Tumors of the major duodenal papilla

Development and validation of web calculators to predict early recurrence and long-term survival in patients with duodenal papilla carcinoma after pancreaticoduodenectomy

BACKGROUND

Duodenal papilla carcinoma (DPC) is prone to relapse even after radical pancreaticoduodenectomy (PD) (including robotic, laparoscopic and open approach). This study aimed to develop web calculators to predict early recurrence (ER) (within two years after surgery) and long-term survival in patients with DPC after PD.

METHODS

Patients with DPC after radical PD were included. Univariate and multivariate logistic regression analyses were used to identify independent risk factors. Two web calculators were developed based on independent risk factors in the training cohort and then tested in the validation cohort.

RESULTS

Of the 251 patients who met the inclusion criteria, 180 and 71 patients were enrolled in the training and validation cohorts, respectively. Multivariate logistic regression analysis revealed that tumor size [Odds Ratio (OR) 1.386; 95% confidence interval (CI) 1070-1.797; P = 0.014]; number of lymph node metastasis (OR 2.535; 95% CI 1.114-5.769; P = 0.027), perineural invasion (OR 3.078; 95% CI 1.147-8.257; P = 0.026), and tumor differentiation (OR 3.552; 95% CI 1.132-11.152; P = 0.030) were independent risk factors for ER. Nomogram based on the above four factors achieved good C-statistics of 0.759 and 0.729 in predicting ER in the training and the validation cohorts, respectively. Time-dependent ROC analysis (timeROC) and decision curve analysis (DCA) revealed that the nomogram provided superior diagnostic capacity and net benefit compared with single variable.

CONCLUSIONS

This study developed and validated two web calculators that can predict ER and long-term survival in patients with DPC with high degree of stability and accuracy.

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

BACKGROUND AND AIM

While recent evidences support endoscopic resection as curative in ampullary tumors with high-grade intraepithelial neoplasia, only small case series have reported endoscopic management of early-stage ampullary cancer; thus, radical surgery remains the only accepted treatment modality. We evaluated the long-term outcomes of early ampullary adenocarcinoma administered endoscopic management.

METHODS

We retrospectively reviewed electronic medical records of 715 patients undergoing endoscopic papillectomy (EP) in a single tertiary medical center in Korea in 2004-2016. We included patients incidentally diagnosed with early-stage adenocarcinoma (Tis and T1a, American Joint Committee on Cancer 8th edition) after EP and with >2 years of follow-up data and analyzed their demographics, histopathologic data, and clinical outcomes.

RESULTS

Among 70 total patients in the EP-alone (n = 42) and subsequent surgery (n = 28) groups, we observed no significant differences in demographics or tumor size (2.0 ± 0.6 vs 1.9 ± 0.5 cm, P = 0.532), histologic grade (P = 0.077), tumor extent (P = 1.000), lymphovascular invasion (2.4% vs 10.7%, P = 0.344), or complete resection rates (57.1% vs 57.1%, P = 1.000) between groups. Adenocarcinoma lesions were larger in the subsequent surgery group (0.7 ± 0.5 vs 1.1 ± 0.7 cm, P = 0.002). The EP-alone group received more additional ablative treatment (42.9% vs 14.3%, P = 0.024). The 5-year disease-free and cancer-free survival rates were 79.1% vs 87.4% (P = 0.111) and 93.5% versus 87.4% (P = 0.726), respectively, and did not differ significantly between groups.

CONCLUSIONS

Endoscopic papillectomy followed by endoscopic surveillance showed long-term outcomes comparable with surgical resection for early ampullary cancer and maybe curable alternative to surgery for incidentally found early-stage ampullary cancer, especially in patients unfit for or refusing radical surgery.

Therapeutic Outcomes and Risk Factors for Complications of Endoscopic Papillectomy: A Retrospective Analysis of a Single-Center Study

Purpose

Endoscopic papillectomy (EP) has been accepted as a viable alternative therapy to surgery in benign duodenal papillary lesions. However, postoperative complications limit its widespread clinical application. This study aimed to evaluate the overall safety of the EP procedure and identify significant risk factors of post-EP complications.

Patients and Methods

We retrospectively collected 76 patients who had undergone EP in Chinese PLA General Hospital from 2016 to 2019 and graded their postoperative complications. We assessed twelve patient-, disease- or procedure-related variables to identify risk factors related to the occurrence of post-EP complications using both univariate and multivariate analyses.

Results

Among the 76 patients included in this study, the incidence of entire post-EP complications was 36.8%, most of which were in a mild form. In both univariate and multivariate analyses, the pathologic tumor types, especially high-grade intraepithelial neoplasia (HIN), and the placement of stents were significantly associated with the occurrence of post-EP complications. Patients with HIN tumors were more likely to have post-EP pancreatitis, bleeding, and overall complications (odds ratio (OR) 11.66, 95% confidence interval (CI) 2.91–62.5, P = 0.001; OR 6.52, 95% CI 1.45–46.77, P = 0.027; OR 9.81, 95% CI 2.75–44.04, P = 0.001, respectively). Pancreatic stent placement may contribute to the occurrence of post-EP pancreatitis (OR 7.61, 95% CI 1.37–64.53, P = 0.033). While biliary stent placement was found negatively related to the occurrence of post-EP bleeding and overall complications (OR 0.02, 95% CI 0–0.37, P = 0.016; OR 0.11, 95% CI 0.01–0.99, P = 0.05, respectively).

Conclusion

EP is a safe procedure for papillary lesion treatment with a low rate and generally mild postoperative complications. Two factors are significantly associated with the occurrence of complications. The selection of eligible patients and suitable procedures is important to reduce the complication rate and severity.

Usefulness of Full-spectrum Endoscopy for the Upper Gastrointestinal Tract

GOALS

We determined whether full-spectrum endoscopy (FUSE) improved the visualization rates of blind spots in a single-center case control study.

BACKGROUND

FUSE provides a 210-degree angle of view with a left side-viewing camera in addition to a forward-viewing camera. FUSE can improve the detectability of blind spots in conventional forward-viewing esophagogastroduodenoscopy (EGD), such as the major duodenal papilla (MDP) and the anal side of the pyloric ring.

STUDY

Between April 2016 and May 2017, successful visualization rates of the whole MDP and anal side of the pyloric ring were compared between 103 participants who underwent FUSE and 1045 participants who underwent EGD. Pain and discomfort at insertion and during and after the examination were assessed using a visual analog scale in 38 participants who underwent FUSE with a previous examination history of EGD.

RESULTS

The successful visualization rates of MDP and the anal side of the pyloric ring in the FUSE group were significantly higher than those in the conventional EGD group; 83.4% versus 35.1% for MDP (P<0.001) and 86.4% versus 7.1% for the anal side of the pyloric ring (P<0.001), respectively. The visual analog scale were not significantly different between FUSE and previous EGD in a portion of the FUSE group. In addition, the detection rate of the periampullary diverticula was also significantly higher in the FUSE group than that in the conventional EGD group (8.7% vs. 1.6%, P<0.001).

CONCLUSIONS

This study provides evidence supporting that FUSE is superior to EGD for precise visualization of blind spots in the duodenum.

Efficacy and safety of endobiliary radiofrequency ablation for the eradication of residual neoplasia after endoscopic papillectomy: a multicenter prospective study

BACKGROUND AND AIMS

Endobiliary dysplasia may persist after endoscopic papillectomy. Intraductal radiofrequency ablation (ID-RFA) is a potential alternative to complementary surgery. The aim of this study was to evaluate the efficacy and safety of ID-RFA for the treatment of adenomatous intraductal residue after endoscopic papillectomy.

METHODS

A prospective open-label multicenter study included patients with histologically proven endobiliary adenoma remnant (ductal extent <20 mm) after endoscopic papillectomy for ampullary tumor. RFA (effect 8, power 10 W, 30 seconds) was performed during ERCP. Biliary ± pancreatic stent was placed at the end of the procedure. Endpoints were (1) the rate of residual neoplasia (ie, low-grade dysplasia [LGD], high-grade dysplasia [HGD], or invasive carcinoma) at 6 and 12 months, (2) rate of surgery, and (3) adverse events.

RESULTS

Twenty patients (67 ± 11 years of age, 12 men) were included. The endobiliary adenoma was in LGD in 15 patients and HGD in 5 patients. All underwent 1 successful ID-RFA session with biliary stent placement and recovered uneventfully. Five (25%) received a pancreatic stent. The rates of residual neoplasia were 15% and 30% at 6 and 12 months, respectively. Only 2 patients (10%) were referred for surgery. Eight patients (40%) experienced at least 1 adverse event between ID-RFA and 12 months of follow-up. No major adverse event occurred. HGD at inclusion was associated with higher dysplasia recurrence at 12 months (P = .01).

CONCLUSIONS

ID-RFA of residual endobiliary dysplasia after endoscopic papillectomy can be offered as an alternative to surgery, with a 70% chance of dysplasia eradication at 12 months after a single session and a good safety profile. Patient follow-up remains warranted after ID-RFA. (Clinical trial registration number: NCT02825524.).

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

Background

Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions.

Methods

All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence.

Results

We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733).

Conclusion

Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.

Pylorus-preserving pancreaticoduodenectomy versus standard pancreaticoduodenectomy in the treatment of duodenal papilla carcinoma

It is not known whether pylorus-preserving pancreaticoduodenectomy (PPPD) is as effective as the standard pancreaticoduodenectomy (SPD) in the treatment of duodenal papilla carcinoma (DPC). A retrospective cohort trial was undertaken to compare the results of these two procedures. Clinical data, histological findings, short-term results, survival and quality of life of all patients who had undergone surgery for primary DPC between January 2003 and February 2010 were analyzed. According to the inclusion criteria and the surgical methods, 116 patients were divided into the PPPD group (n=43) and the SPD group (n=73). There were no significant differences in various indices, including surgery duration, extent of intraoperative hemorrhage and postoperative pathological indexes. The incidence of postoperative complications, including pancreatic fistula and delayed gastric emptying, were also similar between the two groups (20.9 vs. 21.9%; P=0.900 and 11.6 vs. 5.4%; P=0.402). Long-term survival and quality of life were identical following a median follow-up of 45.6 months (range, 4-144 months). Within 6 months, there was a decreased loss of appetite following the pylorus-preserving procedure (26.9 vs. 49.3; P=0.003). The procedures were equally effective for the treatment of DPC. PPPD offers minor advantages in the early postoperative period but not in the long term.

Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM

To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD).

METHODS

This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the χ² test and Fisher’s exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test.

RESULTS

In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (χ² = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047).

CONCLUSION

For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Cap Assisted Upper Endoscopy for Examination of the Major Duodenal Papilla: A Randomized, Blinded, Controlled Crossover Study (CAPPA Study)

OBJECTIVE

Examination of major duodenal papilla (MDP) by standard forward-viewing esophagogastroduodenoscopy (S-EGD) is limited. Cap assisted esophagogastroduodenoscopy (CA-EGD) utilizes a cap fitted to the tip of the endoscope that can depress the mucosal folds and thus might improve visualization of MDP. The aim of this study was to compare CA-EGD to S-EGD for complete examination of the MDP.

METHODS

Prospective, randomized, blinded, controlled crossover study. Subjects scheduled for elective EGD were randomized to undergo S-EGD (group A) or CA-EGD (group B) before undergoing a second examination by the alternate method. Images of the MDP were evaluated by three blinded multicenter-experts. Our primary outcome measure was complete examination of the papilla. Secondary outcome measures were duration and overall diagnostic yield.

RESULTS

A total of 101 patients were randomized and completed the study. Complete examination of MDP was achieved in 98 patients using CA-EGD compared to 24 patients using S-EGD (97 vs. 24%, P<0.001). Median duration from intubation of the esophagus until localization of the MDP was shorter with CA-EGD (46. vs. 96 s., P<0.001). In group A, 11 extra lesions and 12 additional incidental findings were detected by secondary CA-EGD, whereas neither were detected by secondary S-EGD in group B (22 vs. 0% and 24 vs. 0%, P<0.001 and P<0.001).

CONCLUSION

CA-EGD enabled complete examination of MDP in almost all cases compared to a low success rate of S-EGD. CA-EGD detected a significant amount of lesions and incidental findings when added to S-EGD. CA-EGD is a safe and effective method for examination of MDP.

FLUCTUATING JAUNDICE IN THE ADENOCARCINOMA OF THE AMPULLA OF VATER: a classic sign or an exception?

BACKGROUND

Some authors consider the fluctuating jaundice as a classic sign of the adenocarcinoma of the ampulla of Vater.

OBJECTIVE

Assessing the frequency of fluctuating jaundice in their forms of its depiction in the patients with adenocarcinoma of the ampulla of Vater.

METHODS

Observational and retrospective study, conducted through analyses of medical records from patients subjected to pancreatic cephalic resections between February 2008 and July 2013. The pathological examination of the surgical specimen was positive to adenocarcinoma of the ampulla of Vater. Concepts and differences on clinical and laboratory fluctuating jaundice were standardized. It was subdivided into type A and type B laboratory fluctuating jaundice.

RESULTS

Twenty patients were selected. One of them always remained anicteric, 11 patients developed progressive jaundice, 2 of them developed clinical and laboratory fluctuating jaundice, 5 presented only laboratory fluctuating jaundice and one did not present significant variations on total serum bilirubin levels. Among the seven patients with fluctuating jaundice, two were classified as type A, one as type B and four were not classified due to lack information. Finally, progressive jaundice was the prevailing presentation form in these patients (11 cases).

CONCLUSION

This series of cases suggested that clinical fluctuating jaundice is a uncommon signal in adenocarcinoma of the ampulla of Vater.

Endoscopic resection for gastrointestinal neuroendocrine tumors

Gastrointestinal (GI) and neuroendocrine tumors (NETs) can be treated by mini-invasive endoscopic resection when localized in the superficial layers of the bowel wall and their size is <20 mm. Endoscopic diagnosis of NETs is usually incidental or suspected after clinical, laboratory or imaging findings. Endoscopic mucosal resection is the most commonly used technique for NET removal, endoscopic submucosal dissection is indicated in selected cases, while papillectomy is feasible for ampullary lesions. Histopathologic assessment of the resection margin (circumferential and deep) is important for staging. Incidence of endoscopic mucosal resection-/endoscopic submucosal dissection-related complications for removal of GI NETs are similar to those reported for other GI lesions. Endoscopic follow-up is based on histopathologic characteristics of the resected NETs and its site. NETs >20 mm in size, with penetration of the muscle layer and/or serosa are at high risk for metastases and surgical approach is recommended when feasible.

Pancreatic metastasis from a solitary fibrous tumor of the kidney: a rare cause of acute recurrent pancreatitis

Solitary fibrous tumors are unusual spindle cell neoplasms that uncommonly originate from the kidney. We report a case of a 43-year old male who presented with acute recurrent pancreatitis secondary to a mass in the head of the pancreas. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) was performed. Cytology revealed solitary fibrous tumor of the kidney. This is the first reported case of solitary fibrous tumor metastasizing to the pancreas and presenting as acute recurrent pancreatitis.

Efficacy and safety of 0.4 percent sodium hyaluronate for endoscopic submucosal dissection of gastric neoplasms

AIM: To evaluate the efficacy and safety of sodium hyaluronate solution (SH) in endoscopic submucosal dissection (ESD) of gastric neoplasms.

METHODS: A prospective multicenter randomized, double blind, controlled trial was designed and utilized in this study. A total of 76 patients with 5-20 mm sized gastric neoplasms were enrolled at three academic hospitals in South Korea from June 2011 to October 2011. Patients were randomly assigned to the 0.4% sodium hyaluronate or control groups. All lesions underwent endoscopic ESD. ESD was performed with 0.4%SH and normal saline (NS) solution for submucosal injection. Efficacy was assessed using en bloc resection and the number of additional injections. Secondary evaluation variables were the volume of injection material, steepness of mucosal elevation, bleeding rate, procedural time and operator satisfaction. Finally, the safety was assessed by analyzing adverse events during the study.

RESULTS: The usefulness rate in the 0.4%SH group and the controlled group had statistically significant difference under intention to treat (ITT) analysis (90.91% vs 61.11% P = 0.0041). Under per protocol (PP), the usefulness rate is statistically significant different (93.10% vs 61.76%, P = 0.0036). The difference in volume of the solution injected between 0.4%SH group and the controlled group and NS group was also statistically significant under intention to treat and per protocol analysis (ITT: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0003, PP: 0.03 ± 0.02 mL vs 0.06 ± 0.03 mL, P = 0.0004). Satisfaction above the grade good was significantly higher in the SH group under intention to treat and per protocol analysis (ITT: 90.91% vs 61.11%, P = 0.0041, PP = 93.11% vs 61.77%, P = 0.0022). Adverse events above grade 3 were not noticed in either group. All adverse events were treated and were judged as not associated with the submucosal injection solutions.

CONCLUSION: 0.4%SH solution is a safe and effective agent that doesn’t cause any significant adverse events and is useful for submucosal injection during ESD.

Endoscopic approach to the patient with benign or malignant ampullary lesions

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

Successful en bloc resection of papillary neuroendocrine tumors by duodenoscope using endoscopic submucosal dissection method

Neuroendocrine tumors (NETs) of the main duodenal papilla are rare. Surgery such as pancreaticoduodenectomy is traditionally recommended as the standard treatment for papillary neuroendocrine tumors. Endoscopic resection is increasingly used for treating these lesions. However, resection of papillary NETs using endoscopic submucosal dissection (ESD) technique was scarcely reported. In this paper, we report a patient with neuroendocrine tumor of the main duodenal papilla originating from the muscularis propria on EUS underwent successful endoscopic submucosal dissection using a duodenoscope. With 6-month followed up, no stenosis of bile and pancreatic ducts or relapse of tumor occurred.

Endoscopic ampullectomy: techniques and outcomes

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

Can papillary carcinomas be treated by endoscopic ampullectomy?

BACKGROUND

The utility of endoscopic ampullectomy versus surgical ampullectomy remains a topic of debate, particularly for the treatment of malignant tumors. The goal of this study was to prospectively establish the outcomes of endoscopic ampullectomy, with focus on carcinoma.

METHODS

From February 2002 to December 2008, 61 patients underwent endoscopic ampullectomy. The ampulloma was discovered fortuitously in the majority of cases (43 patients, 70%). All patients had had an echoendoscopy revealing a T1N0 lesion without invasion of the orifice.

RESULTS

Forty-three patients (70%) underwent a monobloc resection. Histological analysis revealed a low-grade dysplastic adenoma in 21 patients (35%), a high-grade dysplastic adenoma in 11 patients (18%), no dysplasia in 16 patients (26%), an adenocarcinoma in 10 patients (16%), and a well-differentiated endocrine carcinoma in 3 patients (5%). Among the ten patients with adenocarcinoma, four with adenocarcinoma of poor prognosis were treated by pancreaticoduodenectomy (PD) with R0 resection, of whom one patient had no more lesion. Two intramucosal adenocarcinomas were cured by endoscopic ampullectomy without any recurrence. Four patients received palliative care after endoscopic ampullectomy due to cephalic pancreatico-duodenectomy contraindication. For the three patients with well-differentiated endocrine carcinomas, one was treated by PD with R0 resection and two were treated solely by endoscopic ampullectomy, without recurrence. Eleven patients (18%) presented with complications. The complication rate was 30.5% for carcinomas versus 14.5% for benign tumors (p < 0.05).

CONCLUSION

Endoscopic ampullectomy allows for the oncologic resection of well-differentiated intramucosal carcinomas with negative margins. The risk of complications is greater for papillary carcinomas.

Feasibility of forward-viewing upper endoscopy for detection of the major duodenal papilla

BACKGROUND AND AIM

The purpose of this study was to assess the feasibility of forward-viewing upper endoscopy for detection of the major duodenal papilla (MDP) as an indicator of the descending duodenum.

METHODS

A total of 338 patients were prospectively enrolled. Upper endoscopy was first performed by a routine method for all patients, and a subsequent straightening endoscopic technique, straightening the loop by withdrawal of the scope, was performed if the MDP was not identified during the routine method.

RESULTS

Findings of MDP observation using the upper endoscope could be categorized into five types: Type I, whole area of the papilla; Type II, upper part of the papilla, including the orifice; Type III, upper part of the papilla without the orifice; Type IV, lower part of the papilla, including the orifice; Type V, no part of the papilla was found. Upper endoscopy by a routine method detected the MDP in whole or in part in 194 patients (57.4%). Among 144 patients whose MDP could not be detected by use of a routine method, the MDP was identified by a subsequent straightening endoscopic technique in 108 patients (75.0%). Overall rate of observation of the MDP during full upper endoscopy was 89.3% (302/338). Type I is the most frequent (n = 185, 54.7%), followed by Type IV (n = 73, 21.6%), Type II (n = 23, 6.8%), and Type III (n = 21, 6.2%), in that order.

CONCLUSIONS

Our results support the value of forward-viewing endoscopy in observation of the MDP. Use of a straightening endoscopic technique, in particular, increases in the rate of detection of the MDP.

Large cell neuroendocrine carcinoma of the ampulla of vater with adenocarcinoma and squamous cell carcinoma components

A 73-year-old woman visited our hospital complaining of general fatigue and jaundice. Laboratory tests revealed an elevated total bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase and γ-glutamyltransferase. Computed tomography and magnetic resonance imaging demonstrated a mass lesion at the ampulla of Vater with dilatation of the common bile duct and main pancreatic duct. Percutaneous transhepatic cholangiography revealed dilatation of the bile duct and a negative filling defect due to the tumor. Pancreatoduodenectomy was performed. The specimen included an ulcerated firm tumor of the papilla Vater. The surface of the ampulla consisted of well-differentiated papillary adenocarcinoma, whereas the deep layer, such as submucosal or muscular layer, contained large cell neuroendocrine carcinoma and squamous cell carcinoma. Immunohistochemistry revealed that the large cell neuroendocrine carcinoma component was positive for chromogranin A, synaptophysin and CD56. The patient died from multiple liver and bone metastases 13 months after surgery. This is a very rare case of a large cell neuroendocrine carcinoma accompanied by adenocarcinoma and squamous cell carcinoma components.

Differentiation of benign and malignant ampullary obstructions on MR imaging

OBJECTIVE

To define diagnostic criteria for differentiating malignant ampullary carcinoma from benign ampullary obstruction on MR imaging.

MATERIALS AND METHODS

Nineteen patients with ampullary carcinoma and 22 patients with benign ampullary obstruction were enrolled. At the first session, two radiologists independently evaluated specific imaging findings, and then reached consensus decisions. At the second session, another two radiologists, who were informed about useful differentiation criteria based on the results from the first session, reviewed images and determined the causes of ampullary obstruction. Sensitivity and specificity were calculated for each interpretation session, and the Cohen κ statistic was used to evaluate interobserver agreement.

RESULTS

Findings of the presence of an ampullary mass (P<0.001), papillary bulging (P<0.001), irregular (P=0.021) and asymmetric (P<0.001) common bile duct (CBD) narrowing, and proportional biliary dilatation (P<0.001) were more commonly seen in patients with an ampullary carcinoma. The sensitivity and specificity of the first session were 84.2% and 86.4% after consensus. The sensitivity increased to 100% for both the readers at the second session, while the specificity decreased to 63.6% and 59.1%, respectively.

CONCLUSIONS

Identification of an ampullary mass, papillary bulging, irregular and asymmetric narrowing of the CBD, or proportional biliary dilatation may improve the diagnosis of ampullary carcinoma in patients with ampullary obstruction.

Endocrine carcinoma of the major papilla: report of two cases and review of the literature

To date, about 100 cases of ampullary NET are reported in International literature. These tumors can cause symptoms mainly secondary to their periampullary location. Up to 25% of patients have von Recklinghausen's disease. Carcinoid syndrome is uncommon, unless hepatic metastasis is present. Determination of histopathology is of utmost importance and involves specific immunohistochemical staining. The published data indicate that these tumors, metastasize in approximately half of cases irrespective of primary tumor size. Therefore, radical excision in the form of pancreaticoduodenectomy is recommended regardless of tumor size. Local excision should be confined to patients unable to tolerate more extensive surgery. We here report two case of ampullary neuroendocrine tumors presenting as melena and painless jaundice respectively in a 51-year old man and in a 54-year old man and review the relevant literature, giving special attention to the morphologic features, clinical characteristics, and treatment modalities associated with this disease process.

A novel approach emphasizing preoperative margin enhancement of tumor of the major duodenal papilla with narrow-band imaging in comparison to indigo carmine chromoendoscopy (with videos)

BACKGROUND

Endoscopic papillectomy (EP) has been recognized as a safe and reliable treatment for tumor of the duodenal papilla. For complete resection, precise assessment of not only the intraductal extent but also the lateral margins of the tumor is mandatory before resection.

OBJECTIVE

Our purpose was to prospectively assess the enhancement of the lateral margins of tumor of the duodenal papilla for the treatment of EP by comparing narrow-band imaging (NBI) and indigo carmine (IC) chromoendoscopy.

DESIGN

Prospective study.

SETTING

This procedure was performed in Tokyo Medical University Hospital.

PATIENTS

Fourteen consecutive cases of tumors of the major duodenal papilla.

INTERVENTION

All patients underwent EP after evaluation by NBI and IC.

MAIN OUTCOME MEASUREMENT

Histologic evaluation of diagnosis of NBI and IC by comparison with en bloc tissue.

RESULTS

In all lesions, either IC or NBI were superior to conventional white-light imaging except in 1 IC case. The ability of NBI observation to emphasize the tumor margin was statistically significantly better than IC observation (P< .05). The en bloc EP was endoscopically successful in all cases, without fatal adverse events. En bloc tissue revealed 13 adenomas and 1 adenoma with focal adenocarcinoma. There was no residual adenoma in lateral margin specimens, either endoscopically or histologically.

LIMITATIONS

The lesions resected were all relatively small. This was not a blinded randomized study.

CONCLUSION

This study demonstrated the feasibility and a certain degree of efficacy of NBI for enhancement of the tumor margin of duodenal papilla. Further blinded randomized studies involving large duodenal papillary tumors are required.

Endoscopic papillectomy

PURPOSE OF REVIEW

Although few controlled trials exist in the field, endoscopic papillectomy has evolved over the recent years with new data on preoperative staging and improved methods for its safe and successful completion. In 2006, a consensus guideline was published by the American Society of Gastrointestinal Endoscopy evaluating the role of endoscopy in managing ampullary adenomas.

RECENT FINDINGS

The recent literature of endoscopic papillectomy has focused on the preoperative management of ampullary tumors, with a paper evaluating the role of endoscopic ultrasound. Also, a randomized controlled trial has shown that the use of pancreatic duct stents is associated with less incidence of postendoscopic papillectomy pancreatitis, although the study was probably underpowered. Several methods can be used to help locate the pancreatic duct postendoscopic papillectomy (endoscopic ultrasound-guided rendezvous and methylene blue injection). The recurrence and complication rate in more recent papers continue to be acceptable, at about 30 and 20%, respectively.

SUMMARY

Endoscopic papillectomy is a reasonable alternative to transduodenal surgical excision, but more controlled studies with long-term data are needed to evaluate preoperative staging accuracy and recurrence rates.

Adenoma of the major duodenal papilla with intraductal extension into the lower common bile duct

Although benign and malignant tumors of the major duodenal papilla can be detected endoscopically, definitive diagnosis of such lesions by histologic examination of biopsy specimens is sometimes difficult, especially in cases with intraductal extension into the bile duct or pancreatic duct. We herein report a case of adenoma of the major duodenal papilla showing an intraductal extension into the lower common bile duct that necessitated pylorus-preserving pancreaticoduodenectomy.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

Tertiary-care university teaching hospital.

PATIENTS

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

INTERVENTIONS

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

MAIN OUTCOME MEASUREMENTS

Locoregional extension and follow-up data.

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

CT evaluation of the bulging papilla with endoscopic correlation

A variety of pathologic conditions can cause abnormalities of the ampulla of Vater. A bulging papilla is frequently encountered at computed tomography (CT) and can be seen in healthy individuals as well as in patients with various pathologic conditions such as papillitis, ampullary cancer, and intraductal papillary mucinous tumor. Mural thickening and certain attenuation patterns seen at contrast material-enhanced CT can help differentiate pathologic papilla from normal papilla. Increased targetlike enhancement of the papilla is likely to represent a benign condition such as papillitis, whereas an enhancing polypoid mass or focal asymmetric or irregular thickening with prolonged enhancement in the ampulla of Vater indicates a malignant condition such as ampullary or periampullary carcinoma. Although CT often does not clarify the exact cause of bulging, adequate duodenal distention may allow detection of an abnormal papilla, thereby providing additional information about other abnormalities in the pancreaticobiliary system. Thus, CT findings may prove useful for subsequent imaging studies such as magnetic resonance (MR) cholangiography or endoscopy. MR cholangiography may be equivalent to CT for identifying a bulging papilla and superior for distinguishing the underlying cause. However, endoscopy with or without biopsy is the best method for making a definitive diagnosis in patients with a bulging papilla. Familiarity with the normal imaging anatomy of the periampullary region and with the imaging features of the various pathologic causes of a bulging papilla may be useful in making the diagnosis.

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

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

Ampullary adenomyoma presenting as acute recurrent pancreatitis

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.

Ampulla of Vater: comprehensive anatomy, MR imaging of pathologic conditions, and correlation with endoscopy

Endoscopic retrograde cholangiopancreaticography with or without an endoscopic biopsy is the method for making a definitive diagnosis of disease in or around the ampulla of Vater. However, the endoscopic findings of neoplastic and non-neoplastic conditions involving the perimapullary area may be similar and an endoscopic assessment is not entirely reliable for diagnosis. Recent MR and MRCP can allow the detection of lesions in a small complex structure such as the ampulla of Vater, and distinguish between an ampullary from periampullary lesion. This article reviews the normal anatomy of the ampulla of Vater, describes the role of MR in the detection and characterization of the lesion in or around the ampulla of Vater, and attempts to correlate them with ERCP.

Endoscopic resection of an ampullary carcinoid presenting with upper gastrointestinal bleeding: A case report and review of the literature

Ampullary carcinoid is a rare tumor that can present with gastrointestinal bleeding, obstructive jaundice or pancreatitis. Some of these tumors are associated with Von Recklinghausen disease. The usual surgical options are a biliary-enteric anastomosis, Whipple procedure or rarely a local resection. The mean survival does not appear to be much different after a pancreaticoduodenectomy versus local surgical excision. We report a very rare case of a non-metastatic ampullary carcinoid causing upper gastrointestinal bleeding, which was managed by endoscopic ampullectomy.

New approach to diagnosing ampullary tumors by magnifying endoscopy combined with a narrow-band imaging system

BACKGROUND

A newly developed narrow-band imaging (NBI) system, which uses modified optical filters, can yield clear images of microvessels and surface structure in gastric and colonic diseases. In the present study, we investigated the ability of magnifying endoscopy with NBI (MENBI) to diagnose and differentiate between benign and malignant ampullary tumors.

METHODS

Fourteen patients, whose ampullas were noted to be significantly enlarged or protruding with conventional endoscopy, were enrolled in the study. Specimens, which were obtained by forceps biopsy, endoscopic papillectomy, and/or surgery, were retrieved for histopathological examination. The correlation between MENBI images and histopathological findings was investigated. MENBI findings were classified as I, oval-shaped villi; II, pinecone/leaf-shaped villi; or III, irregular/nonstructured. In addition, tortuous, dilated, and network-like vessels noted on the ampullary lesions with MENBI were defined as abnormal vessels.

RESULTS

In 6 of 14 patients, the ampullary changes were proven to be inflammatory in forceps biopsy specimens, without any evidence of malignancy after more than 1 year of follow-up. In five patients, ampullary lesions were treated by endoscopic papillectomy, and in three, by pancreatoduodenectomy. All adenomas and adenocarcinomas had type II and/or type III surface structures, and patients whose ampulla had a type I surface structure had only inflammatory or hyperplastic changes. In addition, abnormal vessels were seen only in adenocarcinomas and never in adenomas.

CONCLUSIONS

MENBI has the ability and potential to predict histological characteristics of ampullary lesions.

Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth

BACKGROUND

Endoscopic papillectomy of benign papillary tumor is still not widely practiced. Intraductal growth has been considered a contraindication for endoscopic therapy. This prospective study evaluates endoscopic papillectomy for treatment of benign papillary tumors without and with intraductal growth.

METHODS

Monofilament snare and monopolar electrocoagulation were used for papillectomy. A 7F stent was placed in the pancreatic duct. Patients with distal intraductal growth underwent sphincterotomy and endoscopic resection after exclusion of more proximal growth.

RESULTS

Between February 1985 and April 2004, 106 patients (109 lesions), 68 women, 38 men, median age 68 years (range 29-88 years) were included. Median tumor size was 2 cm (range 0.5-6 cm) with one session (range 1-8) required for removal. Nine patients had invasive carcinoma (8%). Surgery for incomplete removal or recurrence was performed in 12% of 75 patients without and 37% of 31 patients with intraductal growth (p < 0.01), respectively. Fifteen patients had recurrence (15%); but, only 4 required surgery. Endoscopic resection was curative (median follow-up, 43 months) in 83% without and 46% with intraductal growth (p < 0.001).

CONCLUSIONS

Endoscopic papillectomy is safe and effective, and may be feasible in cases of intraductal growth. Surveillance and, if required, re-treatment are mandatory because of the risk of recurrence.

Endoscopic mucosal resection: treatment of neoplasia

Techniques of endoscopic mucosal resection (EMR) can dramatically improve the ability to diagnose and treat superficial lesions in the gastrointestinal (GI) tract. Early cancers, submucosal tumors, and sessile polyps can be safely and completely removed in a single procedure, with long-term outcome results comparable to surgery. This is accomplished with a minimum cost, morbidity, and mortality and with little or no impact on the quality of life of patients. This article provides an overview of the techniques, indications, and outcomes of EMR in the management of GI malignancy.

A carcinoid tumor of the ampulla of Vater treated by endoscopic snare papillectomy

Here, a case of a patient with incidental finding of a carcinoid tumor of the ampulla of Vater, who was treated with endoscopic snare papillectomy, is reported. A 62-year-old male was admitted to our hospital due to a carcinoid tumor of the ampulla of Vater, which was found during follow-up endoscopy after an endoscopic mucosal resection of early gastric cancer. No lymphadenopathy or visceral metastasis was found on an abdominal CT scan, In-111 octerotide scan and EUS. The ampulla was then en bloc removed by endoscopic snare papillectomy. The resected specimen revealed a 0.7 x 0.5 x 0.1 cm sized carcinoid tumor. All margins of resection were negative for tumor. After six months of follow-up, there was no evidence of recurrence and metastasis, either endoscopically or radiologically. To our knowledge, this case is the first report of an ampullary carcinoid tumor treated by endoscopic snare papillectomy in Korea.

Endoscopic snare papillectomy for tumors of the duodenal papillae

BACKGROUND

Tumors of the major and the minor duodenal papillae can be malignant or premalignant, and traditionally are treated by surgical excision. This study evaluated the safety and the outcome of endoscopic snare resection of such tumors.

METHODS

All patients with tumors of the major or the minor papilla treated by endoscopic snare resection over a 10-year period (1994-2003) were identified from an ERCP database. Patients with tumors that had endoscopic features of malignancy and those proven to be cancerous by biopsy were excluded. Papillectomy was performed by electrosurgical snare resection. A pancreatic stent usually was placed before or after excision. Residual tumor was eradicated by repeated procedures. Endoscopic surveillance was at the discretion of the endoscopist.

RESULTS

Seventy snare resections were performed in 55 patients (mean age 59 years). Histopathologic diagnoses were the following: adenoma (45 patients; 7 with focal high-grade dysplasia, 6 with intraductal extension), adenocarcinoma (5), carcinoid tumor (2), gastric heterotopia (1), and normal histology (2). Fourteen patients had familial adenomatous polyposis. Of the 39 patients with isolated extraductal adenoma per cholangiogram, two underwent surgical resection because of persistent high-grade dysplasia, and 37 were successfully treated by endoscopic papillectomy alone. During follow-up (mean 30 months), 18 of 37 patients (49%) had no recurrence, 7 had recurrent adenoma (mean time interval to recurrence 27 months), two died of unrelated illnesses, and 10 are awaiting follow-up. Of the 6 patients with intraductal adenoma per cholangiogram, two underwent surgical resection, two had intraductal photodynamic therapy, and two had endoscopic snare resection. Intraductal tumor in the 4 latter patients was eliminated, although it recurred in one of the patients who had photodynamic therapy. Of the 7 patients with adenocarcinoma or carcinoid tumor, pancreaticoduodenectomy was performed in 3 and palliative papillectomy was performed in 4 unsuitable for surgery. One patient with carcinoid tumor of the minor papilla is alive, without recurrence, at 5 years after papillectomy. There were 10 procedure-related complications (14.5%), including pancreatitis (5), bleeding (4), and mild perforation (1). There was no procedure-related death.

CONCLUSIONS

Most adenomas of the duodenal papillae without intraductal extension can be fully resected by snare papillectomy. However, adenoma recurs in about a third of patients. Endoscopic therapy appears to be a reasonable alternative to surgery for management of papillary tumors. Longer follow-up is needed to determine the true recurrence rate and if endoscopic re-treatments are effective.

Evaluation and management of periampullary tumors

Periampullary cancers make up 5% of all gastrointestinal cancers. The complexity of the periampullary anatomy makes determination of the origin of some of these tumors difficult. However, advances in imaging have helped with diagnosis as well as defining the extent of the lesion and its potential resectability. For many of these tumors, surgery is the recommended treatment. However, endoscopic removal is being extended to different lesions with encouraging preliminary results. Improvements in overall prognosis for periampullary tumors will be limited until diagnosis can be established earlier in the course of the disease and adjuvant therapies become more effective.

Approaches to endoscopic ampullectomy

PURPOSE OF REVIEW

Ampullary tumors, usually adenomas, are often encountered during endoscopic evaluation, especially in patients with familial adenomatous polyposis (FAP). Because of the risk of progression to adenocarcinoma, ampullary adenomas should be treated. Endoscopic therapy is an appropriate option and recent experience highlights the effectiveness and safety of this approach.

RECENT FINDINGS

Several authors have published experiences with endoscopic ampullectomy. In the current era, endoscopic ampullectomy is performed like a snare polypectomy using a side-viewing duodenoscope. Tumors are removed either en bloc or in a piecemeal fashion with retrieval of all tissue. Because of the potential for incidental carcinoma when all tissue is removed, complete retrieval is essential. Although initially used as primary therapy, thermal ablation, such as ionized argon coagulation (IAC), is now commonly used as adjunctive therapy. Prophylactic pancreatic or biliary stent placement is also performed to minimize risks of pancreatitis, jaundice, cholangitis, and stenosis. Endoscopic therapy is effective in removing more than 80% of adenomas, though several sessions may be necessary. Complications are reported in 20% of patients from most series and include acute pancreatitis, bleeding, perforation, orifice stenosis, and, rarely death. Recurrence of the adenoma can occur, especially in FAP patients, and warrants periodic surveillance.

SUMMARY

Endoscopic ampullectomy appears to be an effective method for treating ampullary tumors. However, complications are significant and only well-trained and experienced endoscopists should perform ampullectomy. Future research should focus on multicenter, randomized clinical trials to determine the best therapeutic approach for patients with ampullary tumors and to determine methods to decrease complication rates associated with endoscopic therapy.

Ampullary adenoma: clinical manifestations, diagnosis, and treatment

Ampullary adenomas occur sporadically and in the setting of familial polyposis syndromes. In either case, and whether symptomatic at presentation or found asymptomatically in the setting of endoscopic screening programs, they are premalignant lesions with risk for malignant degeneration to carcinoma following the adenoma-to-carcinoma sequence that is well recognized in colonic adenocarcinoma. Accordingly, many experts advocate excision, although others cite the low rate of histologic progression suggested by some recent studies as justification for close endoscopic surveillance rather than excision before demonstration of dysplastic change. This recommendation, however, is complicated by considerable data underscoring the limited accuracy of endoscopic forceps biopsy in detecting occult foci of carcinoma within ampullary adenoma. Thus, the optimal management of these lesions continues to generate considerable controversy. Indications for excision of an ampullary adenoma include treatment of immediate symptoms as well as prevention of malignant degeneration. Although pancreaticoduodenectomy has long been considered the standard procedure for ampullary carcinoma, much controversy exists regarding the procedure of choice for ampullary adenoma. Radical surgery (pancreaticoduodenectomy) possesses the advantage of low recurrence rate but at the expense of higher morbidity (25%-65%) and mortality (0%-10%). Local surgical excision (surgical ampullectomy) possesses the advantages of lower morbidity (0%-25%), essentially nil mortality, and possibly decreased length of hospital stay, but decidedly higher recurrence rates (generally 5%-30%) and the need for postoperative endoscopic surveillance. Snare ampullectomy is a newer endoscopic excisional technique for which limited data are available; advantages compared with radical surgery mirror those of local surgical excision, with apparent lower mortality (0%-1%) and lower morbidity (12%). Presumed advantages compared with local surgical excision include lack of necessity for general anesthesia and laparotomy with comparable morbidity. Disadvantages seem to include limited availability of experienced operators, procedural complexity sometimes requiring adjunctive modalities such as fulguration, the need for multiple procedures (mean, 2.0 procedures) to effect complete excision, and recurrence rates approaching 30%, with a requirement for continued endoscopic surveillance. Ultimately, choice is driven by availability of local expertise, patient tolerance of or expected compliance with long-term endoscopic surveillance programs, presence or absence of coexisting familial polyposis syndromes, medical comorbidities, and overall life expectancy.

Idiopathic acute pancreatitis

After routine investigations, including a thorough history, routine laboratory study, and noninvasive imaging with transcutaneous ultrasonogram, 10% to 25% of cases of acute pancreatitis have no readily identifiable cause and are termed idiopathic. But modern medicine has made notable advances in uncovering various causes of acute pancreatitis, and several new diagnostic tools that allow clinicians to less invasively approach the patient without sacrificing the diagnostic yield have been introduced. By being knowledgeable of these new changes and by their proper use in a proper circumstances, clinicians will be able to find the cause more accurately and earlier. This better management will not only improve the well-being of the patients but also reduce the number of "true" idiopathic acute pancreatitis to a minimum.

Laparoscopic resection of a periampullary villous adenoma

BACKGROUND

Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach.

CASE REPORT

A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction.

CONCLUSIONS

Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions.

Hydroxypropyl methylcellulose: A better submucosal fluid cushion for endoscopic mucosal resection

BACKGROUND

Formation of a submucosal fluid cushion has become integral to endoscopic mucosal and polyp resection. Solutions available for injection into the submucosa of the GI tract create short-lasting submucosal fluid cushions or are costly. The feasibility, durability, and histologic response to submucosal fluid cushions created by injection of hydroxypropyl methylcellulose were studied in the esophagus of pigs.

METHODS

Thirty-six esophageal submucosal fluid cushions created with hydroxypropyl methylcellulose were studied in 12 animals divided in 2 groups of 6 animals each. In Group I, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose followed by tattooing. In Group II, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose, with sites marked by an endoscopically placed suture. In all cases, the duration of the submucosal fluid cushion was measured. After 7 days, submucosal fluid cushion sites were assessed by EGD, necropsy, and histologic evaluation.

RESULTS

The mean submucosal fluid cushion duration was 36 minutes (3-45 minutes) and 38 minutes (5-45 minutes) for, respectively, Groups I and II. EGD and necropsy after 1 week showed normal-appearing mucosa at the site of all submucosal fluid cushions in both groups. Some Group I animals additionally had nodules at the tattoo sites. Histologic assessment demonstrated minimal alterations in 33 of 36 (92%) submucosal fluid cushion sites and localized mild inflammatory reaction in 3 of 36 (8%). In Group I, 8 of 18 (44%) tattoo sites exhibited a significant inflammatory reaction, including 3 abscesses.

CONCLUSIONS

Hydroxypropyl methylcellulose creates a long-lasting submucosal fluid cushion with minimal tissue reaction and should be considered a low-cost option for creating submucosal fluid cushions. The use of tattooing with carbon black should be carefully considered when histologic study is required to assess potential inflammatory tissue responses to an invasive technique or instillation of foreign material in the GI tract.