The Role of Endoscopic Ultrasonography (EUS) and Endoscopic Retrograde Cholangiopancreatography (ERCP) in the Evaluation and Management of Ampullary Adenomas

Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.

Endoscopic ultrasonography in tandem with endoscopic retrograde cholangiopancreatography in the management of suspected distal obstructive jaundice

GOALS

To examine the benefits and feasibility of endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) in tandem for distal obstructive jaundice.

MATERIALS AND METHODS

From September 2007 to August 2012, patients with suspected distal obstructive jaundice were randomized to single-session EUS-ERCP (group A), EUS, and ERCP in different sessions (group B), and an ERCP-only procedure (group C). Data were prospectively collected on the following parameters: ERCP-avoided, duration of procedure, the dose of propofol, complications, and diagnostic yield.

RESULTS

A total of 180 patients were divided randomly into 60 patients in group A, 60 in group B, and 60 in group C. A total of four therapeutic ERCP were canceled after EUS. The ERCP procedural time in group A was shorter, although not significantly different from that in group B (group A vs. group B: 41.24±7.57 vs. 43.38±6.57 min; P>0.05), but both were significantly less than that in group C (group C: 49.12±7.46 min; P<0.05). The total procedural time did not differ significantly between group A and group B (70.05±15.35 vs. 73.70±15.12 min; P>0.05), nor were there significant differences in the dose of propofol between them (group A vs. group B: 357.11±115.86 vs. 369.55±133.86 mg; P>0.05). In all, 22 anesthetic complications and 21 endoscopic complications occurred without significant differences among the three groups (P>0.05).

CONCLUSION

As a triaging or a screening tool, diagnostic EUS gives added benefit to therapeutic ERCP. EUS and ERCP in a tandem approach are safe and feasible in patients with suspected distal obstructive jaundice.

A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes

BACKGROUND

Although benign ampullary tumors are removed endoscopically, due to their potential to progress to malignant disease, the favored treatment for adenocarcinoma is pancreaticoduodenectomy. We reviewed our institution's experience in order to identify which patients were at highest risk of disease progression following surgical resection, as well as evaluate whether localized T1 tumors are best treated by pancreaticoduodenectomy.

METHODS

We retrospectively reviewed 157 patients who presented with an ampullary mass, from 2001 to 2010, and identified 51 with benign adenoma and 106 with adenocarcinoma.

RESULTS

Patients with malignant tumors most often presented with larger tumors and jaundice, which alone was predictive of survival (OR = 67). Forty-five percent of patients with pathologically confirmed T1 tumors had positive lymph nodes and median survival was modest at 60 months. Lymph node involvement was predictive of recurrence and decreased survival.

CONCLUSION

Patients with malignant tumors often present with jaundice and larger tumors. These findings should warrant suspicion for cancer and expedited preoperative workup. Based on our finding that nearly half the patients with T1 tumors had positive lymph nodes, we recommend pancreaticoduodenectomy for any patient with biopsy proven adenocarcinoma who is a suitable candidate for surgery.