei Adenomen ohne duktale Infiltration durchgeführt werden, während es in Hinblick auf das papilläre Adenokarzinom noch keinen Konsens gibt. Jedoch konnten neuere Studien zeigen, dass Patienten mit hochgradiger intraepithelialer Neoplasie der Papilla Vateri keine lymphovaskuläre Invasion oder Lymphknotenmetastasen aufweisen, sodass eine endoskopische Papillektomie gerechtfertigt erscheint. Da papilläre Adenome in bis zu 30% der Fälle das Risiko für fokale karzinomatöse Areale beherbergen können, sollte jede Papillektomie «en bloc» durchgeführt werden.

Diagnosis and management of ampullary adenoma: The expanding role of endoscopy

Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic. It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance. Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy. Those that are used most commonly include computed tomography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography. In recent years, endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas. Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma. This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.

Role of transduodenal ampullectomy for tumors of the ampulla of Vater

PURPOSE

Tumors arising from the ampulla of Vater can be benign or malignant. Recently, endoscopic papillectomy has been employed in the management of benign ampulla of Vater tumors; however, surgical resection is the treatment of choice. The aim of this study was to define indications and suggest a role for transduodenal ampullectomy in the management of ampulla of Vater tumors.

METHODS

We retrospectively reviewed the medical records of 54 patients treated for ampulla of Vater tumors between January 1999 and December 2008.

RESULTS

Twenty-two endoscopic papillectomies and 21 transduodenal ampullectomies were performed. Four patients underwent transduodenal ampullectomy after endoscopic papillectomy due to a recurrent or remnant tumor. Recurrence or a remnant tumor was found in one patient after transduodenal ampullectomy compared to six patients after endoscopic papillectomy. Immediate intraoperative conversion from transduodenal ampullectomy to pancreaticoduodenectomy was performed in five patients based on intraoperative frozen biopsy analysis.

CONCLUSION

Transduodenal ampullectomy should be performed to treat ampulla of Vater tumors that are unsuitable for endoscopic papillectomy. Transduodenal ampullectomy can serve as an intermediate treatment option between endoscopic papillectomy and pancreaticoduodenectomy in the management of ampulla of Vater tumors.

Endoscopic ultrasound in the papilla and the periampullary region

Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected. Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS, for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.

Endoscopic resection of ampullary neoplasms: a single-center experience

BACKGROUND

An ampullary tumor, whether malignant or not, must be completely resected. A benign adenoma has the potential for malignant transformation. Currently, endoscopic papillectomy with curative intent is increasingly performed for benign papillary tumors. This study aimed to evaluate the outcome of endoscopic papillectomy performed for ampullary tumors at a single center.

METHODS

From July 2003 to June 2008, 22 patients with a diagnosis of ampullary tumors determined by endoscopic retrograde cholangiopancreatography (ERCP) were treated using endoscopic resection of the tumors. Endoscopic resection was performed in a radical fashion analogous to polypectomy for colon adenomas.

RESULTS

The 22 patients (9 men and 13 women) had an average age of 58 +/- 14 years (range, 19-85 years). The median follow-up period was 169 days (range, 14-903 days). The papillary lesions ranged in size from 8 to 33 mm. The rate of concordance between the endoscopic forceps biopsy and the resected specimen was 50% (9/18) according to the Vienna classification. Complete endoscopic resections were performed for 17 of 22 the cases (77.3%). The median length of hospital stay was 4 days (range, 2-11 days), and there were no readmissions for complications. Endoscopic complications occurred for 5 (22.7%) of the 22 patients: postpapillectomy pancreatitis for 4 patients, bleeding for 1 patient, and retroperitoneal perforation for 1 patient. However, no procedure-related deaths occurred. After the papillectomy, a pathologically incomplete resection was noted in 10 cases, including submucosal invasion of an adenocarcinoma with lateral clean resection margins.

CONCLUSIONS

The findings showed that an endoscopic papillectomy was safe and effective for benign-appearing adenomas with negative biopsy results for a malignancy. This procedure should be considered as the initial intervention in such cases. The decision whether to perform a pancreatoduodenectomy can be made after the pathology report of the resected specimen is obtained from the endoscopic papillectomy.

Endoscopic papillectomy of minor papillar adenoma associated with pancreas divisum

Tumors of the minor papilla of the duodenum are quite rare. We successfully and safely treated an 18-mm adenoma of the minor papilla associated with pancreas divisum using endoscopic papillectomy. A 64-year-old man was admitted to our hospital for treatment of an asymptomatic mass in the minor papilla detected by upper gastrointestinal endoscopy. Endscopic analysis showed an 18-mm, whitish, sessile mass, located in the duodenum proximal to a normal-appearing major papilla. Endoscopic retrograde pancreatography did not reveal the pancreatic duct. Magnetic resonance cholangiopancreatography showed a lack of the ventral pancreatic duct. We suspected this case was associated with pancreatic divisum; therefore, we performed endoscopic papillectomy of the minor papilla tumor. Subsequently, endoscopic pancreatic stent placement in the minor papilla was done to prevent drainage disturbance. The patient has been asymptomatic without recurrence of tumor or stenosis of the Santorini orifice upon endoscopic examination for the past 2 years.

[Diagnosis and treatment of ampullary tumors]

Tumors of the ampulla of Vater are called ampullary tumors and can arise from any of the three epithelia (duodenal, pancreatic and biliary) that delimit the papilla. These tumors are clinically important and early identification, appropriate staging and proper treatment are essential. The symptoms of these tumors are non-specific and not always evident. All ampullary tumors must be resected but opinions differ on the optimal method of excision. Currently, controlled trials are lacking and consequently the treatment chosen must be individually tailored according to the characteristics of the patient and the tumor. Curative treatment may be endoscopic or surgical. In patients who are not candidates for curative treatment, palliative treatment through drainage can be performed.

Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy?

BACKGROUND

Recently, the evidence has been accumulating that endoscopic resection may be curative in treating ampullary adenoma that contains high-grade intraepithelial neoplasia/in situ tumor (HGIN/Tis). However, there are only anecdotal reports of endoscopic management of "focal" T1 ampullary cancer (T1 cancer), and radical surgery is still considered the only accepted treatment modality.

OBJECTIVE

To assess the possibility of endoscopic papillectomy as an alternative to radical surgery for the treatment of ampullary adenoma with HGIN/Tis or focal T1 cancer.

DESIGN

Retrospective evaluation of case series of our hospital from 1996 to 2006.

SETTING

Tertiary-care university teaching hospital.

PATIENTS

Twenty-three patients who had HGIN/Tis or focal T1 cancer in ampullary adenoma resected by endoscopic papillectomy and 60 patients who initially underwent radical surgery for HGIN/Tis or T1 cancer of the ampulla of Vater. "Focal" was defined as a lesion involving only mucosa, with a size less than a fourth the diameter of main adenoma.

INTERVENTIONS

Review of medical records and analysis of surgically or endoscopically resected specimens of ampullary tumors.

MAIN OUTCOME MEASUREMENTS

Locoregional extension and follow-up data.

RESULTS

Patients with HGIN/Tis of the ampulla of Vater had no lymphovascular invasion or lymph-node metastasis, and there were no occurrences of cancer or deaths during a mean (standard error [+/-SE]) 27.1 +/- 5.9 months after endoscopic papillectomy. T1 cancer was shown to have lymphovascular invasion and/or lymph-node metastasis in 10.7% and duct mucosal involvement in another 17.9%. Among them, patients with focal T1 cancer showed no lymphovascular invasion or lymph-node metastasis and no ductal involvement, and none of the patients who underwent endoscopic papillectomy alone had cancer recurrence or disease-related death for mean (+/-SE) 32.2 +/- 6.7 months.

LIMITATIONS

Single-center, retrospective study, small number of patients, and medium-term follow-up period.

CONCLUSIONS

Endoscopic papillectomy may be a curative treatment for ampullary adenoma with HGIN/Tis and should also be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma.