Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study

Long-term recurrence after endoscopic versus surgical ampullectomy of sporadic ampullary adenomas: a systematic review and meta-analysis

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.

Diagnostic accuracy of endoscopic ultrasound and intraductal ultrasonography for assessment of ampullary tumors: a meta-analysis

BACKGROUND

Accurate preoperative assessment of ampullary tumors (ATs) is critical for determining the appropriate treatment. The reported diagnostic accuracy of endoscopic ultrasound (EUS) and intraductal ultrasonography (IDUS) for detecting tumor depth (T-staging) and regional lymph node status (N-staging) varies across studies.

METHOD

An electronic search of the MEDLINE and Embase databases was conducted to identify studies that assessed the diagnostic accuracy of EUS and IDUS for ATs. Sensitivities and specificities of eligible studies were summarized using either fixed effects or random-effects model.

RESULTS

Twenty-one studies were included in the final analysis. The pooled sensitivity and specificity of EUS were 0.89 and 0.87 for T1, 0.76 and 0.91 for T2, 0.81 and 0.94 for T3 and 0.72 and 0.98 for T4, respectively. For IDUS, estimates from five studies were 0.90 and 0.88 for T1, 0.73 and 0.91 for T2 and 0.79 and 0.97 for T3, respectively. For N-staging, 16 studies using EUS were included with sensitivity and specificity of 0.61 and 0.77, respectively. Moreover, estimates of IDUS for N-staging were 0.61 and 0.92, respectively.

CONCLUSION

Our results imply that EUS and IDUS have good diagnostic accuracy for T-staging of ATs. However, the accuracy of EUS or IDUS is less satisfactory for N-staging. More well-designed prospective studies are warranted to confirm our findings.

Clinical practice guidelines for endoscopic papillectomy

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.

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

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

Endoscopic Evaluation of Biliary Strictures: Current and Emerging Techniques

The diagnosis of biliary strictures in clinical practice can be challenging. Discriminating between benign and malignant biliary strictures is important to prevent the morbidity and mortality associated with incorrect diagnoses. Missing a malignant biliary stricture may delay surgery, resulting in poor prognostic outcomes. Conversely, it has been demonstrated that approximately 20% of patients who undergo surgery for suspected biliary malignancies have a benign etiology on histopathology. Traditional tissue sampling using endoscopic retrograde cholangiography does not always produce a definitive diagnosis, with a considerable proportion of cases remaining as indeterminate biliary strictures. Recent advances in endoscopic techniques have the potential to improve the diagnostic and prognostic accuracy of biliary strictures.

Immunohistochemical staining for IMP3 in patients with duodenal papilla tumors: assessment of the potential for diagnosing endoscopic resectability and predicting prognosis

BACKGROUND

Endoscopic papillectomy of duodenal papillary tumors (PT) is indicated for adenomas or well-differentiated adenocarcinomas that do not involve the sphincter of Oddi. However, there is currently no reliable pre-operative method to diagnose the infiltration in the sphincter of Oddi.' Insulin-like growth factor 2 mRNA protein 3 (IMP3) staining is reportedly associated with advanced disease stage and clinical outcomes in many carcinomas. The aim of this retrospective study was to investigate the ability of diagnosing sphincter of Oddi involvement in PT and predicting the prognoses using IMP3 immunohistochemistry.

METHODS

Twenty-five resected specimens from patients with PT and 24 biopsy specimens from the same patients excluding one were immunostained for IMP3. The percentage of positive cells in the tumor was evaluated and compared with the final pathological diagnosis and prognosis.

RESULTS

The final pathological diagnoses were adenoma in 5 patients and adenocarcinoma in 20 patients (no sphincter of Oddi involvement in 5 and involvement in 15). The ability to diagnose sphincter of Oddi involvement based on the percentage of IMP3-positive cells in resected specimens and tissue biopsies was the area under the curve 0.8 and 0.78, respectively, of the receiver operating characteristic curve, and the accuracies were 80.0% and 75.0% (cutoff value: 10%), respectively. Moreover, patients with an IMP3-positive cell rate of ≥ 10% had a significantly worse prognosis (log-rank test P = 0.01).

CONCLUSION

IMP3 immunostaining of resected and biopsy specimens from PT patients enables the diagnosis of sphincter of Oddi involvement objectively and is also effective in predicting the prognosis.

Transduodenal Ampullectomy for Ampullary Adenomas: A Safe and Effective Procedure with Long-term Salutary Outcomes

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.

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.

A Case of Endoscopic Mucosal Resection of Carcinoma in Adenoma at the Minor Duodenal Papilla

Here, we describe a case of minor papillary adenocarcinoma in adenoma that was treated with endoscopic mucosal resection (EMR). In a 67-year-old woman, sigmoid colon cancer was incidentally detected on preoperative upper gastrointestinal endoscopy. Endoscopy revealed a slightly elevated lesion at the minor duodenal papilla. The findings of a histopathologic examination were suggestive of adenocarcinoma. Computed tomography and magnetic resonance images identified a minute tumor, whereas endoscopic ultrasonography revealed that the tumor did not spread to the pancreas. We performed EMR of this lesion. There were no complications, and relapse has not occurred in 3 years. Cases of minor papillary adenocarcinoma treated with EMR are quite rare.

Miniprobe Endoscopic Sonography for Gastrointestinal Tract Assessment: A Case Series of 1451 Procedures

Conventional endoscopic sonography has allowed precise diagnostics without disturbances, and miniprobes can be easily introduced through the biopsy channel of the endoscope. Miniprobe endoscopic sonography has many benefits compared with conventional endoscopic sonography. Although there are well-known indications for miniprobe endoscopic sonography in endoscopic digestive tract assessment, there is still a need for this method to be widely spread among physicians and commonly used by most endoscopists. The aim of this series was to describe a multicenter retrospective experience with 1451 procedures using miniprobes, presenting examples and the applicability and usefulness of this technology in the daily activities of an endoscopy department.

Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management

AIM

To review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA).

METHODS

SDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed.

RESULTS

Twenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum).

CONCLUSION

SDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.

Wire-guided intraduodenal ultrasonography using a catheter probe in the differential diagnosis of enlarged ampullary lesions

BACKGROUND AND AIM

It can be difficult to identify the cause of an enlarged ampulla of Vater (AOV). This study evaluated the accuracy of wire-guided intraduodenal ultrasonography (US) for the differential diagnosis of an enlarged AOV during endoscopic retrograde cholangiopancreatography (ERCP).

PATIENTS AND METHODS

Thirty-four patients with enlarged AOVs of unknown cause identified on imaging studies or endoscopic observations underwent wire-guided intraduodenal US using a catheter probe.

RESULTS

The final diagnoses were malignant or premalignant tumors in 10 patients (29.4%), stones in nine patients (26.5%), inflammation in 14 patients (41.2%), and cyst in one patient (2.9%). The overall diagnostic accuracy of intraduodenal US for enlarged AOVs was 91.2%. The diagnostic accuracies of stones, inflammation, and AOV tumors were 100.0%, 94.1%, and 91.1%, respectively.

CONCLUSIONS

Wire-guided intraduodenal US using a catheter probe is readily applicable during ERCP and may be useful in the differential diagnosis of enlarged ampullary lesions.

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 papillectomy: The limits of the indication, technique and results

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.

Cancer of the ampulla of vater: current evaluation and therapy

Ampullary cancer is a relatively rare cancer of the digestive tract. In contrast to pancreatic cancer, ampullary cancer is often curable if detected at an early stage. The evaluation and management of ampullary cancer is similar to, but distinct from, that of other pancreaticobiliary tumors. This manuscript will review the current evaluation, diagnosis, and therapy of patients with ampullary cancer. The diagnosis of ampullary cancer is complicated by its similar clinical presentation to pancreatic cancer as well as its nonspecific laboratory findings. Diagnostic modalities such as ERCP, EUS, and biopsy are necessary for differentiating the 2 cancers, and noninvasive imaging techniques such as MRI and CT may be used for tumor staging. Although pancreaticoduodenectomy is considered the primary curative surgical option, consensus guidelines regarding adjuvant and neoadjuvant chemoradiation therapies are lacking.

Recent advances in endoscopic papillectomy for ampulla of vater tumors: endoscopic ultrasonography, intraductal ultrasonography, and pancreatic stent placement

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.

Staging accuracy of ampullary tumors by endoscopic ultrasound: meta-analysis and systematic review

BACKGROUND AND AIM

Accurate preoperative staging of ampullary neoplasms is of paramount importance in predicting prognosis and determining the most appropriate therapeutic approach. The aim of the present review was to evaluate the accuracy of endoscopic ultrasound (EUS) in predicting depth of ampullary tumor invasion (T-stage) and regional lymph node status (N-stage) by carrying out a meta-analysis of all relevant studies.

METHODS

We systematically searched PubMed, Medline and Scopus databases for all studies published between January 1980 and December 2012. Only EUS studies involving ≥ 10 patients with ampullary neoplasms, confirmed by surgical histopathology, with data available for construction of a 2 × 2 table were included.

RESULTS

Meta-analysis of 14 studies involving 422 patients using the Mantel-Haenszel method was performed. Pooled sensitivity and specificity of EUS to diagnose T1-stage tumor were 77% (95% CI: 69-83) and 78% (95% CI: 72-84), respectively. Pooled sensitivity for T4 tumors was 84% (95% CI: 73-92) and specificity was 74% (95% CI: 63-83). Combined sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio for diagnosing nodal status were 0.70 (95% CI: 0.62-0.77), 0.74 (95% CI: 0.67-0.0.80), 2.49 (95% CI: 1.91-3.24), 0.46 (95% CI: 0.36-0.59) and 6.53 (95% CI: 3.81-11.19), respectively.

CONCLUSION

Based on our pooled estimates, EUS had a moderate strength of agreement with histopathology in preoperative staging of ampullary neoplasms in predicting tumor invasion and lymph node involvement. Additional refinement in EUS technologies and diagnostic criteria may be required to enhance staging accuracy.

Endosonographic preoperative evaluation for tumors of the ampulla of vater using endoscopic ultrasonography and intraductal ultrasonography

Background/Aims

In recent years, endoscopic snare papillectomy has been performed to treat tumors of the ampulla of Vater. This procedure requires accurate preoperative evaluation. In this study, we diagnosed the focal extension of such tumors by using endoscopic ultrasonography (EUS) and intraductal ultrasonography (IDUS), and examined the indications for endoscopic snare papillectomy.

Methods

The subjects were 48 patients with a papillary tumor (13 patients, surgical resection; 35 patients, endoscopic snare papillectomy) who were evaluated preoperatively with EUS and IDUS. The tumor-node-metastasis classification was used for the endosonographic evaluation and pathological diagnosis of these tumors.

Results

The diagnostic accuracy of EUS was 97% for diagnosing adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 50% for pT3-4 tumors, for an overall accuracy of 85% for T-staging. The diagnostic accuracy of IDUS was 94% for adenomas and pTis tumors, 73% for pT1 tumors, 50% for pT2 tumors, and 100% for pT3-4 tumors, for an overall accuracy of 80% for T-staging.

Conclusions

EUS and IDUS are highly capable of evaluating tumors of the ampulla of Vater preoperatively. However, these techniques are not sufficient for evaluating the focal extension of carcinomas preoperatively. Currently, endoscopic snare papillectomy is adequate for treating adenomas and pTis tumors.

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 resection of ampullary lesions: a single-center 8-year retrospective cohort study of 91 patients with long-term follow-up

BACKGROUND

Endoscopic ampullectomy is established as a valuable treatment for adenomas of the Vaterian papilla. Few large series are available, however, let alone any with long-term follow-up. Moreover, multiple tangible issues remain. The aim of our study was to evaluate efficacy, safety, and outcome of endoscopic ampullectomy and compare it to existing literature

METHODS

This is a single-center, retrospective study with a minimal follow-up of 3 years including 91 patients, including familial adenomatous polyposis (FAP) and non-FAP, who had an endoscopic ampullectomy between 2000 and 2008. Outcome parameters included ampulloma characteristics, biotical accuracy as well as safety, efficacy, recurrence rate, and survival after endoscopic ampullectomy.

RESULTS

Endoscopic resection was successful in 71 patients (78%). Histological review of the resected specimens revealed nonspecific changes (13.8%), low or medium grade dysplasia (52.9%), high grade dysplasia (21.8%) and carcinoma (18.3%). Bioptic accuracy was 38.3%. Overall complications were observed in 23 patients (25.2%): pancreatitis (15.4%), hemorrhage (12.1%) and cholangitis (4.9%). Recurrence occurred in 18.3%. Fourteen patients underwent pancreaticoduodenectomy. Survival after complete endoscopic ampullectomy was excellent for patients with low to moderate grade dysplasia and high grade dysplasia. Incomplete endoscopic resection of high grade dysplasia or invasive carcinoma was associated with unfavorable outcome when treated merely endoscopically.

CONCLUSIONS

Endoscopic ampullectomy is obligatory for assessment of the true histological nature of an ampulloma. Endoscopic resection is a safe and efficient procedure for adenomas with low to moderate dysplasia but also for high grade dysplastic lesions, provided that a complete endoscopic resection is achieved.

Proposed indications for limited resection of early ampulla of Vater carcinoma: clinico-histopathological criteria to confirm cure

BACKGROUND

Limited resection is reserved for patients with high operative risk or benign adenomas. We aimed to define indications for limited resection of early ampulla of Vater carcinoma with curative intent through detailed preoperative examinations and histopathological evaluations.

METHODS

We performed a retrospective cohort study of all consecutive Japanese patients who underwent resection for ampulla of Vater neoplasms at our hospital from 1986 to 2010.

RESULTS

A total of 75 patients were identified. Moderately/poorly differentiated histology, lympho-vascular/perineural invasion, and duodenal/pancreatic invasion were significant risk factors for lymph node metastases. Macroscopically, non-exposed protruded- or ulcerative-type disease did not correlate directly with lymph node metastases; however, these tumor types were associated with other invasive features. In a subset of early carcinomas fulfilling the conditions of exposed protruded adenoma or papillary/well-differentiated adenocarcinoma determined by endoscopic biopsy, negative duodenal invasion determined by endoscopic ultrasonography, no tumor infiltration into the pancreatic duct determined by intraductal ultrasound, and diameter of the pancreatic duct ≤3 mm determined by endoscopic retrograde cholangiopancreatography (N = 11), the incidence of lymph node metastasis and tumor infiltration into the pancreatic duct was 0%.

CONCLUSION

Strictly selected patients with early ampulla of Vater carcinomas may benefit from limited resection if the resected specimen is evaluated to confirm all histopathological criteria.

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.

Endoscopic ultrasound assessment of lesions of the ampulla of Vater is of particular value in low-grade dysplasia

BACKGROUND

The accurate diagnosis of dysplasia or carcinoma within ampullary lesions can be difficult, but, when possible, identifies patients who require endoscopic or surgical resection, respectively. The role of endoscopic ultrasound (EUS) in diagnosing these lesions and the degree of dysplasia is unclear.

METHODS

Patients with lesions of the ampulla were identified over 5 years. Patients who did not undergo EUS were compared with those who did.

RESULTS

A total of 27 of 58 (47%) patients were investigated with EUS. Pretreatment diagnoses were correct in 93% of the EUS group vs. 78% of the no-EUS group. Rates of diagnostic accuracy in low-grade dysplasia (LGD), high-grade dysplasia (HGD) and adenocarcinoma (ADC) were 72%, 20% and 96%, respectively, in the no-EUS group, and 93%, 50% and 100%, respectively, in the EUS group. Every diagnosis of LGD in the EUS group was correct, whereas these diagnoses accounted for the majority of errors (eight of 13) in the no-EUS group. High-grade dysplasia was frequently misdiagnosed. More patients were treated by endoscopic resection in the EUS group (12 of 27 vs. five of 31; P= 0.025).

CONCLUSIONS

Endoscopic ultrasound increases the accuracy of preoperative diagnosis of ampullary lesions and is particularly useful in patients with LGD because it permits safe endoscopic management. Patients with HGD must be reviewed carefully and considered for pancreatoduodenectomy.

Endoscopic diagnosis and management of ampullary lesions

Most (>95%) ampullary lesions are adenomas or adenocarcinomas. Side viewing endoscopy, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are complementary procedures that have an important role in the diagnosis, staging, and treatment of ampullary lesions. Here the authors review their epidemiology and discuss the evidence for endoscopic modalities, with an emphasis on techniques for endoscopic resection. Although endoscopic papillectomy represents one of the highest-risk endoscopic interventions, it has largely replaced surgical modalities for the treatment of adenomatous lesions. Appropriate patient selection and use of preventive maneuvers will minimize the likelihood of persistent or recurrent lesions and postprocedure complications.

Endoscopic ampullectomy: techniques and outcomes

Advances in endoscopic ampullectomy continue to mitigate concerns regarding incomplete removal of ampullary neoplasias, postprocedure complications, and insufficient treatment of tumors with undetected malignant foci or intraductal invasion. Advanced T staging of these lesions with endoscopic ultrasound and intraductal ultrasound, while useful tools for selection of candidates for snare polypectomy, should be limited to lesions either greater than 3 cm, bearing the macroscopic appearance of malignancy or unamenable to endoscopic therapy. Intraductal ultrasound has demonstrated T-staging accuracy superior to endoscopic ultrasound. One prospective study of prophylactic pancreatic stent placement and a number of retrospective studies have reported reduced complication rates. Recent studies continue to propose follow-up endoscopic retrograde cholangiopancreatography at 3-month intervals after ampullectomy to evaluate for recurrence and ablate residual tissue, with the interval increased to 6 to 12 months for 5 years on obtaining negative biopsies for adenomatous tissue. The development of thermal ablation, notably argon plasma coagulation, for fulguration of residual unresectable tumor, biductal sphincterotomy and prophylactic pancreatic pancreatic stent placement, and advanced diagnostic imaging mitigate the concerns leveled against endoscopic ampullectomy. In experienced hands, endoscopic papillectomy of noninvasive, benign ampullary lesions is a safe, technically feasible, and effective alternative to surgical resection. This study will focus on diagnosis and staging of ampullary adenomas and reviews indications for, and outcomes and complications of, endoscopic papillectomy.

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.

Endoscopic diagnosis and treatment of ampullary neoplasm (with video)

BACKGROUND AND AIM

For ampullary cancer, pancreaticoduodenectomy is considered to be the standard treatment. Endoscopic papillectomy (EP) has been utilized in cases of ampullary adenoma since the early 1980s. We aimed to provide a review concerning EP.

METHODS

We conducted a review of studies regarding EP for ampullary neoplasms.

RESULTS

Since neither lymphatic permeation, vascular invasion, nor lymph node metastasis is observed in patients with ampullary cancer limited to the mucosa, EP of such tumors without ductal infiltration into the pancreatic/bile duct can be justified as radical treatment. For its application in patients with ampullary neoplasms, accurate pretreatment staging is indispensable. EUS, which can be carried out on an outpatient basis with a low risk of complications, is useful for differential diagnosis as well as detection of periampullary tumors. Although intraductal US of the bile duct tends to result in overestimation of tumor staging in cases of ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for EP. While the technical success rate of EP is high, the complication rate and recurrence rate are not as low as a satisfactory level. Pancreatic duct stenting after EP is expected to contribute to prevention of post-EP pancreatitis. There is no consensus regarding the mode of resection current nor the need for addition of biliary/pancreatic sphincterotomy and biliary stenting.

CONCLUSIONS

EP has been reported to be useful in selected patients with ampullary neoplasms. Data on further long-term follow up after EP are awaited.

Using multi-detector-row CT to diagnose ampullary adenoma or adenocarcinoma in situ

OBJECTIVE

To assess the diagnostic accuracy of multi-detector-row computed tomography (MDCT) for the detection of ampullary adenomas or adenocarcinomas in situ.

MATERIALS AND METHODS

We retrospectively reviewed 21 computed tomography (CT) images from 20 patients with ampullary tumors, and 22 CT images from 22 patients without periampullary tumor. Three radiologists blindly and independently reviewed CT images. The sensitivities and specificities for identification of ampullary masses were calculated in all cases and in cases with adequate duodenal distension. The sensitivities and specificities for the diagnosis of ampullary tumors were calculated using the following criteria: identification of mass alone; presence of extrahepatic bile duct (EBD) dilation or identification of mass; presence of pancreatic duct (PD) dilation or identification of mass. Paired t-tests were performed to assess differences in mean values.

RESULTS

The mean sensitivity and specificity of MDCT for the detection of an ampullary mass in all cases were 47.6% and 86.4%, and in cases with adequate duodenal distension, 66.7% (p=0.07) and 80.5% (p=0.32), respectively. When the presence of EBD dilation or identification of mass were used as criteria, the mean sensitivity and specificity were 73.0% (p=0.03) and 60.6% (p=0.03), respectively. When presence of PD dilation or identification of mass were used as criteria, the mean sensitivity and specificity were 47.6% and 81.8% (p=0.23).

CONCLUSIONS

MDCT is moderately accurate for the diagnosis of ampullary adenoma or adenocarcinoma in situ. When EBD dilation or identification of mass were used as criteria, the sensitivity can be improved.

Intraductal ultrasonography (IDUS) for the diagnosis of biliopancreatic diseases

Intraductal ultrasonography (IDUS) is an imaging modality having unique characteristics and suitable for imaging of a narrow ductal cavity, its wall and the neighbouring structures. As IDUS uses high-frequency ultrasound (12-30MHz), its image quality is very high within approximately 2-cm range of radius. The bile duct and the pancreatic duct, therefore, are good targets for the assessment by IDUS. Biliopancreatic IDUS is mainly performed through the papilla of Vater in the same session as endoscopic retrograde cholangiopancreatography (ERCP). Biliary IDUS is possible through the percutaneous transhepatic route as well. Not many comparative studies on biliopancreatic IDUS have been published. Gallbladder IDUS as well as most pancreatic IDUS are still at the level of clinical research. Constant delineation of Oddi's sphincter with the improvement of instruments will expand the use of IDUS for the assessment of the papilla of Vater lesions.

Clinical application of intraductal ultrasound during endoscopic retrograde cholangiopancreatography

Intraductal ultrasound (IDUS) used during endoscopic retrograde cholangiopancreatography (ERCP) can facilitate reliable evaluation of biliary and pancreatic disorders. The smaller diameter, flexibility, and the image quality offered by IDUS devices makes them ideal for evaluating a variety of difficult biliary and pancreatic diseases, especially in undefined strictures, luminal filling defects, and ampullary neoplasms. This article examines the numerous possible roles for IDUS in the evaluation of biliary and pancreatic conditions, as well as in ampullary neoplasms. IDUS is a simple, easy to learn, and safe technique that should be considered an integral tool in the therapeutic endoscopist's armamentarium.

[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.

Applicative value of intraductal ultrasonography in the removal of calculus by endoscopic retrograde cholangiopancreatgraphy

AIM: To discuss the value of intraductal ultrasonography (IDUS) in removing calculus by endoscopic retrograde cholangiopan-creatography (ERCP).

METHODS: One hundred patients with suspected extrahepatic bile duct stones were included in this study. ERCP was performed first followed by IDUS through endoscopic working channel to detect extrahepatic bile duct; finally the substance in extrahepatic bile duct was proved by endoscopic sphincterotomy (EST) and stone extraction. For the patients whose calculus was removed by galet basket, IDUS was performed again.

RESULTS: Of the 100 patients, bile duct stones were found in 93 cases, and cancer embolus, floccule, gas and Mirrizzi syndrome were found in 1 case respectively. Three cases were found without stones. Stones of 37 cases were extracted by galet basket and retained stones were found in 3 cases after ERCP. By ERCP, ninety-two cases were diagnosed with bile duct stones, 3 cases suspected, and 5 cases without stones and the final result showed that 3 cases were misdiagnosed. So the accuracy and sensitivity of ERCP were 97% and 94.8% respectively. By IDUS, no misdiagnosis and missing diagnosis occurred. So the accuracy and sensitivity of IDUS in the diagnosis of extrahepatic bile duct stones were 100% and 100% respectively.

CONCLUSION: IDUS can compensate the visual error of ERCP on extrahepatic bile duct stones. IDUS is superior to ERCP in the diagnosis of extrahepatic bile duct stones, especially cholangiectasis and Mirrizzi syndrome. Besides, IDUS can prevent retained stones after ERCP.

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.

Diagnosis of biliary tract and ampullary carcinomas

Diagnostic methods for biliary tract carcinoma and the efficacy of these methods are discussed. Neither definite methods for early diagnosis nor specific markers are available in this disease. When this disease is suspected on the basis of clinical symptoms and risk factors, hemato-biochemical examination and abdominal ultrasonography are performed and, where appropriate, enhanced computed tomography (CT) and/or magnetic resonance cholangiopancreatography (MRCP) is carried out. Diagnoses of extrahepatic bile duct cancer and ampullary carcinoma are often made based on the presence of obstructive jaundice. Although rare, abdominal pain and pyrexia, as well as abnormal findings of the hepatobiliary system detected by hemato-biochemical examination, serve as a clue to making a diagnosis of these diseases. On the other hand, the early diagnosis of gallbladder cancer is scarcely possible on the basis of clinical symptoms, so when this cancer is found with the onset of abdominal pain and jaundice, it is already advanced at the time of detection, thus making a cure difficult. When gallbladder cancer is suspected, enhanced CT is carried out. Multidetector computed tomography (MDCT), in particular — one of the methods of enhanced CT — is useful for decision of surgical criteria, because MDCT shows findings such as localization and extension of the tumor, and the presence or absence of remote metastasis. Procedures such as magnetic resonance imaging, endoscopic ultrasonography, bile duct biopsy, and cholangioscopy should be carried out taking into account indications for these procedures in individual patients. However, direct biliary tract imaging is necessary for making a precise diagnosis of the horizontal extension of bile duct cancer.

Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study

BACKGROUND

Endoscopic papillectomy is performed in selected patients with ampullary neoplasm, and, thus, accurate preoperative tumor staging is indispensable for its application.

DESIGN

Prospective and histopathologically controlled study.

SETTING

Single center.

PATIENTS AND INTERVENTIONS

EUS and transpapillary intraductal US (IDUS) were performed in 40 patients with ampullary neoplasm before surgery (n = 30) or endoscopic papillectomy (n = 10). Ductal infiltration by a tumor into the bile duct (BD) or the pancreatic duct (PD) was also evaluated. The indication for endoscopic papillectomy was determined by findings obtained by EUS and IDUS. These findings were compared with histologic features of the resected specimens.

MAIN OUTCOME MEASUREMENTS AND RESULTS

Thirty-three patients had adenocarcinoma (14 pT1, 11 pT2, 8 pT3-4) and 7 had adenoma. Tumor depiction by EUS and IDUS was achieved in 95% and 100% of the patients, respectively. The diagnostic accuracy of EUS and IDUS in T staging was 62% and 86% in adenoma and pT1, 45% and 64% in pT2, and 88% and 75% in pT3-4, respectively. The overall accuracy by EUS and IDUS in T staging was 63% and 78%, respectively (P = .14). In 10 patients who underwent endoscopic papillectomy, the accuracy of IDUS in T staging with EUS and IDUS was 80% and 100%, respectively. Ductal infiltration into the BD and the PD was correctly assessed in 88% and 90% by EUS and in both BD and the PD in 90% by IDUS, respectively. Ductal infiltration was correctly diagnosed by EUS and IDUS in all patients who had a papillectomy.

CONCLUSION

Although IDUS had a tendency of overestimation in tumor staging for ampullary neoplasm, it can provide useful information for making therapeutic decisions, especially in cases appropriate for endoscopic papillectomy.

State of the art on endoscopic mucosal resection and endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) provide new alternatives for minimally invasive treatment of superficial gastrointestinal malignancies. Evidence suggests that these techniques can be performed safely and have comparable outcomes to surgery with less morbidity and better quality of life due to their tissue-sparing nature when compared with conventional surgery. Although the techniques and accessories have become standardized, there is room for improvement, and further research and development are required. Current challenges facing American gastroenterologists or endoscopic surgeons include access to training and lack of appropriate reimbursement for these heavy-weighted and technically demanding procedures. Nevertheless, EMR and ESD are here to stay and are only the first steps toward true radical endoluminal resection of GI malignancies.