Endoscopic vs surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg. 2013;257:315-322. [PMID: 23059497 DOI: 10.1097/sla.0b013e318269d010]

The Role of Endoscopic Ultrasound in Ampullary Lesion Management

Ampullary lesions, neoplasms originating in the papilla of Vater, represent a rare yet clinically significant group of tumors with diverse etiologies and management challenges. This comprehensive review aims to elucidate the pivotal role of endoscopic ultrasound (EUS) in the diagnosis, staging, and management of ampullary lesions. This review begins by providing an overview of ampullary lesions, their epidemiology, and associated risk factors. We delve into their clinical presentation, emphasizing the importance of early and accurate diagnosis. Furthermore, we explore the limitations of traditional diagnostic modalities and highlight the growing relevance of EUS in ampullary lesion evaluation. We discuss the superior spatial resolution of EUS in comparison with other imaging methods, and we present an in-depth analysis of EUS-guided sampling and its pivotal role in obtaining histological samples for accurate diagnosis. In addition to diagnosis, we examine the indispensable role of EUS in ampullary lesion staging and its clinical implications. Furthermore, we discuss the potential of EUS in the surveillance and follow-up of ampullary lesions, ensuring timely detection of recurrence and monitoring treatment response in sporadic cases and in the context of familial syndromes, such as familial adenomatous polyposis (FAP). In conclusion, this review underscores the indispensable role of endoscopic ultrasound in the multifaceted approach to ampullary lesion evaluation. EUS not only enhances diagnostic accuracy but also informs treatment decisions and minimally invasive therapeutic interventions. As our understanding of ampullary lesions continues to evolve, EUS remains an invaluable tool for the improvement of patient outcomes and quality of life.

Endoscopic vacuum therapy (eVAC) combined with continuous perianastomotic irrigation for prevention of anastomotic leak after surgical ampullectomy

PURPOSE

Transduodenal surgical ampullectomy (tAMP) with papillary reimplantation is a valid alternative to pancreaticoduodenectomy for lesions of the periampullary region not amenable to endoscopic resection. As tAMP is burdened by high rates of biliopancreatic-enteric anastomotic leak, we tested preventive endoluminal vacuum therapy (eVAC) combined with post-operative continuous perianastomotic irrigation (CPI) to reduce such anastomotic leak.

METHODS

Between 10/2013 and 09/2023, 37 patients undergoing laparotomic tAMP (with or without jejunal transposition) and papillary reimplantation at Hirslanden Klinik Zurich were retrospectively analysed; of these, 16 received prophylactic eVAC combined with CPI, while the remaining represented the historical cohort.

RESULTS

The eVAC-CPI-group and the historical-cohort were homogeneous in demographic characteristics. Surgery in the prophylactic eVAC-CPI-group lasted about 30 min longer due to eVAC application (p = 0.008). The biliopancreatico-enteric anastomotic leak rates were 6.2% in the eVAC-CIP-group vs. 19.0% in the historical-cohort (p = 0.266). Along, a strong trend of less severe post-operative complications in general (p = 0.073), and borderline-significantly less cases of acute pancreatitis (p = 0.057) and tAMP-related re-operations or re-interventions (p = 0.057) in particular, were observed in the eVAC-CPI-group. The only anastomotic leak in the eVAC-CPI-group was successfully managed through repeated cycles of eVAC. The device was well tolerated by all patients; no vacuum/irrigation-related complications or malfunctioning occurred.

CONCLUSION

Our study is the first to provide some technical insights demonstrating the safety and feasibility of a prophylactic approach with eVAC and perianastomotic irrigation to reduce anastomotic leak after tAMP. Increasing the number of subjects will confirm the benefit of our promising results.

Endoscopic Versus Surgical Treatment for Ampullary Lesions: A Systematic Review With Meta-Analysis

Ampullary lesions (ALs) can be treated through either an endoscopic approach (EA) or a surgical approach (SA). However, it is important to note that EAs carry a significant risk of incomplete resection, while opting for surgical interventions can result in substantial morbidity. We performed a systematic review and meta-analysis for R0 resection, recurrence, adverse events in general, major adverse events, mortality, and length of hospital stay between SAs and EAs. Electronic databases were searched from inception to 2023. We identified nine independent studies. The risk difference was -0.32 (95% CI: -0.50, -0.15; p <0.001) for R0, 0.12 (95% CI: 0.06, 0.19; p < 0.001) for recurrence, -0.22 (95% CI: -0.43, 0.00; p 0.05) for overall adverse events, -0.11 (95% CI: -0.32, 0.10; p = 0.31) for major complications, -0.01 (95% CI: -0.02, 0.01; p = 0.43) for mortality, and -14.69 (95% CI: -19.91, -9.47; p < 0.001) for length of hospital stay. As expected, our data suggest a higher complete resection rate and lower recurrence from surgical interventions, but this is associated with an elevated risk of adverse events and a longer hospital stay.

A Case of Breast Cancer Metastasizing to the Ampulla of Vater

Secondary tumors of the ampulla of Vater are exceedingly rare and associated with relatively poor prognosis. Tumors of the ampulla are classified into four distinct subtypes based on the location and involvement of surrounding structures. Most reported cases are of renal cell or malignant skin melanoma primary with only five previously reported cases of breast primary found in a literature review. We present a 72-year-old woman with metastatic breast cancer to the ampulla of Vater as well as multiple bones. She had a history of breast cancer status post bilateral mastectomy and chemo 27 years prior. She presented to the hospital with altered mental status and was found to have an acute liver injury. Magnetic resonance cholangiopancreatography revealed a distended gallbladder and an indeterminate left retroperitoneal mass concerning for cystic or necrotic lymphadenopathy. Endoscopy then showed an edematous and erythematous periampullary region, which was biopsied and returned positive for carcinoma. Immunohistochemical staining of the retroperitoneal mass returned positive for keratin, estrogen receptor, GATA3, and MOC31 and negative for progesterone receptor, WT1, calretinin, and E-cadherin. The periampullary region's immunohistochemistry returned positive for pankeratin (AE1/AE3) and CD138 and negative for CD45 and S100, supporting a diagnosis of primary breast carcinoma. The average time from diagnosis of breast cancer to metastasis was found to be 2.5 years. Endoscopic visual presentation of metastatic cancer to the ampulla is indistinguishable from that of primary cancers. Thus, a biopsy with cytology and immunohistochemical analysis is necessary for diagnosis. Management of secondary ampullary tumors requires a multidisciplinary team, including gastroenterology, surgery, oncology, and often palliative care. Secondary tumors have been found to be treated by any combination of Whipple's resections, chemotherapy, drainage/stenting, and endoscopic ampullectomy.

Endoscopic papillectomy could be rewarding to patients with early stage duodenal ampullary carcinoma?

BACKGROUND/PURPOSE

There is currently no consensus on the use of endoscopic papillectomy (EP) for early stage duodenal ampullary adenocarcinoma. This study aimed to evaluate the feasibility of EP for patients with early stage duodenal ampullary adenocarcinoma.

METHODS

Patients who underwent EP for ampullary adenocarcinomas were investigated. Complete and clinical complete resection rates were evaluated. Clinical complete resection was defined as either complete resection or resection with positive or unknown margins but no cancer in the surgically resected specimen, or no recurrence on endoscopy after at least a 1-year follow-up.

RESULTS

Adenocarcinoma developed in 30 patients (carcinoma in situ [Tis]: 21, mucosal tumors [T1a(M)]: 4, tumors in the sphincter of Oddi [T1a(OD)]: 5). The complete resection rate was 60.0% (18/30) (Tis: 66.7% [14/21], T1a[M]: 50.0% [2/4], and T1a[OD]: 40.0% [2/5]). The mean follow-up period was 46.8 months. The recurrence rate for all patients was 6.7% (2/30). The clinical complete resection rates of adenocarcinoma were 89.2% (25/28); rates for Tis, T1a(M), and T1a(OD) were 89.4% (17/19), 100% (4/4), and 80% (4/5), respectively.

CONCLUSIONS

EP may potentially achieve clinical complete resection of early stage (Tis and T1a) duodenal ampullary adenocarcinomas.

Bleeding after endoscopic papillectomy and its risk factors: A single center experience of 196 cases

BACKGROUND

Endoscopic papillectomy (EP) is an effective method to remove an ampulla of Vater (AoV) adenoma with minimal invasiveness. We reviewed the clinical outcomes and prognosis of patients undergoing EP, including tumor recurrence and adverse events.

METHODS

A total of 196 patients who underwent EP from January 2004 to December 2017 were included. Clinical information was collected through electronic medical records, and risk factors to predict post-procedural bleeding were analyzed using a multivariate logistic regression model.

RESULTS

A total of 93.9% patients (184/196) underwent complete resection. During the follow-up period, 14.7% patients (27/184) experienced tumor recurrence, and two of seven surgically resected tumors were malignant. A total of 45.4% patients (89/196) experienced adverse events related to EP. Delayed bleeding occurred in 16.3% of the patients (32/196), and they were all successfully treated with endoscopic hemostasis and conservative management. The most frequent site of delayed bleeding was the distal end of the papillary orifice, and 56.2% (18/32) patients of delayed bleeding were classified as having mild severity, the others had moderate severity. Familial adenomatous polyposis (FAP) [odds ratio (OR) = 3.80, 95% confidence interval (CI): 1.01-14.29; P < 0.05] and male sex (OR = 2.82, 95% CI: 1.04-7.63; P = 0.04) showed statistical significance in predicting delayed post-EP bleeding.

CONCLUSIONS

EP for AoV adenoma was a highly effective and safe procedure. The risk of post-EP delayed bleeding was increased in patients with FAP syndrome and male patients, and post-EP bleeding occurred most commonly in the distal part of the AoV.

The Significance of Histopathological Findings on Clinical Outcomes in Endoscopic Papillectomy with Endocut

This study aimed to evaluate primary clinical outcomes in patients who underwent endoscopic papillectomy (EP) using the Endocut mode while examining the pathological characteristics of the margin of the resected specimen. To this end, 70 patients who underwent Endocut EP were included. Resection margins were classified according to pathological findings as "negative", "positive", or "uncertain (difficult pathological evaluation)". The effect of pathological resection margins on residual tumor recurrence rates was evaluated. The median follow-up was 47 months (range, 22-84). Eleven patients (15.7%) were diagnosed with residual tumors, ten of whom were diagnosed within 6 months after EP. The resection margins were pathologically negative in 27 patients, positive in 15, and uncertain in 28; residual tumors occurred in 5 patients (33.3%) in the positive group, 5 (17.9%) in the uncertain group, and 1 (3.7%) in the negative group. The patient in the negative group had familial adenomatous polyposis (FAP). Female sex, FAP, and uncertain or positive resection margins were significantly more common in residual patients (p = 0.009, 0.044, and 0.041, respectively). Pathological resection margins can be used to infer the residual tumor incidence, leading to early post-treatment of residual tumors.

Long-term follow-up of endoscopic papillectomy and the value of preventive pancreatic stent placement (with videos)

Background

Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management. Hence, this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy (EP).

Methods

In this study, 115 patients who underwent EP at Changhai Hospital (Shanghai, China) between January 2012 and December 2018 were retrospectively analysed. Endoscopy was performed at 1, 3, 6, and 12 months after EP. Data were statistically analysed using the t-test or the Mann-Whitney U test.

Results

A total of 107 patients were included in this study and the follow-up period was 75 ± 43 months. The average age of the 107 patients was 54.6 years and the average tumor size was 17 mm. The average age of the patients (53.7 ± 10.7 years vs 55.2 ± 10.5 years, P = 0.482), minimum tumor size (13 vs 19 mm, P = 0.063), and complete resection rate (84.78% vs 85.25%, P = 0.947) did not differ significantly between the stent placement and non-stent placement groups. Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48% and 4.35%, respectively. The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis, but not in multivariate analysis. The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis. Moreover, delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up.

Conclusions

EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.

Laparoscopic transduodenal ampullectomy: initial experience from a single center

Background

Laparoscopic transduodenal ampullectomy (LTDA) is a function-preserving surgery for pre-malignant tumors of the ampulla of Vater (AoV). However, it is technically challenging, and only a few case reports of LTDA are available in the literature.

Methods

A total of 43 cases of pre-malignant tumors of AoV were operated in West China Hospital, Sichuan University between January 2017 and July 2022. Among these patients, 9 patients (group 1) underwent LTDA, 19 patients (group 2) underwent laparoscopic pancreaticoduodenectomy (LPD), and 15 patients (group 3) underwent open transduodenal ampullectomy (OTDA). Prospective collection and retrospective analysis of the demographic characteristics, intraoperative variables, and postoperative variables were carried out.

Results

The patients in the three groups were comparable in terms of sex, age, body mass index, tumor size, and preoperative blood tests. In comparison to the patients in group 2, the patients in group 1 were found to require less operative time (159.7 ± 47.5 min vs. 298.1 ± 62.6, p < 0.01) and suffered lower blood losses (23.3 ± 16.7 ml vs. 156.8 ± 112.1, p = 0.002) and complications. Moreover, the postoperative hospital stays (POHS) were significantly shorter for patients in group 1 (9.0 ± 5.3 days vs. 15.5 ± 7.3 days, p = 0.04). Compared to patients who underwent OTDA, the patients in LTDA suffered from less blood loss. The operative time and post-operative details were comparable.

Conclusion

Therefore, LTDA was found to be safe and feasible in the setting of pre-malignant tumors of AoV in well-selected patients. However, multidisciplinary preoperative planning is essential before the surgery.

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

BACKGROUND AND AIMS

Ampullary adenomas are treated both surgically and endoscopically, however, data comparing both techniques are lacking. We aimed to compare long-term recurrence of benign sporadic adenomas after endoscopic (EA) and surgical ampullectomy (SA).

METHODS

A comprehensive literature search of multiple databases (until December 29, 2020) was performed to identify studies reporting outcomes of EA or SA of benign sporadic ampullary adenomas. The outcome was recurrence rate at 1 year, 2-year, 3 year and 5 years after EA and SA.

RESULTS

A total of 39 studies with 1753 patients (1468 EA [age 61.1 ± 4.0 years, size 16.1 ± 4.0 mm], 285 SA [mean age 61.6 ± 4.48 years, size 22.7 ± 5.4 mm]) were included in the analysis. At year 1, pooled recurrence rate of EA was 13.0% (95% confidence interval [CI] 10.5-15.9], I² = 31%) as compared to SA 14.1% (95% CI 9.5-20.3 I² = 15.8%) (p = 0.82). Two (12.5%, [95% CI, 8.9-17.2] vs. 14.3 [95% CI, 9.1-21.6], p = 0.63), three (13.3%, [95% CI, 7.3-21.6] vs. 12.9 [95% CI, 7.3-21.6], p = 0.94) and 5 years (15.7%, [95% CI, 7.8-29.1] vs. 17.6% [95% CI, 6.2-40.8], p = 0.85) recurrence rate were comparable after EA and SA. On meta-regression, age, size of lesion or enbloc and complete resection were not significant predictors of recurrence.

CONCLUSION

EA and SA of sporadic adenomas have similar recurrence rates at 1, 2, 3 and 5 years of follow up.

Transduodenal ampullectomy for early ampullary cancer: Clinical management, histopathological findings and long-term outcomes at a single center

BACKGROUND

Transduodenal ampullectomy has been attempted in ampullary tumors, including early ampullary cancer. However, the indication and extent of transduodenal ampullectomy with curative intent remain controversial. Herein, we address the perioperative and long-term outcomes of patients with early ampullary cancer who underwent transduodenal ampullectomy at a single center.

METHODS

We retrospectively enrolled 10 early ampullary cancer patients who underwent transduodenal ampullectomy and 11 early ampullary cancer patients who underwent subtotal stomach-preserving pancreatoduodenectomy at Saitama Cancer Center between October 2008 and May 2021. Among this cohort, we analyzed the perioperative outcomes and long-term outcomes.

RESULTS

In terms of the perioperative outcomes between the transduodenal ampullectomy and subtotal stomach-preserving pancreatoduodenectomy groups, the transduodenal ampullectomy group exhibited a shorter operating time (244 minutes vs 390 minutes, P = .003), less intraoperative blood loss (67.5 grams vs 774 grams, P = .006) and shorter length of postoperative hospital stay (15 days vs 33 days). With respect to the postoperative nutrition status, the transduodenal ampullectomy group exhibited less postoperative weight loss (0.67% vs 8.95%, P = .021), a better Controlling Nutritional Status score (1.0 vs 2.1, P = .011) and a better Prognostic Nutritional Index score (42.9 vs 40.9, P = .018). The 5-year survival in the adenoma with high-grade dysplasia and T1 ampullary cancer which invaded the mucosal layer groups was 100%, whereas the median survival time in the T1 ampullary cancer which invaded the sphincter of Oddi group was 20.7 months (P = .0028).

CONCLUSION

Transduodenal ampullectomy is assumed to be a feasible and effective surgical procedure for the treatment of selected patients with early ampullary cancer, including patients with adenoma with high-grade dysplasia or T1 ampullary cancer which invaded the mucosal layer ampullary cancer.

Endoscopic Surveillance and Treatment of Upper GI Tract Lesions in Patients with Familial Adenomatous Polyposis-A New Perspective on an Old Disease

Familial adenomatous polyposis (FAP) is an autosomal dominant disease caused by a germline mutation in the adenomatous polyposis coli (APC) gene. Patients with FAP develop up to thousands of colorectal adenomas as well as lesions in the upper GI tract. In FAP, the upper digestive lesions include gastric fundic gland polyps (FGPs), antrum adenomas, duodenal or small intestinal adenomas, and carcinoma. Patients, after colectomy, are still at significant risk for extracolonic malignancies. Advances in endoscope resolution and optical enhancement technologies allow endoscopists to provide assessments of benign and malignant polyps. For this reason, in the past decades, endoscopic resection techniques have become the first line of treatment in patients with polyps in the upper GI, whereby polyps and even early cancers can be successfully cured. In FAP patients, endoscopic ampullectomy appears to be a safe and effective way of treating patients with ampullary tumors. According to current indications, endoscopic retrograde cholangiopancreatography (ERCP) and stenting of the main pancreatic duct follow ampullectomy.

Analysis of risk factors for post-endoscopic papillectomy bleeding

BACKGROUND

Endoscopic papillectomy (EP) is an effective treatment for ampullary lesions but technically challenging because of anatomical specificities concerning the high rate of adverse events. Bleeding is one of the most feared complications and can be potentially life-threatening.

AIM

To study the risk factors for bleeding after EP are presented with the goal of establishing preventive measures.

METHODS

A total of 173 consecutive patients with ampullary lesions undergone EP from January 2006 to October 2020 were enrolled in this study. They were divided into a bleeding group and a non-bleeding group depending on whether postoperative bleeding occurred. Related factors were analyzed by univariate and multivariate logistics regression.

RESULTS

Postoperative bleeding was experienced in 33 patients (19.07%). Multivariate analysis also identified intraoperative bleeding (OR: 4.38, 95% CI: 1.87-11.15, p = .001) and endoscopic closure (OR: 0.25, 95% CI: 0.10-0.58, p = .001) as independent factors significantly associated with bleeding after EP. Lesion size (≥3 cm) was shown as an independent factor significantly associated with intraoperative bleeding (OR: 4.25, 95% CI: 1.21-16.44, p = .028).

CONCLUSIONS

This retrospective evaluation found that endoscopic closure was associated with reduced risk and intraoperative bleeding with increased risk of bleeding after EP. Lesion size may indirectly influence the risk of postoperative bleeding by increasing the risk of intraoperative bleeding.

Endoscopic Management of Ampullary Adenomas in Familial Adenomatous Polyposis Syndrome: A Systematic Review with Pooled Analysis

BACKGROUND

Endoscopic papillectomy is a viable therapy in ampullary lesions. Prior studies have reported on outcomes of sporadic ampullary lesions, and only small cohort studies have reported outcomes associated with familial adenomatous polyposis (FAP) syndrome.

AIMS

We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for treating ampullary adenomas in FAP.

METHODS

We performed a comprehensive literature search of major databases from inception to May 2020. Studies that included patients with endoscopically resected ampullary lesions and FAP were eligible. The rate of technical success, en bloc resection, piecemeal resection, recurrence, and adverse events was pooled by means of a random-effects model to obtain a proportion with a 95% confidence interval (CI).

RESULTS

Six studies, including a total of 99 patients, were included in our final analysis. Patient age ranged from 28 to 91 years. Pooled technical success was 90.3% (CI 76.9-96.3%, I² = 31%). Rate of en bloc resection was 60.6% (CI 47.9-72.0%, I² = 0%). Recurrence rate was 25.4% (5.7-65.9%, I² = 82%). The post-procedural pancreatitis rate was 14.7% of which 68% (51 of 75) utilized prophylactic pancreatic stenting. Other adverse events included bleeding (9.2%) and perforation (4%).

CONCLUSION

Endoscopic papillectomy offers high technical success but remains challenging in patients with FAP, particularly due to high recurrence rates.

Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study

BACKGROUND

Ampullary adenoma is a rare premalignant lesion, but its incidence is increasing. Endoscopic papillectomy has become the first treatment of choice for ampullary adenomas due to its safety and effectiveness, thereby replacing surgical resection. However, recurrence rates and adverse events after endoscopic papillectomy were reported in up to 30% of cases.

AIM

To review the long-term outcomes of endoscopic papillectomy and investigate the factors that affect these outcomes.

METHODS

We retrospectively analyzed the data of patients who underwent endoscopic papillectomy for ampullary adenoma at five tertiary hospitals between 2013 and 2020. We evaluated clinical outcomes and their risk factors. The definitions of outcomes were as follow: (1) curative resection: complete endoscopic resection without recurrence; (2) endoscopic success: treatment of ampullary adenoma with endoscopy without surgical intervention; (3) early recurrence: reconfirmed adenoma at the first endoscopic surveillance; and (4) late recurrence: reconfirmed adenoma after the first endoscopic surveillance.

RESULTS

A total of 106 patients were included for analysis. Of the included patients, 81 (76.4%) underwent curative resection, 99 (93.4%) had endoscopic success, showing that most patients with non-curative resection were successfully managed with endoscopy. Sixteen patients (15.1%) had piecemeal resection, 22 patients (20.8%) had shown positive/uncertain resection margin, 11 patients (16.1%) had an early recurrence, 13 patients (10.4%) had a late recurrence, and 6 patients (5.7%) had a re-recurrence. In multivariate analysis, a positive/uncertain margin [Odds ratio (OR) = 4.023, P = 0.048] and piecemeal resection (OR = 6.610, P = 0.005) were significant risk factors for early and late recurrence, respectively. Piecemeal resection was also a significant risk factor for non-curative resection (OR = 5.424, P = 0.007). Twenty-six patients experienced adverse events (24.5%).

CONCLUSION

Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas. Careful selection and follow-up of patients is mandatory, particularly in cases with positive/uncertain margin and piecemeal resection.

The impact of the age-adjusted Charlson comorbidity index as a prognostic factor for endoscopic papillectomy in ampullary tumors

BACKGROUND

The prognostic nutritional index (PNI) and Charlson comorbidity index (CCI) have been useful for predicting the prognosis based on nutritional condition and comorbidities in surgery and endoscopic mucosal dissection. The age-adjusted CCI (ACCI) has also been reported to be useful in surgery, but it has not been applied to endoscopic treatment. We therefore clarified the prognostic factors associated with ampullary tumors treated with endoscopic papillectomy (EP).

METHODS

From January 2003 to December 2020, 236 patients who underwent EP for sporadic ampullary tumors at Nagoya University Hospital were included in this study. The 5-year survival and ability to predict the prognosis were evaluated in terms of the sex, PNI, ACCI, final pathological diagnosis, and intraductal extension.

RESULTS

During a median follow-up period of 1558 days, 17 patients died. No patient died of the primary disease. The 5-year survival rate was 91.1%. In a univariate analysis, only a high ACCI (≥ 5) was extracted as a significant prognostic factor (Odds ratio, 12.2; 95% confidence interval, 3.81-39.3; p < 0.001). The 5-year survival rates for a low ACCI (≤ 4) and high ACCI were 96.6% and 73.5%, respectively (p < 0.001).

CONCLUSIONS

A high ACCI is an important prognostic factor associated with the 5-year survival and a risk of death from other illness. Ampullary tumors suitable for EP are less likely to be a prognostic factor, and treatment-free follow-up may be acceptable in patients with a high ACCI.

Clinical practice guidelines for endoscopic papillectomy

The Japan Gastroenterological Endoscopy Society has developed the "Clinical Practice Guidelines for Endoscopic Papillectomy (EP)" as a fundamental guideline using scientific approach. EP is a recently spreading therapeutic modality for ampullary tumors ranked as high risk endoscopic technique. Because of the paucity of high level of evidence, strength of recommendations had to be determined by a consensus among specialists. These guidelines, shed light on the following five issues: Indications, Preoperative/intraoperative preparations and techniques, Early adverse events, Therapeutic outcomes and remnants/recurrences, and Follow-up and late adverse events, to guide current clinical practice on EP.

Histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in nonampullary duodenal epithelial tumors

For patients with nonampullary duodenal epithelial tumors (NADETs), endoscopic forceps biopsy results that reflect the final histopathologic results of the entire lesion are indispensable for accurate diagnosis and appropriate treatment modality selection. This study aimed to investigate the histopathologic discrepancies between endoscopic forceps biopsy and endoscopic resection specimens in NADETs and to elucidate the factors contributing to such discrepancies.This retrospective observational study included 105 patients (105 lesions) who underwent endoscopic resection for NADETs at the Pusan National University Hospital between May 2006 and October 2019. NADETs were classified as low-grade intraepithelial neoplasms (LGINs), high-grade intraepithelial neoplasms (HGINs), or adenocarcinomas. Following slide reviews, the histopathologic concordance between endoscopic forceps biopsy and endoscopic resection specimens was assessed for each case.The histopathologic discrepancy rate between endoscopic forceps biopsy and endoscopic resection specimens was 19.0% (20/105 lesions). Among the 20 diagnostically discordant lesions, up- and downgrade of the histopathologic diagnosis occurred in 17 and 3 lesions, respectively. The predominant discrepancies involved upgrades from LGIN to HGIN (n = 14) and upgrades from LGIN to adenocarcinomas (n = 2). The 3 downgraded cases included 2 from LGIN to inflammation and 1 from HGIN to LGIN. In the multivariate analyses, the old age (>67 years) was the only factor significantly associated with histopathologic upgrade (odds ratio 4.553, 95% confidence interval 1.291-15.939; P = .018).Considerable histopathologic discrepancies were observed between endoscopic forceps biopsy and endoscopic resection specimens in NADETs. Older age was significantly associated with these discrepancies.

Surgical Outcomes and Comparative Analysis of Transduodenal Ampullectomy and Pancreaticoduodenectomy: A Single-Center Study

Background

Transduodenal ampullectomy (TDA) is performed for adenoma or early cancer of the ampulla of Vater (AoV). This study aimed to analyze the short- and long-term outcomes of TDA (TDA group) when compared with conventional pancreaticoduodenectomy (PD) or pylorus-preserving pancreaticoduodenectomy (PD group).

Methods

Patients who underwent TDA between January 2006 and December 2019, and PD cases performed for AoV malignancy with carcinoma in-situ (Tis) (high-grade dysplasia, HGD) and T1 and T2 stage from January 2010 to December 2019 were reviewed.

Results

Forty-six patients underwent TDA; 21 had a benign tumor, and 25 cases with malignant tumors were compared with PD cases (n = 133). Operation time (p < 0.001), estimated blood loss (p < 0.001), length of hospital stays (p = 0.003), and overall complication rate (p < 0.001) were lower in the TDA group than in the PD group. Lymph node metastasis rates were 14.6% in pT1 and 28.9% in pT2 patients. The 5-year disease-free survival and 5-year overall survival rates for HGD/Tis and T1 tumor between the two groups were similar (TDA group vs PD group, 72.2% vs 77.7%, p = 0.550; 85.6% vs 79.2%, p = 0.816, respectively).

Conclusion

TDA accompanied with lymph node dissection is advisable in HGD/Tis and T1 AoV cancers in view of superior perioperative outcomes and similar long-term survival rates compared with PD.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11190-9.

Surgical ampullectomy: A comprehensive review

Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system. They are typically diagnosed at an earlier stage than other types of tumours in this region, due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct. Consequently, many are potentially curable by excision. Surgical ampullectomy (SA) (or transduodenal ampullectomy) for an ampullary tumour was first described in 1899, but was soon surpassed by pancreatoduodenectomy (PD), which offered a more extensive resection resulting in a lower risk of recurrence. Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy (EP), particularly for adenomas and even early cancers. The vast majority of resectable ampullary tumours are now treated using either PD or EP. However, SA continues to play a role in specific circumstances. Many authors have suggested specific indications for SA based on their own data, practices, or interpretations of the literature. However, certain issues have attracted controversy, such as its use for early ampullary cancers. Consequently, there has been a lack of clarity regarding indications for SA, and no evidence-based consensus guidelines have been produced. All studies reporting SA have employed observational designs, and have been heterogeneous in their methodologies. Accordingly, characteristics of patients and their tumours have differed substantially across treatment groups. Therefore, meaningful comparisons of clinical outcomes between SA, PD and EP have been elusive. Nevertheless, it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival, hence its role in this setting warrants further clarification, while it can also be useful in the management of specific benign entities. Whilst the commissioning of a randomised controlled trial seems unlikely, well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA, potentially informing the eventual development of consensus guidelines. In this comprehensive review, we explore the role of SA in the modern management of ampullary lesions.

Endoscopic papillectomy; a retrospective international multicenter cohort study with long-term follow-up

BACKGROUND

Endoscopic papillectomy (EP) is considered a relatively safe and minimally invasive treatment for papillary adenomas. In the literature a significant risk for local recurrence is described. The aim of this study was to evaluate long-term recurrence rates and time-to-recurrence. Additionally, risk factors for recurrence, malignancy and adverse events were studied.

METHODS

This is a retrospective study in consecutive patients with papillary adenomas who underwent EP in two tertiary referral hospitals between 2001 and 2018. Primary outcome was recurrence in patients with at least 1-year endoscopic follow-up. Secondary outcomes were surgery free survival, adverse events, and mortality within 30 days after the index procedure.

RESULTS

A total of 259 patients were found eligible [median age 66 years, 130 male (50.2%)]. Forty-three patients were known with familial adenomatous polyposis (FAP) (16.6%). At least 1-year endoscopic follow-up was available in 154 patients with a total follow-up of 586 person-years and median of 40 months [interquartile range (IQR) 25-75]. Recurrence occurred in 24 cases (15.6%) of which 8 were known with FAP, leading to a recurrence incidence rate of 4.1 per 100 person-years with a median time-to-recurrence of 29 months (IQR 14.75-59.5). Fifty-three patients underwent at least 5-year follow-up, in 6 (11.3%) of them recurrence was encountered after 5 years of which four were known with FAP. No risk factors for recurrence could be identified. Adverse events occurred in 50/259 patients (19.3%). One patient died within 30 days after the procedure. Papillary stenosis occurred in 19/259 (7.3%) of the patients. There were no cases of malignant degeneration during follow-up.

CONCLUSIONS

Recurrence after EP occurs in a significant proportion of patients and occurs even 5 years after EP. This emphasizes the need for long-term follow-up. We advise to consider at least 5-year follow-up in case of a sporadic adenoma, unless comorbidity makes follow-up clinically irrelevant.

Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature

BACKGROUND

Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.

CASE SUMMARY

A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.

CONCLUSION

Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.

Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection?

BACKGROUND

Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions.

MATERIALS AND METHODS

Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen.

RESULTS

In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma.

CONCLUSIONS

In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.

Radiofrequency ablation for intraductal extension of ampullary adenomatous lesions: proposal for a standardized protocol

Background and study aims  Intraductal extension of ampullary adenoma represents a challenging endoscopic issue. Intraductal radiofrequency ablation (RFA) has been recently suggested, but evidence and standardization of this technique are still lacking. This study aimed to provide a long-term evaluation of clinical efficacy and safety of intraductal RFA ablation with a standardized algorithm of treatment. Patients and methods  Data were prospectively collected from consecutive patients with intraductal extension of adenomatous ampullary lesions from January 2016 to November 2018. Endpoints of the study were clinical success evaluated on histology results at the last follow-up, technical success, and adverse events assessment. Results  Nine patients with intraductal (biliary ± pancreatic) extension of ampullary adenomas were treated with RFA during the study period. Histology on the papillectomy specimen confirmed intraductal involvement with low-grade dysplasia (LGD) in five cases (56 %), high-grade dysplasia (HGD) in three (33 %), and HGD with intramucosal adenocarcinoma in one patient (11 %). Additional argon plasma coagulation to ablate the adenoma on the duodenal mucosa was applied in five patients (56 %). Technical success was 100 %. One patient (11 %) with failed pancreatic stenting, developing acute pancreatitis after RFA, recovered with medical therapy. After a median follow-up of 21 months (IQR 20-31), six patients (67 %) achieved clinical success being free of recurrence, whereas one was diagnosed with persistence of adenocarcinoma, one with recurrent HGD, and one with recurrent LGD. Conclusions  In our experience, intraductal RFA achieved acceptable results after a 2-year follow-up. Further studies are required to confirm our results and to select those patients most likely to respond.

The Long-Term Outcomes of Endoscopic Papillectomy and Management of Cases of Incomplete Resection: A Single-Center Study

BACKGROUND

Endoscopic papillectomy is increasingly performed as an alternative to surgery for early ampullary tumors.

AIM

This retrospective study aimed to evaluate the long-term results of endoscopic papillectomy, the management of cases with incomplete endoscopic resection, and the long-term recurrence rates.

METHODS

All 46 patients who underwent endoscopic papillectomy for ampullary tumors between November 2003 and March 2018 were retrospectively evaluated.

RESULTS

The final pathological diagnoses were adenoma (n = 44) and adenocarcinoma (n = 2). Histopathological evaluations after endoscopic papillectomy revealed that complete resection was achieved in 19 patients (19/46, 41.3%). Among the 27 patients with incomplete resection, the margin was histopathologically positive in 14 patients and difficult to evaluate in 13. Additional surgery was performed for 2 of the 14 patients with positive margins. Excluding 2 patients who received additional surgery, 7 of the 25 patients with incomplete resection had recurrence, and 18 had no recurrence during the follow-up period. Ten (77%) of the 13 patients in whom the margin was difficult to evaluate had no recurrence.

CONCLUSION

Approximately 80% of the patients in whom the histopathological evaluation of the resected margin was difficult had no recurrence even after approximately 5 years of follow-up. Thus, careful observation may be considered for these patients.

Endoscopic Ampullectomy of Benign Ampullary Lesions: Outcomes From a Single Center Study

BACKGROUND

Endoscopic ampullectomy (EA) offers an insignificantly intrusive strategy for viably treating mucosal and occasionally submucosal lesions of the ampulla of Vater and encompassing periampullary area with high achievement and is more secure. The aim of this study was to present safety, efficacy, and outcomes of EA in the treatment of benign lesions of ampulla Vater performed by single experienced endoscopists in a high volume center.

METHODS

This retrospective study was conducted in patients referred to our hospital (Turkey High Speciality Training and Research Hospital, Turkey) for endoscopic evaluation of ampullary benign lesions over an 8-year period (between October 2011 and September 2019). Success rate was defined as complete resection of lesions.

RESULTS

Twenty-nine patients with a median age of 64 years were included. Twenty-five patients had lesions confined to the ampulla vateri (86.2%). Accordingly, 2 lesions had intraductal extension adenoma (IDA) (6.9%) and 2 were lateral spreading adenoma (6.9%). The median size of the lesion was 17.5 mm (10 to 36 mm). Nineteen lesions (65.5%) were resected en bloc and 10 lesions (34.5%) were resected in piecemeal manner. Complete resection was achieved in 21 of 23 patients with benign ampullary lesions. The procedure success rate was 91.3%. Complications occurred in 6 patients (20.6%) of these 3 had (10.3%) bleeding, 2 (6.8%) had pancreatitis, and 1 had (3.4%) perforation. Four patients (13.7%) had a recurrence.

CONCLUSIONS

Deep resection of the benign ampullary lesions increases the complete resection rate, cannulation rate of the pancreatic duct, and stenting rate of the pancreatic duct. EA is a safe and successful procedure in patients with benign lesions of ampulla vater.

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

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.

Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis

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.

Endoscopic management of duodenal adenomas in patients with familial adenomatous polyposis

BACKGROUND AND AIMS

Almost all patients with familial adenomatous polyposis (FAP) develop duodenal adenomas, with a 4% to 18% risk of progression into duodenal cancer. Prophylactic endoscopic resection of duodenal adenomas may prevent cancer and is considered safer than surgical alternatives; however, data are limited. Therefore, the aim of this study was to assess safety and effectiveness of endoscopic duodenal interventions in patients with FAP.

METHODS

We performed a historical cohort study including patients with FAP who underwent an endoscopic duodenal intervention between 2002 and 2018. Safety was defined as adverse event rate per intervention and effectiveness as duodenal surgery-free and duodenal cancer-free survival. Change in Spigelman stage was assessed as a secondary outcome.

RESULTS

In 68 endoscopy sessions, 139 duodenal polypectomies were performed in 49 patients (20 men; median age, 43). Twenty-nine patients (14 men; median age, 49) underwent a papillectomy. After polypectomy, 9 (13%) bleedings and 1 (2%) perforation occurred, all managed endoscopically. Six (21%) bleedings (endoscopically managed), 4 (14%) cases of pancreatitis, and 1 (3%) perforation (conservatively treated) occurred after papillectomy. Duodenal surgery-free survival was 74% at 89 months after polypectomy and 71% at 71 months after papillectomy; no duodenal cancers were observed. After a median of 18 months (interquartile range, 10-40; range, 3-121) after polypectomy, Spigelman stages were significantly lower (P < .01).

CONCLUSIONS

In our FAP patients, prophylactic duodenal polypectomies were relatively safe. Papillectomies showed substantial adverse events, suggesting its benefits and risk should be carefully weighted. Both were effective, however, because surgical interventions were limited and none developed duodenal cancer.

Endoscopic Papillectomy for Ampullary Adenomas: Different Outcomes in Sporadic Tumors and Those Associated with Familial Adenomatous Polyposis

BACKGROUND

Ampullary adenomas are rare and potentially malignant. Surgery was the standard treatment but endoscopic papillectomy (EP) is a possible alternative.

AIM

We retrospectively evaluated the principal clinical outcomes of EP in all patients referred to our unit also dividing sporadic ampullary adenoma (SAA) from familial adenomatous polyposis (FAP)-associated adenomas.

METHODS

All consecutive patients who underwent endoscopic papillectomy because of ampullary adenoma were considered. The primary outcome was the technical success of EP. Secondary outcomes included the number of procedures, the adverse event rate, the recurrence rate, the concordance of histology pre- and post-EP, and the evaluation of factors related to technical success.

RESULTS

Between January 2001 and December 2015, sixty-two patients were included (21 FAP and 41 SAA). Technical success was achieved in 75.8% and was different in the two groups (FAP 95.2%, SAA 65.8%, p 0.025). Intraductal invasion was negatively associated with technical success (41.7% vs. 84.0%; p 0.005). The intestinal subtype was predictive of success (79.7% vs. 0%; p 0.012) as well as en bloc resection (90.3% vs. 61.3%; p 0.016). Adverse events were reported in 14 patients (22.6%).

CONCLUSIONS

EP is an effective and safe procedure and is a viable alternative to surgery.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03494543.

Transduodenal surgical ampullectomy: a procedure that requires a multidisciplinary approach

Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180-390), mean tumor size was 2.3 cm (range 1.5-3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1-96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8-60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.

Clinical practice guidelines for the management of biliary tract cancers 2019: The 3rd English edition

BACKGROUND

The Japanese Society of Hepato-Biliary-Pancreatic Surgery launched the clinical practice guidelines for the management of biliary tract cancers (cholangiocarcinoma, gallbladder cancer, and ampullary cancer) in 2007, then published the 2nd version in 2014.

METHODS

In this 3rd version, clinical questions (CQs) were proposed on six topics. The recommendation, grade for recommendation, and statement for each CQ were discussed and finalized by an evidence-based approach. Recommendations were graded as Grade 1 (strong) or Grade 2 (weak) according to the concepts of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

The 31 CQs covered the six topics: (a) prophylactic treatment, (b) diagnosis, (c) biliary drainage, (d) surgical treatment, (e) chemotherapy, and (f) radiation therapy. In the 31 CQs, 14 recommendations were rated strong and 14 recommendations weak. The remaining three CQs had no recommendation. Each CQ includes a statement of how the recommendations were graded.

CONCLUSIONS

This latest guideline provides recommendations for important clinical aspects based on evidence. Future collaboration with the cancer registry will be key for assessing the guidelines and establishing new evidence.

Systematic Review with Meta-Analysis: Endoscopic and Surgical Resection for Ampullary Lesions

Ampullary lesions (ALs) can be treated by endoscopic (EA) or surgical ampullectomy (SA) or pancreaticoduodenectomy (PD). However, EA carries significant risk of incomplete resection while surgical interventions can lead to substantial morbidity. We performed a systematic review and meta-analysis for R0, adverse-events (AEs) and recurrence between EA, SA and PD. Electronic databases were searched from 1990 to 2018. Outcomes were calculated as pooled means using fixed and random-effects models and the Freeman-Tukey-Double-Arcsine-Proportion-model. We identified 59 independent studies. The pooled R0 rate was 76.6% (71.8-81.4%, I2 = 91.38%) for EA, 96.4% (93.6-99.2%, I2 = 37.8%) for SA and 98.9% (98.0-99.7%, I2 = 0%) for PD. AEs were 24.7% (19.8-29.6%, I2 = 86.4%), 28.3% (19.0-37.7%, I2 = 76.8%) and 44.7% (37.9-51.4%, I2 = 0%), respectively. Recurrences were registered in 13.0% (10.2-15.6%, I2 = 91.3%), 9.4% (4.8-14%, I2 = 57.3%) and 14.2% (9.5-18.9%, I2 = 0%). Differences between proportions were significant in R0 for EA compared to SA (p = 0.007) and PD (p = 0.022). AEs were statistically different only between EA and PD (p = 0.049) and recurrence showed no significance for EA/SA or EA/PD. Our data indicate an increased rate of complete resection in surgical interventions accompanied with a higher risk of complications. However, studies showed various sources of bias, limited quality of data and a significant heterogeneity, particularly in EA studies.

A Comparison of Clinical Outcomes between Endoscopic Resection and Surgical Resection in Ampullary Tumors

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A Novel Technique of Endoscopic Papillectomy with Hybrid Endoscopic Submucosal Dissection for Ampullary Tumors: A Proof-of-Concept Study (with Video)

BACKGROUND

Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Since hybrid endoscopic submucosal dissection (ESD) had been established as an alternative option for relatively large and difficult gastrointestinal tumors, we evaluated a novel EP with hybrid ESD (hybrid ESD-EP) for curative safe margin in this proof-of-concept study.

METHODS

A total of eight cases who underwent hybrid ESD-EP between 2018 and 2020 were identified from our prospectively maintained database. Hybrid ESD-EP involved a (sub)circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated.

RESULTS

En bloc resection was achieved by hybrid ESD-EP in all eight cases, with the median procedure time of 112 (range: 65-170) minutes. The median diameters of the resected specimens and tumors were 18 and 12 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in three (38%), resulting in the complete resection rate of 63%. Postoperative bleeding and pancreatitis developed in each one (13%). No tumor recurrence was observed even in those cases with uncertain vertical margin, after a median follow-up of 244 (range, 97-678) days.

CONCLUSIONS

Hybrid ESD-EP seems to be feasible and promising in ensuring the lateral resection margin. However, further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required.

A Comprehensive Approach to the Management of Benign and Malignant Ampullary Lesions: Management in Hereditary and Sporadic Settings

PURPOSE OF REVIEW

The purpose of this review was to examine the historical roots of endoscopic management of ampullary lesions and explore emerging data on improved techniques, technologies, and outcomes. Of specific interest was answering whether there exists a reasonable body of data to support one resection technique or strategy above others.

RECENT FINDINGS

Review of recent literature suggests the continued use of endoscopic ampullectomy is a safe and effective means of curative treatment of ampullary adenomas. Complications are relatively infrequent and complete endoscopic resection is possible in a majority of cases, with proper patient and lesion selection. Greater than 2 decades of experience with endoscopic ampullectomy have shown this to be a viable, well-tolerated, and highly effective means of treating ampullary adenomas. While few concrete guidelines exist to advise endoscopists on the ideal technique for resection, experience, patient selection, and prior planning can greatly influence the technical and clinical success of endoscopic ampullectomy.

Endoscopic papillectomy of benign papillary tumors: A single-center experience

Endoscopic treatment of duodenal papillary tumors is well described. This study aims to provide new evidence for the treatment of benign papillary tumors through comparisons between endoscopic snare papillectomy (ESP) and endoscopic mucosal resection (EMR).Between May 2010 and December 2017, 72 patients were enrolled. Diagnosis and treatment procedures were ESP and EMR. Endoscopic follow-up evaluation was done periodically as a surveillance measurement for recurrence.Seventy-two patients with ampullary tumors were enrolled, of which 66 had adenomas including 9 high-grade intraepithelial neoplasias and 2 carcinomas in adenoma. Complete resections with tumor-free lateral and basal margins were achieved in all patients. Postoperative complications were bleeding (9.5% in EMR vs 10% in ESP) and pancreatitis (2.4% in EMR and 3.3% in ESP), with no occurrence of perforation, cholangitis or papillary stenosis. Adenoma recurrence was found in 7 patients (14.3% in EMR vs 3.3% in ESP) at 1 year.The ESP procedure is safe and effective for benign ampullary adenoma, high-grade intraepithelial neoplasias, and noninvasive cancer without intraductal tumor growth, which has a shorter procedural duration, as well as lower complication, recurrence rates and hospitalization costs.

Study Protocol of the ESAP Study: Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodenectomy for Ampullary Neoplasm-A Pancreas2000/EPC Study

Background: Lesions of the Ampulla of Vater are a rare condition and represent <10% of peri-ampullary neoplasms. Nevertheless, ampullary adenomas have the potential for malignant transformation to ampullary carcinomas by an adenoma-to-carcinoma sequence. Thus, adequate patient selection and complete resection (R0) of non-invasive ampullary lesions either by endoscopic papillectomy (EP), surgical ampullectomy (SA), or pancreaticoduodenectomy (PD) is essential. Although PD was traditionally performed, recent studies reported considerable efficacy and fewer complications following EP and SA. Since consistent comparative data are lacking, the Endoscopic Papillectomy vs. Surgical Ampullectomy vs. Pancreaticoduodectomy (ESAP) study will provide evidence for a therapeutic standard and post procedure morbidity in ampullary lesions. Methods: International multicenter retrospective study. Adult patients (>18 years of age) who underwent SA or PD for ampullary neoplasm between 2004 and 2018 or EP between 2007 and 2018 will be evaluated. Main inclusion criteria are ampullary lesions strictly located to the ampulla. This includes adenoma, adenocarcinoma (T1 and T2), neuroendocrine tumors, gastrointestinal stroma tumors and other rare conditions. Exclusion criteria are peri-ampullary lesions, e.g., from the duodenal wall or the head of the pancreas, and interventions for tumor stages higher than T2. The main objective of this study is to analyze rates of complete resection (R0), recurrence and necessity for complementary interventions following EP, SA, and PD. Treatment-quality for each procedure will be defined by morbidity, mortality and complication rates and will be compared between EP, SA, and PD. Secondary objectives include outcome for patients with incomplete resection or initially understated tumors, lesions of the minor papilla, hereditary syndromes, neuroendocrine tumors, mesenchymal lesions, and other rare conditions. Additionally, we will analyze therapy by argon plasma coagulation and radiofrequency ablation. Furthermore, outcome in curative and palliative interventions can be distinguished. Conclusion: The ESAP study will provide evidence for therapeutic algorithms and data for the implementation of guidelines in the treatment of different types of ampullary tumors, including recurrent, or incomplete resected lesions.

Effect of preventive closure of the frenulum after endoscopic papillectomy: A prospective pilot study

BACKGROUND AND AIM

The usefulness of preventive closure of the frenulum after endoscopic papillectomy (EP) could reduce bleeding. The feasibility and safety of clipping were evaluated in this prospective pilot study.

METHODS

This study involved 40 consecutive patients who underwent preventive closure of the frenulum by clipping just after EP. The outcome data were compared with those of the previous 40 patients in whom no preemptive closure had been performed (no-closure group) (UMIN000014783). Additionally, the bleeding sites were examined.

RESULTS

The clipping procedure was successful in all patients. As compared to the no-closure group, the rate of bleeding (P = 0.026) and period of hospital stay (P < 0.001) were significantly reduced in the closure group. There was no difference in the procedure time between the two groups. Furthermore, the incidence rates of pancreatitis and perforation were comparable in the two groups. The bleeding was noted in the frenulum area rather than at any other site in 90.9% of cases.

CONCLUSION

Preventive closure of the frenulum after EP is an effective, safe, rational, and economical method to reduce the incidence of delayed bleeding, without prolonging the procedure time or increasing the risk of post-procedure pancreatitis perforation.

Methods and outcome of the endoscopic treatment of ampullary tumors

Ampullary tumors are rare neoplasms but increasingly encountered due to an increase in diagnostic procedures, mainly upper gastrointestinal endoscopy. Diagnosis, staging, and treatment of these tumors are described and recommendations given based on the most recent literature.

Surgical versus endoscopic resection of large sessile duodenal and papillary lesions

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Endoscopic papillectomy for neoplastic ampullary lesions: A systematic review with pooled analysis

Endoscopic papillectomy (EP) is a viable therapy in ampullary lesions (AL). Many series have reported low morbidity and acceptable outcomes. We performed a systematic review with pooled analysis to assess the safety and efficacy of EP for AL. Electronic databases (Medline, Scopus and EMBASE) were searched up to September 2018. Studies that included patients with endoscopically resected AL were eligible. The rate of adverse events (AEs; primary outcome) and the rates of both technical and clinical efficacy outcomes were pooled by means of a random- or fixed-effects model to obtain a proportion with a 95% confidence interval (CI). Twenty-nine studies were included (1751 patients). The overall AE rate was 24.9%. The post-procedural pancreatitis rate was 11.9%, with the only factor affecting this outcome being prophylactic pancreatic stenting. The complete resection rate was 94.2%, with a rate of oncologically curative resection of 87.1%. The recurrence rate was 11.8% (follow-up: 9.6-84.5 months). EP is a relatively safe and effective option for AL. Our study might definitively suggest the protective role of prophylactic pancreatic stenting against post-procedural pancreatitis.

Duodenal intussusception secondary to ampullary adenoma: A case report

BACKGROUND

Because the duodenum is fixed onto the retroperitoneum, duodenal intussusception is usually impossible except in cases of malrotational abnormality. Although cases of duodenal intussusception without malrotational abnormalities have been reported, it is unclear whether they constitute true intussusception or simple mucosal prolapse.

CASE SUMMARY

A 66-year-old woman presented with whole-body edema and malaise. Blood analysis indicated severe anemia and cholestasis. Endoscopic examination revealed a pedunculate polyp on the second part of the duodenum that migrated distally with mucosal elongation. Computed tomography showed duodenal intussusception. A tumor as the lead point and retroperitoneal structure, including the head of the pancreas and fat, invaginated beyond the duodenojejunal flexure. She was diagnosed with ampullary adenoma caused repeated intussusception that reduced spontaneously and underwent pancreaticoduodenectomy. Laparotomy showed tumor prolapse beyond the duodenojejunal flexure without intussusception. There was no evidence of malrotational abnormality. She was discharged with no complications.

CONCLUSION

We report true duodenal intussusception without malrotational abnormality. This phenomenon was also associated with mucosal prolapse.

The impact of endoscopic ultrasound in preoperative evaluation for ampullary adenomas

OBJECTIVE

We aimed to evaluate the efficacy of endoscopic ultrasonography (EUS) in assessing locoregionally and determining therapeutic options for ampullary adenomas and the related factors.

METHODS

Patients undergoing EUS and surgical or endoscopic resection for biopsy-proven ampullary adenomas between 2009 and 2016 were retrospectively analyzed. The depth of tumor invasion, intraductal extension, and regional lymph node staging evaluated by EUS were compared with post-treatment pathological findings.

RESULTS

Altogether 120 patients were enrolled in this study. The overall accuracy for EUS in T staging was 81.7%. The sensitivity and specificity of EUS for T staging were 93.9%, 45.5% for adenoma and T1, 50.0% and 96.5% for T2, 66.7% and 97.4% for T3, 50.0% and 97.5% for T4 lesions, respectively. The sensitivity, specificity, and accuracy of EUS for the diagnosis of any intraductal extension were 89.5%, 86.1%, and 86.7%, respectively. The overall accuracy of EUS for regional lymph node staging was 75.0%. The sensitivity and specificity of EUS for diagnosing N1 were 62.5% and 87.5%. By multivariate analysis no factors were found to be independently associated with EUS accuracy for tumor invasive depth. However, small lesion size (≤15 mm) and dilated duct were associated with an overestimation in intraductal extension.

CONCLUSION

EUS may be a useful diagnostic tool for selecting endoscopic or surgical treatment for ampullary adenomas.

Surgical method choice and coincidence rate of pathological diagnoses in transduodenal ampullectomy: A retrospective case series study and review of the literature

BACKGROUND

Transduodenal ampullectomy (TDA) is not in wide clinical use due to its low radical effect and a high recurrence rate of tumors. However, TDA is still an effective treatment method; it has great clinical value in cases of duodenal benign tumors, precancerous lesions, and benign and malignant borderline tumors, and can avoid the risks associated with pancreaticoduodenectomy with larger resection range and greater thoroughness than endoscopic papillectomy.

AIM

To investigate the surgical method choice and the coincidence rate of pathological diagnoses in TDA for ampullary neoplasms.

METHODS

Ten patients with ampullary neoplasms underwent TDA based on the fact that their endoscopic biopsy results suggested benign lesions, and the endoscopic ultrasound (EUS)-assessed tumors were resectable. All cases underwent duodenal ampullary lesion endoscopic biopsy, intraoperative frozen-section pathological examination, and postoperative pathological examination.

RESULTS

This study included seven patients with benign tumors and three with malignant tumors (1 pTis, 2 pT1), according to the postoperative pathology results. The coincidence rate of the postoperative pathology results with the intraoperative frozen-section biopsy results was 100% (10/10), and the coincidence rate with the endoscopic biopsy results was 70% (7/10) based on pathological characteristics. The endoscopic biopsy false-negative rate was 30% (3/10). All patients were followed for 6 to 70 mo without tumor recurrence or metastasis.

CONCLUSION

The coincidence rate of postoperative pathology results, intraoperative frozen-section pathology results, and endoscopic biopsy results is the restraining factor of TDA clinical application. Endoscopic biopsy results and EUS have importance relevance to surgical planning. Intraoperative frozen-section pathology results have a significant influence on the choice of surgical procedure.