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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.,Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia.,Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Abstract
INTRODUCTION Endoscopic papillectomy (EP) has been established as a useful endoscopic therapy by the efforts of many pancreatobiliary endoscopists and is presently accepted as a reliable alternative therapy to surgery in patients with ampullary adenoma. Moreover, there have been numerous advancements in EP techniques in recent years. Various approaches and attempts toward expanding the indications of endoscopic resection have been reported. Furthermore, the management and prevention of adverse events (AEs) and endoscopic treatment for remnant or recurrent lesions have also been reported. In the present review, we focus on recent advancements in the EP technique, as well as speculate on the future issues of EP. AREA COVERED This review of EP encompasses the indications, preoperative assessments, endoscopic techniques, outcomes, and AEs of EP, post-EP surveillance techniques, and treatments for remnant or recurrence lesions. EXPERT OPINION The ultimate goal of EP is the complete resection of ampullary tumors, regardless of whether they are adenomatous or carcinomatous lesions, without causing any AEs. Therefore, the most important issue is preoperative evaluation, that is, the accurate diagnosis of lesions contraindicated for EP. In addition, further research on the prevention of AEs is also necessary towards establishing EP as a safe endoscopic procedure.
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Affiliation(s)
- Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine , Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University , Tokyo, Japan
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Iwasaki E, Minami K, Itoi T, Yamamoto K, Tsuji S, Sofuni A, Tsuchiya T, Tanaka R, Tonozuka R, Machida Y, Takimoto Y, Tamagawa H, Katayama T, Kawasaki S, Seino T, Horibe M, Fukuhara S, Kitago M, Ogata H, Kanai T. Impact of electrical pulse cut mode during endoscopic papillectomy: Pilot randomized clinical trial. Dig Endosc 2020; 32:127-135. [PMID: 31222794 DOI: 10.1111/den.13468] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/16/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Endoscopic papillectomy is increasingly being used for ampullary adenoma treatment. However, it remains challenging despite increased safety with treatment advances. The ideal power output and electrosurgical current mode for mucosal resection are not established. We aimed to identify the ideal electrical pulse for use during resection. METHODS This pilot randomized, single-blind, prospective, multicenter trial, recruited patients with ampullary adenomas and conventional anatomy who were scheduled to undergo endoscopic papillectomy. Endoscopic treatment was performed using a standardized algorithm and patients were randomized for endoscopic papillectomy with Endocut or Autocut. The primary outcome was the incidence of delayed bleeding. Incidence of procedure-related pancreatitis, successful complete resection, pathological findings, and other adverse events were secondary endpoints. RESULTS Sixty patients were enrolled over a 2-year period. The incidences of delayed bleeding (13.3% vs. 16.7%, P = 1.00) and pancreatitis (27% vs. 30%, P = 0.77) were similar between both groups. The rate of crush artifacts was higher in the Endocut than in the Autocut group (27% vs. 3.3%, P = 0.03). Immediate bleeding when resecting tumors greater than 14 mm in diameter was more common in the Autocut than in the Endocut group (88% vs. 46%, P = 0.04). CONCLUSIONS The Autocut and Endocut modes have similar efficacy and safety for endoscopic papillectomy. The Endocut mode may prevent immediate bleeding in cases with large tumor sizes, although it causes more frequent crush artifacts. REGISTRY AND THE REGISTRATION NUMBER The Japanese UMIN Clinical Trials Registry (UMIN-CTR: 000021382).
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Affiliation(s)
- Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kenjiro Yamamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shujiro Tsuji
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Atsushi Sofuni
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takayoshi Tsuchiya
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Reina Tanaka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Tonozuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Minami K, Iwasaki E, Kawasaki S, Fukuhara S, Seino T, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Horibe M, Kitago M, Ogata H, Kanai T. A long (7 cm) prophylactic pancreatic stent decreases incidence of post-endoscopic papillectomy pancreatitis: a retrospective study. Endosc Int Open 2019; 7:E1663-E1670. [PMID: 31788550 PMCID: PMC6877413 DOI: 10.1055/a-1010-5581] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background and study aims Endoscopic papillectomy (EP) is a minimally invasive treatment for ampullary neoplasms and is recognized as an alternative treatment to surgical resection; however, there are few reports on a suitable pancreatic stent (PS) after EP for preventing pancreatitis. The aim of this study was to evaluate the efficacy of a long PS after EP. Patients and methods In this retrospective single-center study, 39 patients with pathologically proven ampullary neoplasms who underwent EP between March 2012 and August 2018 were enrolled. The study participants were divided into two subgroups according to the PS length: those with a PS shorter than 5 cm (short PS group, n = 17) and those with a PS of 7 cm (long PS group, n = 22). The incidence of adverse events and risk factors for pancreatitis were evaluated. Results The diameter of all PSs was 5 Fr. Post-EP pancreatitis occurred in nine patients (23.1 %), with two cases of severe pancreatitis (5.1 %). Pancreatitis occurred more frequently in the short PS group (7/17, 41.2 %) than in the long PS group (2/22, 9.1 %) ( P = 0.026). There were no significant differences between the two groups in terms of other adverse events. Univariate and multivariate analyses showed that a long PS was the only factor associated with a decreased incidence of post-EP pancreatitis ( P = 0.042; odds ratio, 0.16; 95 % confidence interval, 0.027-0.94). Conclusion A long (7 cm) PS significantly decreased incidence of pancreatitis after EP. Prospective randomized studies with a larger number of patients and wider range of PS lengths are required.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Minoru Kitago
- Division of Hepato-Pancreato-Biliary and Transplant Surgery, Department of Surgery, Keio University School of Medicine, Tokyo, Japan
| | - Haruhiko Ogata
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan,Corresponding author Takanori Kanai MD, PhD Chief Professor, Division of Gastroenterology and HepatologyDepartment of Internal MedicineKeio University School of Medicine35 ShinanomachiShinjuku-ku, Tokyo 160-8582Japan+81-(0)3-3353-6247
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Minami K, Iwasaki E, Fukuhara S, Horibe M, Seino T, Kawasaki S, Katayama T, Takimoto Y, Tamagawa H, Machida Y, Kanai T, Itoi T. Electric Endocut and Autocut Resection for Endoscopic Papillectomy: A Systematic Review. Intern Med 2019; 58:2767-2772. [PMID: 31243201 PMCID: PMC6815892 DOI: 10.2169/internalmedicine.2720-19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.
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Affiliation(s)
- Kazuhiro Minami
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Eisuke Iwasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Seiichiro Fukuhara
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Japan
| | - Masayasu Horibe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takashi Seino
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Shintaro Kawasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Tadashi Katayama
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Youichi Takimoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Hiroki Tamagawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Yujiro Machida
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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Jang S. Endoscopic management of ampullary neoplasm. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2019. [DOI: 10.18528/ijgii190007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Sunguk Jang
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
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Ardengh JC, Kemp R, Lima-Filho &ER, Santos JSD. Endoscopic papillectomy: The limits of the indication, technique and results. World J Gastrointest Endosc 2015; 7:987-994. [PMID: 26265992 PMCID: PMC4530332 DOI: 10.4253/wjge.v7.i10.987] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 12/31/2014] [Accepted: 07/17/2015] [Indexed: 02/05/2023] Open
Abstract
In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy (EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.
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Han J, Lee DW, Kim HG. Recent advances in endoscopic papillectomy for ampulla of vater tumors: endoscopic ultrasonography, intraductal ultrasonography, and pancreatic stent placement. Clin Endosc 2015; 48:24-30. [PMID: 25674523 PMCID: PMC4323428 DOI: 10.5946/ce.2015.48.1.24] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 12/27/2014] [Accepted: 12/27/2014] [Indexed: 12/16/2022] Open
Abstract
Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.
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Affiliation(s)
- Jimin Han
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Dong Wook Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Ho Gak Kim
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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Palma GDD. Endoscopic papillectomy: Indications, techniques, and results. World J Gastroenterol 2014; 20:1537-1543. [PMID: 24587629 PMCID: PMC3925862 DOI: 10.3748/wjg.v20.i6.1537] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Accepted: 12/13/2013] [Indexed: 02/06/2023] Open
Abstract
Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.
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Will U, Müller AK, Fueldner F, Wanzar I, Meyer F. Endoscopic papillectomy: Data of a prospective observational study. World J Gastroenterol 2013; 19:4316-4324. [PMID: 23885142 PMCID: PMC3718899 DOI: 10.3748/wjg.v19.i27.4316] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 04/16/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical value of endoscopic papillectomy indicated by feasibility and safety of the procedure in various diseases of the papilla in a representative number of patients in a setting of daily clinical and endoscopic practice and care by means of a systematic prospective observational study.
METHODS: Through a defined time period, all consecutive patients with tumor-like lesions of the papilla, who were considered for papillectomy, were enrolled in this systematic bicenter prospective observational study, and subdivided into 4 groups according to endoscopic and endoscopic ultrasonography (EUS) findings as well as histopathological diagnosis: adenoma; carcinoma/neuroendocrine tumor (NET)/lymphoma; papilla into which catheter can not be introduced; adenomyomatosis, respectively. Treatment results and outcome were characterized by R0 resection, complication, recurrence rates and tumor-free survival.
RESULTS: Over a 7-year period, 58 patients underwent endoscopic papillectomy. Main symptoms prompting to diagnostic measures were unclear abdominal pain in 50% and cholestasis with and without pain in 44%. Overall, 54/58 patients [inclusion rate, 93.1%; sex ratio, males/females = 25/29 (1:1.16); mean age, 65 (range, 22-88) years] were enrolled in the study. Prior to papillectomy, EUS was performed in 79.6% (n = 43/54). Group 1 (adenoma, n = 24/54; 44.4%): 91.6% (n = 22/24) with R0 resection; tumor-free survival after a mean of 18.5 mo, 86.4% (n = 19/22); recurrence, 13.6% (n = 3/22); minor complications, 12.5% (n = 3/24). Group 2 (carcinoma/NET/lymphoma, n = 18/54; 33.3%): 75.0% (n = 12/18) with R0 resection; tumor-free survival after a mean of 18.5 (range, 1-84) mo, 88.9% (n = 8/9); recurrence, 11.1% (n = 1/9). Group 3 (adenomyomatosis, n = 4/54; 7.4%). Group 4 (primarily no introducible catheter into the papilla, n = 8; 14.8%). The overall complication rate was 18.5% (n = 10/54; 1 subject with 2 complications): Bleeding, n = 3; pancreatitis, n = 7; perforation, n = 1 (intervention-related mortality, 0%). In summary, EUS is a sufficient diagnostic tool to preoperatively clarify diseases of the papilla including suspicious tumor stage in conjunction with postinterventional histopathological investigation of a specimen. Endoscopic papillectomy with curative intention is a feasible and safe approach to treat adenomas of the papilla. In high-risk patients with carcinoma of the papilla with no hints of deep infiltrating tumor growth, endoscopic papillectomy can be considered a reasonable treatment option with low risk and an approximately 80% probability of no recurrence if an R0 resection can be achieved. In patients with jaundice and in case the catheter can not be introduced into the papilla, papillectomy may help to get access to the bile duct.
CONCLUSION: Endoscopic papillectomy is a challenging interventional approach but a suitable patient- and local finding-adapted diagnostic and therapeutic tool with adequate risk-benefit ratio in experienced hands.
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Qin H, Zhao Q, Li DM, Gao HY, Li RX, Zhang M, Hu JF, Wang Y. Clinical evaluation of endoscopic papillectomy for the diagnosis of tumors of the ampulla of Vater. Shijie Huaren Xiaohua Zazhi 2012; 20:2305-2309. [DOI: 10.11569/wcjd.v20.i24.2305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the value of endoscopic papillectomy (EP) for the diagnosis of tumors of the ampulla of Vater.
METHODS: The clinical data for 16 patients with tumors of the ampulla of Vater were analyzed. The clinical efficacy, complications and safety of EP were evaluated.
RESULTS: Before EP, 12 patients were diagnosed with adenoma and 4 with chronic inflammation by endoscopic biopsy. After EP, 2 cases were diagnosed with poorly differentiated adenocarcinoma, 1 with well differentiated adenocarcinoma, and 13 with adenoma (including one case of adenoma with malignant transformation and all 4 cases diagnosed with "chronic inflammation" by endoscopic biopsy). The accuracy of EP was significantly higher than that of endoscopic biopsy (P < 0.05). In 9 cases, EUS showed that the lesions originated from the submucosal layer with dilated pancreatic and biliary ducts. None of the cases had submucosal continuity interruption, invasion to pancreatic/biliary ducts or enlarged retroperitoneal lymph nodes on EUS. Twelve patients with high echoic lesions were confirmed to have adenoma, one patient with hyperechoic lesion with localized low echo area were confirmed to have adenoma with malignant transformation, and 3 patients with low echo lesions were confirmed to have adenocarcinoma. After EP, residual lesions were found in bile duct orifice in 2 cases of poorly differentiated adenocarcinoma, 1 case of adenoma with malignant transformation and 1 case of adenoma, indicating invasion to the bile duct. All of them had a negative preoperative EUS. Lesions were completely resected in 1 case of well differentiated adenocarcinoma and 11 cases of adenoma, and the resection stump was histologically negative for neoplasm. After EP, two patients developed transient melena, but no acute pancreatitis, perforation or other complications occurred. There was no procedural-related death in this group of patients.
CONCLUSION: EP is safe and has a higher accuracy in the diagnosis of tumors of the ampulla of Vater.
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Heinzow HS, Meister T, Domagk D. Endoskopische Papillenresektion: Indikation und Grenzen. Visc Med 2012. [DOI: 10.1159/000345869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Adenome der Papilla Vateri sind selten. Prävalenzen von 0,04–0,12% werden beschrieben. Eine maligne Transformation von benignen Adenomen zu Papillenkarzinomen ist möglich und folgt der Adenom-Karzinom-Sequenz. Die meisten Papillenadenome treten sporadisch auf, können jedoch z.B. bei Patienten mit familiärer adenomatöser Polyposis genetisch häufiger vorkommen. <b><i>Methode: </i></b>Es erfolgte eine aktuelle PubMed-Recherche zum Thema endoskopische Papillenresektion. <b><i>Ergebnisse/Schlussfolgerung: </i></b>Eine endoskopische Papillektomie kann bei Adenomen ohne duktale Infiltration durchgeführt werden, während es in Hinblick auf das papilläre Adenokarzinom noch keinen Konsens gibt. Jedoch konnten neuere Studien zeigen, dass Patienten mit hochgradiger intraepithelialer Neoplasie der Papilla Vateri keine lymphovaskuläre Invasion oder Lymphknotenmetastasen aufweisen, sodass eine endoskopische Papillektomie gerechtfertigt erscheint. Da papilläre Adenome in bis zu 30% der Fälle das Risiko für fokale karzinomatöse Areale beherbergen können, sollte jede Papillektomie «en bloc» durchgeführt werden.
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