1
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Takada Y, Ishikawa T, Yamao K, Mizutani Y, Iida T, Uetsuki K, Gibo N, Ohno E, Kawashima H. Outcomes of endoscopic papillectomy of ampullary carcinoma and factors affecting additional surgery. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2024; 31:110-119. [PMID: 37811583 DOI: 10.1002/jhbp.1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/21/2023] [Accepted: 09/01/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND/PURPOSE Data on the prognosis of endoscopic papillectomy (EP) for ampullary carcinoma (AC) is limited; therefore, we aimed to identify the factors associated with endoscopically controlled AC. METHODS Between January 2003 and October 2022, 75 patients underwent EP for ampullary tumors and were diagnosed with AC based on the pathological features of the resected tissue. The factors associated with additional surgery after EP were also evaluated. RESULTS A total of 67 patients had ACs ranging from carcinoma in situ to tumors limited to the mucosa (M group), and eight patients had ACs ranging from those limited to the sphincter of Oddi to those invading the duodenal muscularis propria (OD group). The 3-year endoscopic tumor control (condition not requiring additional surgery) rates in the M and OD groups were 90.8% and 84.6% (p = .033), respectively. In the M group, the presence of tumor components in the resection margins was the only significant factor associated with additional surgeries (p = .010) in the univariate analysis. The 3-year endoscopic tumor control rates were 100% for negative and uncertain resection margins and 76.6% for positive margins (p = .009). CONCLUSIONS If the AC is confined to the mucosa and the resection margins are negative or uncertain, the tumor can be well-controlled endoscopically.
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Affiliation(s)
- Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kentaro Yamao
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kota Uetsuki
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Noriaki Gibo
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Japan
| | - Hiroki Kawashima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Maselli R, de Sire R, Fugazza A, Spadaccini M, Colombo M, Capogreco A, Beyna T, Repici A. Updates on the Management of Ampullary Neoplastic Lesions. Diagnostics (Basel) 2023; 13:3138. [PMID: 37835881 PMCID: PMC10572979 DOI: 10.3390/diagnostics13193138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Ampullary neoplastic lesions (ANLs) represent a rare cancer, accounting for about 0.6-0.8% of all gastrointestinal malignancies, and about 6-17% of periampullary tumors. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis (FAP). Usually, noninvasive ANLs are asymptomatic and detected accidentally during esophagogastroduodenoscopy (EGD). When symptomatic, ANLs can manifest differently with jaundice, pain, pancreatitis, cholangitis, and melaena. Endoscopy with a side-viewing duodenoscopy, endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP) play a crucial role in the ANL evaluation, providing an accurate assessment of the size, location, and characteristics of the lesions, including the staging of the depth of tumor invasion into the surrounding tissues and the involvement of local lymph nodes. Endoscopic papillectomy (EP) has been recognized as an effective treatment for ANLs in selected patients, providing an alternative to traditional surgical methods. Originally, EP was recommended for benign lesions and patients unfit for surgery. However, advancements in endoscopic techniques have broadened its indications to comprise early ampullary carcinoma, giant laterally spreading lesions, and ANLs with intraductal extension. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of ampullary neoplastic lesions.
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Affiliation(s)
- Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University Federico II of Naples, 80126 Naples, Italy
| | - Alessandro Fugazza
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Marco Spadaccini
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Matteo Colombo
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus, 40217 Düsseldorf, Germany;
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
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3
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Kwon HJ, Kim SG, Park J. Adenomyoma of the ampulla of Vater mimicking malignancy: A case report and literature review. Medicine (Baltimore) 2023; 102:e34080. [PMID: 37327261 PMCID: PMC10270535 DOI: 10.1097/md.0000000000034080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023] Open
Abstract
RATIONALE Adenomyoma is a rare reactive, hamartomatous benign tumor-like lesion. Although adenomyoma can occur anywhere in the gastrointestinal tract, including the gallbladder, stomach, duodenum, and jejunum, it is very rarely observed in the extrahepatic bile duct and ampulla of Vater (AOV). The preoperative accurate diagnosis of adenomyoma of the Vaterian system, including the AOV and common bile duct, is significant to appropriate patient management. However, discriminating between benign and malignancy is highly challenging. Patients are frequently mistaken as having periampullary malignancy, thereby leading to unnecessary extensive surgical resection with a high risk of complications. PATIENT CONCERNS A 47-year-old woman visited a local hospital owing to epigastric and right upper-quadrant abdominal pain for 2 days. DIAGNOSES Abdominal ultrasonography performed in the local hospital revealed suspicious of a distal common bile duct malignancy. She was transferred to our hospital for further evaluation and management. INTERVENTIONS After consulting with the patient, a multidisciplinary team, including a gastroenterologist, finally decided to perform surgery under the impression of an ampullary malignancy, and pylorus-preserving pancreatoduodenectomy was performed without any complications. She was histopathologically diagnosed with an adenomyoma of the AOV. OUTCOMES At the 5-year follow-up, she was well and did not develop further symptoms or complications. LESSONS Although adenomyoma is very rare, it should be included in the differential diagnosis of mass-like lesions of the AOV to avoid unnecessary surgeries.
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Affiliation(s)
- Hyung Jun Kwon
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Sang Geol Kim
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Jinyoung Park
- Department of Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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4
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Yoon SB, Jung MK, Lee YS, Park JK, Jang DK, Lee JM, Lee HS, Shin DW, Lee JC, Hwang JH. Long-term outcomes of endoscopic papillectomy for ampullary adenoma with high-grade dysplasia or adenocarcinoma: a propensity score-matched analysis. Surg Endosc 2022; 37:3522-3530. [PMID: 36587061 DOI: 10.1007/s00464-022-09856-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 12/27/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND Evidence of endoscopic papillectomy (EP) for ampullar adenoma with high-grade dysplasia (HGD) or adenocarcinoma is insufficient. Here we investigated the long-term outcomes of the advanced ampullary tumors treated by EP with careful surveillance comparing to subsequent surgery after EP. METHODS Patients treated with EP for ampullary adenoma with HGD or adenocarcinoma from the multi-center retrospective Korean cohort of ampulla of Vater tumor were categorized into EP alone versus EP with subsequent surgery groups. The overall survival (OS) and recurrence-free survival (RFS) were analyzed for unmatched and matched cohorts using propensity score with nearest neighbor method. RESULTS During a median 43.3 months of follow-up, 5-year OS was not significantly different between the EP alone and EP surgery groups (91.9% vs. 82.3%, P = 0.443 for unmatched cohort; 89.2% vs. 82.3%, P = 0.861 for matched cohort, respectively). Furthermore, 5-year RFS was not significantly different between the two groups (82.1% vs. 86.7%, P = 0.520 for unmatched cohort; 66.1% vs. 86.7%, P = 0.052 for matched cohort, respectively). However, the patients with positive both (lateral and deep) margins showed significantly poorer survival outcomes than those with negative margins within the EP alone group (P = 0.007). CONCLUSION EP alone with careful surveillance showed comparable survival outcomes to those of EP with subsequent surgery for ampullar HGD or adenocarcinoma. Resection margin status could be a parameter to determine whether to perform subsequent radical surgery after EP.
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Affiliation(s)
- Seung Bae Yoon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Kyu Jung
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Republic of Korea
| | - Yoon Suk Lee
- Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Republic of Korea. .,Division of Gastroenterology, Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Juhwa-ro 170, Ilsan Seogu, Goyang, 10380, South Korea.
| | - Joo Kyung Park
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Seoul Metropolitan Government Boramae Medical Center, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Min Lee
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hee Seung Lee
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Woo Shin
- Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Republic of Korea
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Cho KB. Endoscopic Papillectomy for Ampullary Tumors. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2022. [DOI: 10.7704/kjhugr.2022.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ampullary tumors originate from the ampulla of Vater and are often discovered incidentally during an upper endoscopy. These tumors usually occur sporadically and may be benign or malignant in nature. Tumor growth clinically presents with cholestasis, pancreatitis, and bleeding. Patients with ampullary adenomas are often asymptomatic; however, removal of these lesions is recommended in view of their malignant potential. Following advances in endoscopic techniques and the accumulation of experience, considering high recurrence, mortality, and morbidity rates associated with surgery, endoscopic papillectomy may be useful as first-line treatment for adenomatous lesions with ambiguous malignant changes or focal intraepithelial carcinoma. Although it is relatively safe and easy to perform, the operation is a high-level procedure that may be associated with serious complications. It should be performed by an experienced endoscopist at a well-equipped hospital/center with emergency facilities and support personnel. Accurate resection is associated with high treatment success rates. Most complications are mild and can be treated medically. Pancreatitis is the most common complication, and pancreatic duct stenting is useful for prophylaxis. Recurrence may occur, and is more frequently observed during segmental resection; therefore, close periodic follow-up is essential. Although there are no unified indications or guidelines for endoscopic papillectomy, endoscopic papillectomy may be safe and effective for management of ampullary adenomas. Careful patient selection and follow-up are mandatory.
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6
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Ye X, Wang L, Jin Z. Diagnostic accuracy of endoscopic ultrasound and intraductal ultrasonography for assessment of ampullary tumors: a meta-analysis. Scand J Gastroenterol 2022; 57:1158-1168. [PMID: 35486096 DOI: 10.1080/00365521.2022.2067785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND 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.
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Affiliation(s)
- Xiaohua Ye
- Department of Gastroenterology, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, P.R. China
| | - Lei Wang
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P.R. China
| | - Zhendong Jin
- Department of Gastroenterology, Digestive Endoscopy Center, Changhai Hospital, Naval Medical University, Shanghai, P.R. China
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7
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Maruyama H, Nagami Y, Fujiwara Y. Successful diagnosis using a precutting method for intra-ampullary carcinoma of Vater. Dig Endosc 2022; 34:e94-e95. [PMID: 35581744 DOI: 10.1111/den.14300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/09/2022] [Accepted: 03/16/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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8
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Tan YB, Wang LM, Kwek ABE. Unusual cause of a polypoid lesion in the extrahepatic bile duct. JGH OPEN 2022; 6:282-284. [PMID: 35475206 PMCID: PMC9021710 DOI: 10.1002/jgh3.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 03/29/2022] [Indexed: 11/19/2022]
Abstract
Adenomyomas are benign lesions that are most frequently found in the gallbladder but can also be rarely found in the biliary tract. Although benign, they present close similarity to malignant lesions and thus deserve important clinical consideration. We present a case of a 74‐year‐old Chinese man who presented acutely with fever and painless obstructive jaundice. CT imaging showed a large calculus within a dilated common bile duct (CBD) and, despite undergoing an endoscopic retrograde cholangiopancreatography (ERCP) with stone clearance, there was a persistent filling defect that was adherent to the wall of the proximal common bile duct. His CA 19–9 was also significantly raised. Intraductal ultrasonography (IDUS) showed a polypoid mass with papillary‐like projections, and ERCP forcep biopsies were unable to exclude a lesion with neoplastic potential. The patient subsequently underwent cholecystectomy with open CBD excision and Roux‐en‐Y hepaticojejunostomy, and histology showed features consistent with a biliary adenomyoma.
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Affiliation(s)
- Yu Bin Tan
- Department of Gastroenterology Changi General Hospital Singapore
| | - Lai Mun Wang
- Pathology Section, Department of Laboratory Medicine Changi General Hospital Singapore
| | - Andrew B E Kwek
- Department of Gastroenterology Changi General Hospital Singapore
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9
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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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10
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Park Y, Lee J, Kim Y, Cho BS, Park KS, Woo CG. Differentiation of Adenomyoma from Localized Adenocarcinoma of the Ampulla of Vater Using Multidetector CT. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:393-405. [PMID: 36238730 PMCID: PMC9431932 DOI: 10.3348/jksr.2020.0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/25/2020] [Accepted: 06/11/2020] [Indexed: 11/30/2022]
Abstract
Purpose To determine the multidetector CT (MDCT) findings that differentiate adenomyoma of the ampulla of Vater (AOV) from localized adenocarcinoma of the AOV. Materials and Methods Sixteen and 30 patients with adenomyoma and localized adenocarcinoma of the AOV, respectively, were evaluated using MDCT. We analyzed the size and attenuation value and presence of uniform enhancement of the lesions, diameters of the extrahepatic bile duct (EHD) and main pancreatic duct, presence of regional lymph node enlargement, and laboratory findings. We determined the independent findings for differentiating adenomyoma from localized adenocarcinoma of the AOV using multivariate analysis. Results The size of the lesion and diameter of the EHD were significantly smaller for adenomyoma than those for localized adenocarcinoma of the AOV (all p < 0.001). In multivariate analyses, a lesion size of ≤ 1.3 cm, an EHD diameter of ≤ 1.3 cm, and an alanine transaminase level of ≤ 31 IU/L significantly differentiated adenomyoma from localized adenocarcinoma of the AOV. When all of these three findings were met, the specificity for adenomyoma of the AOV was 93.3%. Conclusion MDCT imaging may facilitate the differential diagnosis of adenomyoma and localized adenocarcinoma of the AOV based on the size of the lesion and diameter of the EHD.
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11
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Gambitta P, Aseni P, Villa F, Fontana P, Armellino A, Vertemati M. Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis. Surg Laparosc Endosc Percutan Tech 2021; 31:462-467. [PMID: 33538546 DOI: 10.1097/sle.0000000000000909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis. MATERIALS AND METHODS Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed. RESULTS Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA. CONCLUSIONS EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benign-appearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.
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Affiliation(s)
- Pietro Gambitta
- Gastroenterology Division, Legnano Hospital, ASST Ovest Milanese, Legnano
| | - Paolo Aseni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda
- Department of Biomedical and Clinical Sciences "L. Sacco," Università degli Studi di Milano, Milan
| | - Federica Villa
- Gastroenterology Division, Legnano Hospital, ASST Ovest Milanese, Legnano
| | - Paola Fontana
- Gastroenterology Division, Legnano Hospital, ASST Ovest Milanese, Legnano
| | - Antonio Armellino
- Endoscopy Division, Ospedale San Leopoldo Mandic di Merate, ASST Lecco, Lecco, Italy
| | - Maurizio Vertemati
- Department of Biomedical and Clinical Sciences "L. Sacco," Università degli Studi di Milano, Milan
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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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Gouveia C, Fidalgo C, Loureiro R, Oliveira H, Maio R, Cravo M. Adenomyomatosis of the Common Bile Duct and Ampulla of Vater. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:121-133. [PMID: 33791399 DOI: 10.1159/000507788] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/06/2020] [Indexed: 01/03/2023]
Abstract
Adenomyomatosis is a rare benign lesion that has been observed in different sites throughout the gastrointestinal tract, most frequently in the gallbladder. Few cases have been described in the stomach, small bowel, bile ducts, and ampullary region. Adenomyomas of the vaterian system (ampulla and common bile duct) have important clinical consequences, since the majority of these lesions present with biliary tract obstruction and mimic malignant behavior. As a consequence, considering the diagnostic difficulty of these lesions, patients are often treated with extensive surgery (pancreaticoduodenectomy). We report 2 cases of adenomyomatosis: one of the ampulla of Vater and the other of the common bile duct, as well as a review of reported cases in the literature. Both of our patients presented with epigastralgia and had laboratory or endoscopic evidence of biliary obstruction. Both patients underwent endoscopic ultrasound, one of them with fine-needle aspiration; however, it was not possible to exclude the possibility of cancer. The diagnosis of adenomyoma was only confirmed by the surgical specimen after pancreaticoduodenectomy.
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Affiliation(s)
- Catarina Gouveia
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Catarina Fidalgo
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Rui Loureiro
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Helena Oliveira
- Pathology Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Rui Maio
- General Surgery Department, Beatriz Ângelo Hospital, Loures, Portugal
| | - Marília Cravo
- Gastroenterology Department, Beatriz Ângelo Hospital, Loures, Portugal
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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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Endoscopic ampullectomy for non-invasive ampullary lesions: a single-center 10-year retrospective cohort study. Surg Endosc 2020; 35:684-692. [PMID: 32215745 DOI: 10.1007/s00464-020-07433-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Accepted: 02/10/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Lesions involving the ampulla of Vater have traditionally been managed by surgical resection, albeit with high rates of morbidity and mortality. Endoscopic ampullectomy is increasingly recognized as an efficacious and safer treatment option. This study aims to evaluate the safety and efficacy of endoscopic ampullectomy for non-invasive ampullary lesions in a single tertiary referral center. METHODS Patients with non-invasive ampullary lesions, with or without familial adenomatous polyposis (FAP), were identified using pathology and endoscopy databases. The study included all patients who underwent the index ampullectomy between January 2007 and January 2017. Outcome parameters included accuracy of forceps biopsies, adverse events, success of endoscopic resection, and rate of recurrence. RESULTS A total of 53 patients underwent endoscopic ampullectomy over the 10-year period. Histological upstaging was seen in 37.8% of cases at ampullectomy compared to biopsy, including 5 cases (9.4%) of invasive adenocarcinoma. Adverse events occurred in 10 patients (18.9%) consisting of bleeding (11.3%), benign papillary stenosis (3.8%), acute pancreatitis (1.9%), and duodenal perforation (1.9%). Recurrence occurred in 32.7% over a median follow-up of 30 months (range 6-104 months), with the majority (18.4%) occurring at the first surveillance endoscopy. Nonetheless, 75% of recurrences were able to be cleared endoscopically. Endoscopic resection was successful in 91.1% of patients. CONCLUSIONS Endoscopic ampullectomy is an effective and safer therapeutic modality for non-invasive ampullary lesions, in addition to being a valuable diagnostic and staging tool. Nevertheless, careful patient selection and a commitment to endoscopic follow-up are of primary importance to achieve an optimal therapeutic outcome.
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Kim NH, Kim HJ. Unsolved problems in endoscopic papillectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nam Hee Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Joo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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17
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Xu LM, Hu DM, Tang W, Wei SH, Chen W, Chen GQ. Adenomyoma of the distal common bile duct demonstrated by endoscopic ultrasound: A case report and review of the literature. World J Clin Cases 2019. [DOI: 10.12998/wjcc.v7.i21.3598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Xu LM, Hu DM, Tang W, Wei SH, Chen W, Chen GQ. Adenomyoma of the distal common bile duct demonstrated by endoscopic ultrasound: A case report and review of the literature. World J Clin Cases 2019; 7:3615-3621. [PMID: 31750345 PMCID: PMC6854403 DOI: 10.12998/wjcc.v7.i21.3615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/20/2019] [Accepted: 10/05/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Adenomyomatous hyperplasia of the distal common bile duct (CBD) is very rare, with only scarce case reports in the literature. Diagnosis is usually based on imaging findings, and endoscopic biopsy is very difficult before operation. It is believed that adenomyomatous hyperplasia has little or no risk of malignant transformation.
CASE SUMMARY A 68-year-old woman with abdominal pain in the right upper quadrant was referred to our hospital. Abdominal ultrasonography in the emergency ward revealed acute cholecystitis and dilated CBD. Laboratory findings showed elevated levels of transaminases, phosphatase, and γ-glutamyltranspeptidase. Pharmaceutical treatment for 3 d did not relieve the symptoms. Magnetic resonance cholangiopancreatography (MRCP) and computed tomography (CT) showed proximal bile duct dilatation but could not identify the cause. Endoscopic ultrasonography (EUS) demonstrated a mixed echogenic mass in the distal CBD. During surgery, a firm mass was found in the distal CBD and the Whipple procedure was performed with the initial concern of malignancy. Histology showed diffuse adenomyomatous hyperplasia.
CONCLUSION EUS may be a useful choice to diagnose adenomyoma of the distal CBD before operation, especially in patients with ambiguous MRCP/CT findings.
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Affiliation(s)
- Li-Ming Xu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Duan-Min Hu
- Department of Gastroenterology, The Second Affiliated Hospital of Soochow University, Suzhou 215004, Jiangsu Province, China
| | - Wen Tang
- Endoscopy Center, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Shao-Hua Wei
- Department of Hepatological Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Wei Chen
- Department of Hepatological Surgery, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
| | - Guang-Qiang Chen
- Imaging Department, The Second Affiliated Hospital of Soochow University, Suzhou 215000, Jiangsu Province, China
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Kawashima Y, Ogawa M, Yamaji Y, Kodama T, Yokota M, Kawanishi A, Hirabayashi K, Mine T. A Case of Endoscopic Mucosal Resection of Carcinoma in Adenoma at the Minor Duodenal Papilla. Case Rep Oncol 2019; 12:354-363. [PMID: 31182951 PMCID: PMC6547284 DOI: 10.1159/000499968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 03/26/2019] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Yohei Kawashima
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Masami Ogawa
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Yoko Yamaji
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Toshiki Kodama
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Masashi Yokota
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Aya Kawanishi
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
| | - Kenichi Hirabayashi
- Department of Pathology, Tokai University School of Medicine, Isehara, Japan
| | - Tetsuya Mine
- Department of Gastroenterology, Tokai University School of Medicine, Isehara, Japan
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Moura DTH, de Moura EGH, Matuguma SE, dos Santos ME, Moura ETH, Baracat FI, Artifon ELA, Cheng S, Bernardo WM, Chacon D, Tanigawa R, Jukemura J. EUS-FNA versus ERCP for tissue diagnosis of suspect malignant biliary strictures: a prospective comparative study. Endosc Int Open 2018; 6:E769-E777. [PMID: 29876515 PMCID: PMC5988546 DOI: 10.1055/s-0043-123186] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 10/27/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Biliary strictures are frequently a challenging clinical scenario and the anatomopathological diagnosis is essential in the therapeutic management, whether for curative or palliative purposes. The acquisition of specimens is necessary since many benign diseases mimic biliopancreatic neoplasms. Endscopic retrograde cholangiopancreatography (ERCP) is the traditionally used method despite the low sensitivity of biliary brush cytology and forceps biopsy. On the other hand, several studies reported good accuracy rates using endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). The aim of this prospective study was to compare, the accuracy of EUS-FNA and ERCP for tissue sampling of biliary strictures. PATIENTS AND METHODS After performing the sample size calculation, 50 consecutive patients with indeterminate biliary strictures were included to undergo ERCP and EUS on the same sedation.The gold-standard was surgery or 6 months' follow-up. Evaluation of the diagnostic indices (sensitivity, specificity, positive and negative predictive value, positive and negative likelihood ratio), concordance and adverse events among the methods were performed. Also, subtype analyses of the techniques, anatomical localization and size of the lesion were included. RESULTS The final diagnoses reported in 50 patients were 47 malignant, 1 suspicious and 2 benign lesions. 31 lesions were extraductal and 19 intraductal, 35 were distal and 15 proximal strictures. In the intention-to-treat analysis, the sensitivity and accuracy of EUS-FNA were superior than ERCP tissue sampling (93,8 %, 94 % vs. 60,4 %, 62 %, respectively) ( P = 0.034), with similar adverse events. There was no concordance between the methods and combining both methods improved the sensitivity and accuracy for 97.9 % and 98 %, respectively. In the subtype analyses, the EUS-FNA was superior, with a higher accuracy than ERCP tissue sampling in evaluating extraductal lesions (100 % vs. 54.8 %, P = 0.019) and in those larger than 1.5 cm (95.8 % vs. 61.9 %, P = 0.031), but were similar in evaluating intraductal lesions and lesions smaller than 1.5 cm. There was no significant difference between the methods in the analyzes of proximal, distal and pancreatic lesions. CONCLUSION EUS-FNA is better than ERCP with brush cytology and intraductal forceps biopsy in diagnosing malignant biliary strictures, mainly in the assessment of extraductal lesions and in those larger than 1.5 cm. Combining ERCP with tissue sampling and EUS-FNA is feasible, the techniques have similar complication rates, and the combination greatly improves diagnostic accuracy.
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Affiliation(s)
- Diogo Turiani Hourneaux Moura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil,Corresponding author Diogo Turiani Hourneaux Moura Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy UnitRua Ana Vieira de Carvalho, 362casa 15 São PauloSão Paulo 05679065Brazil+55-113-885-7981
| | | | - Sergio Eiji Matuguma
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Marcos Eduardo dos Santos
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Eduardo Turiani Hourneaux Moura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Felipe Iankelevich Baracat
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Everson LA Artifon
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Spencer Cheng
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Wanderley Marque Bernardo
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Danielle Chacon
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - Ryan Tanigawa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
| | - José Jukemura
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – Gastrointestinal Endoscopy Unit, São Paulo, Brazil
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21
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Klein A, Tutticci N, Bourke MJ. Endoscopic resection of advanced and laterally spreading duodenal papillary tumors. Dig Endosc 2016; 28:121-30. [PMID: 26573214 DOI: 10.1111/den.12574] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Revised: 11/08/2015] [Accepted: 11/11/2015] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Amir Klein
- Department of Gastroenterology and Hepatology, Westmead Hospital
| | | | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital.,University of Sydney, Sydney, Australia
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22
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Pittayanon R, Rerknimitr R, Imraporn B, Wisedopas N, Kullavanijaya P. Diagnostic values of dual focus narrow band imaging and probe-based confocal laser endomicroscopy in FAP-related duodenal adenoma. Endosc Int Open 2015; 3:E450-5. [PMID: 26528500 PMCID: PMC4612245 DOI: 10.1055/s-0034-1392235] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 04/16/2015] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Familial adenomatous polyposis (FAP) is associated with an increased risk of development of periampullary and nonampullary adenoma. Either routine biopsy or endoscopic removal of the lesion is generally required to identify the presence of adenoma. Because the risk of tissue sampling from the ampulla is high and nonampullary polyps are sometimes numerous, resection of all the lesions is time-consuming. This study aimed to evaluate the diagnostic values of duodenal adenoma by dual focus NBI (dNBI) and probe-based confocal endomicroscopy (pCLE) in FAP patients. PATIENTS AND METHODS The authors conducted a diagnostic study in a single tertiary-care referral center. Surveillance esophagogastroduodenoscopy with dNBI and pCLE was performed on 26 patients with FAP for real-time adenoma diagnosis by two different endoscopists; one used dNBI and the other pCLE. Histology from the matched lesion was used as the gold standard. RESULTS A total of 55 matched biopsies (25 ampullas, 30 nonampullas) were performed. The sensitivity, specificity, post predictive value (PPV), negative predictive value (NPV), and accuracy of dNBI vs. pCLE from all duodenal lesions were 96.9 % vs. 93.8 %, 78.3 % vs. 81 %, 86.1 % vs. 88.2 %, 94.7 vs. 89.5 %, and 92.4 % vs. 88.6 %, respectively. CONCLUSIONS For surveillance of periampullary and nonampullary adenoma in patients with FAP, the real-time readings provided a high degree of diagnostic value when histology was used as the gold standard. ( CLINICAL TRIAL REGISTRATION NUMBER NCT02162173).
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross Society, Bangkok, 10330, Thailand.,Corresponding author Rapat Pittayanon, M.D Division of GastroenterologyDepartment of Internal MedicineFaculty of MedicineChulalongkorn UniversityBangkok 10330Thailand66-2-252-7839
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross Society, Bangkok, 10330, Thailand.
| | - Boonlert Imraporn
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross Society, Bangkok, 10330, Thailand.
| | - Naruemon Wisedopas
- Department of Pathology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Pinit Kullavanijaya
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital The Thai Red Cross Society, Bangkok, 10330, Thailand.
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23
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Lee HS, Jang JS, Lee S, Yeon MH, Kim KB, Park JG, Lee JY, Kim MJ, Han JH, Sung R, Park SM. Diagnostic Accuracy of the Initial Endoscopy for Ampullary Tumors. Clin Endosc 2015; 48:239-46. [PMID: 26064825 PMCID: PMC4461669 DOI: 10.5946/ce.2015.48.3.239] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 12/30/2022] Open
Abstract
Background/Aims Ampullary tumors come in a wide variety of malignant forms. We evaluated the diagnostic accuracy of endoscopy for ampullary tumors, and analyzed the causes of misdiagnosis. Methods We compared endoscopic imaging and biopsy results to final diagnoses. Types of endoscope, numbers of biopsy specimens taken, and final diagnoses were evaluated as possible factors influencing diagnostic accuracy. Results Final diagnoses were 19 adenocarcinomas, 18 normal or papillitis, 11 adenomas, two adenomyomas, one paraganglioma, and one neuroendocrine tumor. The diagnostic accuracy of endoscopic imaging or the initial biopsy was identical (67.3%). At least one test was concordant with the final diagnosis in all except two cases. Compared with the final diagnosis, endoscopic imaging tended to show more advanced tumors, whereas the initial biopsy revealed less advanced lesions. The diagnostic accuracy of the initial biopsy was influenced by the type of endoscope used and the final diagnosis, but not by the number of biopsies taken. Conclusions Endoscopy has limited accuracy in the diagnosis of ampullary tumors. However, most cases with concordant endoscopic imaging and biopsy results are identical to the final diagnosis. Therefore, in cases where both of these tests disagree, re-evaluation with a side-viewing endoscope after resolution of papillitis is required.
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Affiliation(s)
- Hee Seung Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jong Soon Jang
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seungho Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Myeong Ho Yeon
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Ki Bae Kim
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Jae Geun Park
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joo Young Lee
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Mi Jin Kim
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Rohyun Sung
- Department of Pathology, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Seon Mee Park
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju, Korea
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Ahmad SR, Adler DG. Cancer of the ampulla of vater: current evaluation and therapy. Hosp Pract (1995) 2015; 42:45-61. [PMID: 25485917 DOI: 10.3810/hp.2014.12.1158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Sarah R Ahmad
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, UT
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25
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Choi YH, Kim MJ, Han JH, Yoon SM, Chae HB, Youn SJ, Kang MH, Sung R, Choi JW, Park SM. Clinical, pathological, and immunohistochemical features of adenomyoma in the ampulla of vater. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 62:352-8. [PMID: 24365734 DOI: 10.4166/kjg.2013.62.6.352] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND/AIMS Ampullary adenomyoma is a benign lesion whose malignant potential has yet to be confirmed. Despite its benign nature, adenomyoma is frequently misdiagnosed as a carcinoma or adenoma and is overtreated by extensive surgery. This study was performed to analyze the clinical, pathological, and immunohistochemical features of adenomyomas in the ampulla of Vater. METHODS Nine cases of adenomyoma in the ampulla of Vater, diagnosed in Chungbuk National University Hospital between 2008 and 2011, were enrolled in this study. We reviewed the clinical data on the symptoms, laboratory data, and radiologic findings of the abdominal computed tomography and endoscopic retrograde cholangiopancreatography. For pathological analysis, all the slides were reviewed by one pathologist, and immunohistochemical stainings with antibodies against cytokeratin 7 (CK7), cytokeratin 20 (CK20), α-smooth muscle actin (α-SMA), and Ki-67 antigen were performed. RESULTS All the cases were CK7 positive and CK20 negative. A strong cytoplasmic expression of α-SMA was confirmed in all cases. The Ki-67 index was less than 1% in eight cases and 5% in one case. Four cases underwent endoscopic papillectomy, and one case received surgical ampullectomy during colorectal cancer surgery. Five cases that underwent endoscopic or surgical treatment remained symptom-free for three years. Four cases that were closely observed with repeated endoscopic examinations exhibited no interval changes in the papillary lesions. CONCLUSIONS Endoscopic biopsy and immunohistochemistry can aid in the diagnosis of ampullary adenomyomas. Endoscopic papillectomy or surgical ampullectomy is adequate for the treatment of symptomatic ampullary adenomyomas.
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Affiliation(s)
- Yong Hyeok Choi
- Department of Internal Medicine, Chungbuk National University College of Medicine, 52 Naesudong-ro, Heungdeok-gu, Cheongju 361-711, Korea
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Ogura T, Hara K, Hijioka S, Mizuno N, Imaoka H, Niwa Y, Tajika M, Kondo S, Tanaka T, Shimizu Y, Hosoda W, Yatabe Y, Bhatia V, Higuchi K, Yamao K. Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for tumors of the ampulla of vater? -an initial study. Endosc Ultrasound 2014; 1:84-9. [PMID: 24949343 PMCID: PMC4062218 DOI: 10.7178/eus.02.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 06/28/2012] [Indexed: 12/11/2022] Open
Abstract
Objective: No previous studies have described endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) only for intra-ampullary lesions of the papilla of Vater. We aimed to examine whether EUS-FNA can be used to diagnose such lesions. Methods: This study included a subset of 10 consecutive patients in whom EUS-FNA targeted the ampulla of Vater. All the patients underwent biopsy and/or brushing cytology under endoscopic retrograde cholangiopancreatography (ERCP) prior to EUS-FNA. The final diagnosis was based on pathological examinations of specimens obtained by surgical resection or clinical follow-up more than 1 year in case of evidence of benign lesions. Results: Tissues from the ampulla of Vater could be obtained by EUS-FNA for all 10 patients. The final diagnosis was papillitis (n = 7) and intra-ampullary carcinoma (n = 3). Carcinoma of the ampulla of Vater showed neither exposure on the duodenal mucosal surface nor invasion to the pancreas. The diagnostic accuracy of surface biopsy with duodenoscopy, and intra-ampullary biopsy and/or brush cytology with ERCP and/or intra-ampullary biopsy after endoscopic sphincterotomy (EST) in distinguishing between benign and malignancy was 70%. The diagnostic accuracy of EUS-FNA was 100%. No complications associated with EUS-FNA were encountered in this study. Conclusion: EUS-FNA for ampulla of Vater may be safely and accurately performed, and should be considered as a diagnostic modality before EST.
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Affiliation(s)
- Takeshi Ogura
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan ; 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kazuo Hara
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Susumu Hijioka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Nobumasa Mizuno
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Hiroshi Imaoka
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasumasa Niwa
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Masahiro Tajika
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Shinya Kondo
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tsutomu Tanaka
- Department of Endoscopy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasuhiro Shimizu
- Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Waki Hosoda
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yasushi Yatabe
- Department of Pathology and Molecular Diagnostics, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Vikram Bhatia
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), Delhi, India
| | - Kazuhide Higuchi
- 2nd Department of Internal Medicine, Osaka Medical College, Osaka, Japan
| | - Kenji Yamao
- Department of Gastroenterology, Aichi Cancer Center Hospital, Nagoya, Japan
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Pittayanon R, Imraporn B, Rerknimitr R, Kullavanijaya P. Advances in diagnostic endoscopy for duodenal, including ampullary, adenoma. Dig Endosc 2014; 26 Suppl 2:10-5. [PMID: 24750142 DOI: 10.1111/den.12244] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Accepted: 01/08/2014] [Indexed: 12/12/2022]
Abstract
Currently, the strategy for real-time endoscopic diagnosis of duodenal, including ampullary, adenoma is still unclear. In the era of high-definition and magnification endoscopy, using this modality for the detection and diagnosis of these neoplasms is very challenging for endoscopists. Over the past 10 years, many instruments have been developed to improve the detection rate of duodenal and ampullary polyps and to distinguish between adenoma and non-adenoma. The present review will focus on these novel methods and their usefulness in the diagnosis of ampullary and non-ampullary adenoma.
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Palma GDD. Endoscopic papillectomy: Indications, techniques, and results. World J Gastroenterol 2014; 20:1537-1543. [PMID: 24587629 PMCID: PMC3925862 DOI: 10.3748/wjg.v20.i6.1537] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
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.
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Kim HJ, Kim JS. [Necessity of histologic confirmation for adequate management in ampullary tumors]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2014; 62:315-6. [PMID: 24505821 DOI: 10.4166/kjg.2013.62.6.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Soni RC, Puri AS, Garg V, Sachdeva S, Banka A, Tyagi P, Saran RK. Comparative yield of fine needle aspiration cytology, ampullary biopsy, and needle knife assisted biopsy in the diagnosis of nonulcerated periampullary tumors. Indian J Gastroenterol 2013; 32:258-61. [PMID: 23700137 DOI: 10.1007/s12664-013-0333-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 04/12/2013] [Indexed: 02/04/2023]
Abstract
AIM Periampullary tumors (PAT) are defined as tumors arising within 2 cm of the major duodenal papilla. Studies on yield of preoperative biopsy for nonulcerated PAT are scarce. Needle knife papillotomy-assisted biopsy (NKAB) may sample the deeper tissues and thereby increase the histologic yield. We aimed to compare the diagnostic yield of fine needle aspiration cytology (FNAC), surface ampullary biopsy, and NKAB in nonulcerated PAT. METHODS Patients with suspected PAT based on clinical, biochemical, and radiologic investigations were evaluated. Patients with smooth ampullary bulge on side viewing endoscopy (SVE) were included, while those with gastric outlet obstruction or obvious ulceration of ampulla on SVE were excluded. RESULTS Twenty-five of 78 patients with PAT met the inclusion criteria. The median (range) age was 60 (43-75) years, and 13 were male. Serum CA 19.9 was 466 (2-9372) U/mL. Histopathological positivity rate for surface biopsy, FNAC, and NKAB was 10 (40 % and 95 % CI: 21.8 % to 61.1 %), 12 (48 % and 95 % CI: 28.3 % to 68.2 %), and 21 (84 % and 95 % CI: 63.1 % to 94.7 %), respectively. Diagnostic yield of NKAB was significantly better than surface biopsy (p = 0.001) and FNAC (p = 0.007). None of the patients subjected to NKAB had any complications other than self-limited minor ooze. CONCLUSION NKAB was superior to surface biopsy or FNAC to establish preoperative tissue diagnosis of nonulcerated PAT. NKAB is safe and simple in expert hands and may be recommended as standard procedure to obtain histological specimen in these patients.
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Affiliation(s)
- Ram Chandra Soni
- Department of Gastroenterology, G B Pant Hospital, J L Nehru Marg, New Delhi 110 002, India
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Kim HK, Lo SK. Endoscopic approach to the patient with benign or malignant ampullary lesions. Gastrointest Endosc Clin N Am 2013; 23:347-83. [PMID: 23540965 DOI: 10.1016/j.giec.2013.01.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Hyung-Keun Kim
- Division of Gastroenterology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Uijeongbu St. Mary's Hospital, Guemo-dong, Uijeongbu, Republic of Korea
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Ampullectomy for an unexpected ampullary hamartoma in a heterotaxic patient. Int J Surg Case Rep 2013; 4:544-6. [PMID: 23608516 DOI: 10.1016/j.ijscr.2013.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Heterotaxy designates rare congenital disorders of organ positioning in the thoracic and abdominal cavities, which can be associated with numerous anomalies, complicating the surgical management because of the loss of conventional anatomic landmarks. PRESENTATION OF CASE A 72-year-old man was found to have asymptomatic cholestasis. Further workup included computed tomography and magnetic resonance cholangiopancreatography that revealed anomalies of lateralization of digestive organs associated with intestinal malrotation and polysplenia, and a stone-like element in the main bile duct. Endoscopic retrograde cholangiopancreatography failed to extract the lesion. Laparotomy found no stone, but a polypoid tumor with ampullary implantation. Pancreaticoduodenectomy was judged unreasonable due to the presence of macroscopic cirrhosis and a complete ampullectomy was performed. Histopathological examination revealed a hamartomatous polyp. DISCUSSION The unusual angle of the duodenoscope in a left-sided duodenum may have contributed to the improper pre-operative diagnosis. Endosonography could have recognized the tissular origin of the lesion and prompted a more detailed preoperative planning. It was fortunate that the patient ended up receiving the appropriate treatment despite the absence of an adequate pre-operative diagnosis, as the option of performing an extended resection was ruled out due to the presence of cirrhosis. CONCLUSION Although heterotaxy leads to increased technical difficulties in performing usual endoscopic and surgical procedures, it can be safely managed by experienced surgeons as illustrated by the present case. Imaging modalities have limited sensitivity in the diagnosis of small ampullary tumors. As false-negatives are likely to occur, this possibility should guide the choice of the best operation.
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Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg 2013; 257:315-22. [PMID: 23059497 DOI: 10.1097/sla.0b013e318269d010] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). BACKGROUND The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. METHODS Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. RESULTS After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. CONCLUSIONS In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.
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Anderson MA, Appalaneni V, Ben-Menachem T, Decker GA, Early DS, Evans JA, Fanelli RD, Fisher DA, Fisher LR, Fukami N, Hwang JH, Ikenberry SO, Jain R, Jue TL, Khan K, Krinsky ML, Malpas PM, Maple JT, Sharaf RN, Shergill AK, Dominitz JA, Cash BD. The role of endoscopy in the evaluation and treatment of patients with biliary neoplasia. Gastrointest Endosc 2013; 77:167-74. [PMID: 23219047 DOI: 10.1016/j.gie.2012.09.029] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 09/20/2012] [Indexed: 02/08/2023]
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Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: The expanding role of endoscopy. World J Gastrointest Endosc 2011; 3:241-7. [PMID: 22195233 PMCID: PMC3244941 DOI: 10.4253/wjge.v3.i12.241] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 08/21/2011] [Accepted: 08/28/2011] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Payam Chini
- Payam Chini, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, FL 32610, United States
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Noor MT, Vaiphei K, Nagi B, Singh K, Kochhar R. Role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma. World J Gastrointest Endosc 2011; 3:220-4. [PMID: 22110838 PMCID: PMC3221954 DOI: 10.4253/wjge.v3.i11.220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 09/23/2011] [Accepted: 10/18/2011] [Indexed: 02/05/2023] Open
Abstract
AIM: To study the role of needle knife assisted ampullary biopsy in the diagnosis of periampullary carcinoma.
METHODS: In this study the authors retrospectively analyzed clinical records of patients with periampullary tumors diagnosed by ampullary biopsy taken after needle knife papillotomy in whom surface ampullary biopsies were non contributory.
RESULTS: Between January 2008 and December 2010, 38 patients with periampullary tumors were seen by us and initial side viewing endoscopy with surface biopsy from the papilla was positive for malignancy in 25 patients. Thirteen patients with a negative surface biopsy for malignancy underwent a repeat ampullary biopsy following needle knife papillotomy. There were 8 (61.5%) males and 5 (38.5%) females. The most common presenting symptom was jaundice (100%), followed by fever (46.2%), melena (38.5%), abdominal pain (30.8%) and weight loss (30.8%). All the patients had hyperbilirubinemia with a mean ± SD serum bilirubin of (11.2 ± 1.9) mg/dL (normal value < 1 mg%) and the mean ± SD serum alkaline phosphatase was (288.0 ± 94.3) IU/L (normal value < 129 IU/L). Serum CA 19.9 level estimation was done in 11 patients; it was elevated (cut off value > 70.5 IU/L) in all of them with a median of 1200 IU/L (inter quartile range 274-3500). Side viewing endoscopy showed a bulky papilla in all of them. Adequate tissue was obtained in all of the 13 patients for histological evaluation; 12 of the 13 patients were reported to have adenocarcinoma while one patient had adenoma. There were no complications from the needle knife papillotomy in any of the patients.
CONCLUSION: Needle knife assisted ampullary biopsy appears to be a safe and effective diagnostic modality for periampullary carcinoma.
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Affiliation(s)
- Mohd Talha Noor
- Mohd Talha Noor, Kim Vaiphei, Birinder Nagi, Kartar Singh, Rakesh Kochhar, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
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Harano M, Ryozawa S, Iwano H, Taba K, Sen-Yo M, Sakaida I. Clinical impact of endoscopic papillectomy for benign-malignant borderline lesions of the major duodenal papilla. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2011; 18:190-4. [PMID: 20853010 DOI: 10.1007/s00534-010-0327-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The present study retrospectively analyzed the clinical impact of endoscopic papillectomy on the selection of a treatment strategy for patients with benign-malignant borderline lesions of the major duodenal papilla. PATIENTS AND METHODS Between November 1995 and July 2009, 28 patients were selected for endoscopic papillectomy. The clinical impact of endoscopic papillectomy was assessed. Snare resection was performed in a radical fashion. RESULTS An endoscopic papillectomy was technically feasible in all patients. En bloc excision was achieved in 22 cases (79%). The final histopathological diagnoses of the endoscopic specimen were 17 adenoma (61%), 7 carcinoma in adenoma (25%), and 4 adenocarcinoma (14%). Two out of the four adenocarcinoma cases were referred for surgery. The other two patients with negative margins have not experienced recurrences during the follow-up period. A residual tumor was detected in 1 out of 17 cases (6%) of adenoma and 2 out of 7 cases (29%) of carcinoma in adenoma. CONCLUSIONS Endoscopic papillectomy is therefore considered to be an effective treatment for patients with a benign-malignant borderline lesion of the major duodenal papilla. This method also has an important clinical impact because it provides an accurate diagnosis, aids in the selection of an appropriate treatment strategy, and reduces unnecessary surgery.
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Affiliation(s)
- Megumi Harano
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan
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Bellizzi AM, Kahaleh M, Stelow EB. The assessment of specimens procured by endoscopic ampullectomy. Am J Clin Pathol 2009; 132:506-13. [PMID: 19762527 DOI: 10.1309/ajcpuzwj8wa2ihbg] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endoscopic ampullectomy (EA) is increasingly used in the management of ampullary neoplasia. Although studies on the safety and efficacy of this procedure exist, no study has specifically addressed the histopathologic features of the specimens. We review our experience with 45 EA specimens assessed for the following: diagnosis, high-grade dysplasia (HGD), submucosal ampullary gland/ductule involvement, specimen integrity, and margin status. Familial adenomatous polyposis (FAP) status and the endoscopist's impression of completeness of removal were also ascertained. Previous biopsy diagnoses were compared with ampullectomy diagnoses, and histologic and clinical features were correlated with disease persistence. The histologic features of the ampullectomy specimens were as follows: diagnosis (no diagnostic abnormality, 3; reactive, 8; adenoma, 26; adenocarcinoma, 7; other, 1); HGD, 1; submucosal ampullary gland/ductule involvement, 20; specimen integrity (intact, 22; fragmented, 23); and margin status (positive, 20; negative, 2; could not be assessed, 12). Five patients had FAP, and EA was deemed complete in 21 (47%). The diagnostic agreement between preampullectomy biopsy and ampullectomy was 64%. Of the patients, 33 (73%) had documented persistent disease. None of the histologic or clinical features had a statistically significant relationship with disease persistence.
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Affiliation(s)
- Andrew M. Bellizzi
- Department of Pathology, University of Virginia Health System, Charlottesville
| | - Michel Kahaleh
- Digestive Health Center, University of Virginia Health System, Charlottesville
| | - Edward B. Stelow
- Department of Pathology, University of Virginia Health System, Charlottesville
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Kim JH, Kim JH, Han JH, Yoo BM, Kim MW, Kim WH. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol 2009; 16:2547-54. [PMID: 19568817 DOI: 10.1245/s10434-009-0509-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/16/2009] [Accepted: 04/16/2009] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study was designed to provide safe management guidelines for ampullary adenoma by analysis of clinicopathological features. BACKGROUND The treatment of ampullary cancer has been established; however, the indications for treatment of ampullary adenoma remain controversial. METHODS Between July 1997 and July 2008, a total of 33 patients were diagnosed with ampullary adenoma prior to procedures: 20 endoscopic papillectomies (ESP), 5 transduodenal resections (TDR), and 8 pancreatoduodenectomies (PD). RESULTS The false-negative rate of biopsy for cancer was 27.5% (8/29). Coexistence of cancer in patients with pre-high-grade dysplasia (HGD) was 50.0% (5/10), whereas it was 15.7% in pre-low-grade dysplasia (LGD). In addition, the rate of recurrence was 80% (8/10) in patients with pre-HGD. The size of tumor by final pathology was 1.27 +/- 0.89 cm in LGD, 1.81 +/- 0.99 cm in HGD, and 1.98 +/- 1.08 cm in cancer group. There was a significant correlation between size of tumor and final pathology (P = 0.036). According to receiver operating characteristic (ROC) curve, criterion to predict HGD/cancer was tumor size larger than 1.5 cm; sensitivity and specificity were 55.6% and 80.0%, respectively, and likelihood ratio was 2.778. However, size of tumor was not associated with preprocedural pathology. CONCLUSIONS Ampullary adenoma with preprocedural HGD was highly associated with coexistence of cancer and recurrence. Moreover, most of large tumors were treated by surgical procedures and proved to be cancer. Therefore, we suggest that ampullary adenoma with preprocedural HGD or more than 1.5 cm should not be managed with endoscopic papillectomy due to high associated rates of recurrence.
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Affiliation(s)
- Ji Hun Kim
- Departments of Surgery, School of Medicine, Ajou University, Suwon, Korea
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Lorenzo-Zúñiga V, Moreno De Vega V, Domènech E, Boix J. [Diagnosis and treatment of ampullary tumors]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:101-8. [PMID: 19231683 DOI: 10.1016/j.gastrohep.2008.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Accepted: 02/19/2008] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
- Vicente Lorenzo-Zúñiga
- Unidad de Endoscopias, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD).
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Woo SM, Ryu JK, Lee SH, Lee WJ, Hwang JH, Yoo JW, Park JK, Kang GH, Kim YT, Yoon YB. Feasibility of endoscopic papillectomy in early stage ampulla of Vater cancer. J Gastroenterol Hepatol 2009; 24:120-4. [PMID: 19032444 DOI: 10.1111/j.1440-1746.2008.05578.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Although endoscopic papillectomy has been attempted in early stage ampullary cancer (pTis, T1), its curative role and indications remain uncertain. The present study was designed to assess the factors that predict malignancy and lymph node metastasis and to suggest potential indications for endoscopic papillectomy by analyzing clinicopathological data. METHODS We performed a retrospective analysis of clinical and histopathological data of 216 patients with ampullary cancer between 1991 and 2006. RESULTS No tumor in pTis stage had metastasized to lymph nodes and only 9% of tumors in pT1 had metastasized. Tumor size (P = 0.018), depth of invasion (P = 0.021) and venous invasion (P = 0.014) were found to be significantly related to lymph node metastasis. Cases with early stage ampullary cancer of less than 2 cm with a well-differentiated histology and no angiolymphatic invasion (n = 13) showed no lymph node metastasis and no recurrence during a median follow up of 35.9 months. CONCLUSION Endoscopic papillectomy can be adopted as a viable alternative to surgery in patients with early stage ampullary cancer of less than 2 cm in size and with a well-differentiated histology. When a resected specimen has a well-differentiated histology, and there is no resection margin involvement and no angiolymphatic invasion, our findings indicate that subsequent radical surgery is unnecessary.
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Affiliation(s)
- Sang Myung Woo
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Boix J, Lorenzo-Zúñiga V, Moreno de Vega V, Domènech E, Gassull MA. Endoscopic resection of ampullary tumors: 12-year review of 21 cases. Surg Endosc 2008; 23:45-9. [DOI: 10.1007/s00464-008-9866-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Accepted: 01/01/2008] [Indexed: 12/18/2022]
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Abstract
This paper described a rare case of adenomyoma of common bile duct. The case is a 51-year-old man who was hospitalized for yellow color skin and sclera and itching for 2 mo without abdominal pain. Nothing special was found in physical examination except yellowish skin and sclera. The clinical presentation and Contrast-enhanced magnetic resonance imaging (MRI), Magnetic resonance cholangiopancreatography (MRCP), and ultrasonography suspected a tumor of the distal bile duct. The patient was treated successfully by pancreaticoduodenectomy. Histologically, the lesion consisted of adenoid and myofibrous tissue and moderate atypia. The immunophenotype of the epithelial component was cytokeratin 7+/cytokeratin 20-. The patient has been well without any evidence of recurrence for 12 mo since his operation.
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Kycler W, Teresiak M. Planoepitheliale cell carcinoma arising from ampullo-pancreatic unit. Rep Pract Oncol Radiother 2008. [DOI: 10.1016/s1507-1367(10)60081-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Plard L, Leone S, Rod J, Chiche L. [Adenomyoma of the main biliary tract: a real diagnostic trap. Two cases and a review of the literature]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:1005-1009. [PMID: 18166896 DOI: 10.1016/s0399-8320(07)78321-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Adenomyoma of the biliary tract is a benign neoplasm but its clinical, radiological and intraoperative features can mimic pancreatic or biliary cancer. These similarities may yield to useless pancreatoduodenectomy. We report here two cases of adenomyoma treated by pancreatoduodenectomy. The analysis of these two cases and the review of literature show that radiological and pathological knowledge of this disease, associated with pre and intraoperative evaluation (echoendoscopy-guided biopsy, brushing and intraoperative biopsy) can achieve diagnosis and thus may avoid inappropriate resection. For asymptomatic patient, simple follow-up seems to be the rule. For symptomatic patient endoscopic resection or surgical segmentary resection where appropriate is recommended.
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Affiliation(s)
- Laurent Plard
- Service de chirurgie hépatobiliaire et transplantation hépatique, CHU Caen, Caen
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Kwon TH, Park DH, Shim KY, Cho HD, Park JH, Lee SH, Chung IK, Kim HS, Park SH, Kim SJ. Ampullary adenomyoma presenting as acute recurrent pancreatitis. World J Gastroenterol 2007; 13:2892-4. [PMID: 17569131 PMCID: PMC4395647 DOI: 10.3748/wjg.v13.i20.2892] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Adenomyoma is a term generally applied to nodular lesions showing proliferation of both epithelial and smooth muscle components. Despite its benign nature, ampullary adenomyoma is usually presented as biliary obstruction. Most cases are misdiagnosed as carcinoma or adenoma by preoperative endoscopic or radiologic procedure. Therefore, it is frequently treated with extensive surgery. To our knowledge, this is the first reported case in English literature of adenomyoma located in the peripancreatic orifice resulting in intermittent pancreatic duct obstruction and recurrent pancreatitis diagnosed by the endoscopic piecemeal resection.
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Affiliation(s)
- Tae-Hee Kwon
- Division of Gastroenterology, Department of Internal Medicine, Soon Chun Hyang University Cheonan Hospital 23-20 Bongmyung-dong, Cheonan, Choongnam 330-721, Korea
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Hayashibe A, Kameyama M, Shinbo M, Makimoto S. The extended local resection for the lesion of the vater papilla papillosphincterectomy. Pancreas 2007; 34:483-5. [PMID: 17446853 DOI: 10.1097/mpa.0b013e318033619a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Masoom S, Venkataraman G, Hammadeh R. Symptomatic adenomyoma of the Vaterian system: a pathologic curiosity with a potential for misdiagnosis. APMIS 2006; 114:559-61. [PMID: 16907862 DOI: 10.1111/j.1600-0463.2006.apm_476.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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