Efficacy of Hypertonic Saline-Epinephrine Local Injection Around the Anal Side before Endoscopic Papillectomy for Ampullary Tumors

Okano, Naoki; Igarashi, Yoshinori; Ito, Ken; Mizutani, Saori; Nakagawa, Hiroki; Watanabe, Koji; Yamada, Yuto; Yoshimoto, Kensuke; Kimura, Yusuke; Iwasaki, Susumu; Takuma, Kensuke; Hara, Seiichi; Kishimoto, Yuui

doi:10.5946/ce.2020.208

Cited by 4 publications

(5 citation statements)

References 22 publications

(54 reference statements)

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“…In addition, recurrences and remnant lesions were not significantly different when using submucosal injection in a prospective trial 32 . More recently, a modified technique of submucosal injection only in the distal part of the papilla resulted in comparable rates of complete resection but less periprocedural bleeding and pancreatitis 33 34 . Therefore, the use of submucosal injection is still a matter of debate and submucosal injection alone is not an adequate explanation for the lower R0 rate in the FAP group.…”

Section: Discussionmentioning

confidence: 99%

Endoscopic papillectomy for ampullary lesions in patients with familial adenomatous polyposis compared with sporadic lesions: a propensity score-matched cohort

et al. 2023

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Background: Familial-adenomatous-polyposis (FAP) is a rare inherited cancer predisposition syndrome. The treatment for FAP-related ampullary lesions (AL) is challenging and the role of endoscopic papillectomy (EP) is not elucidated yet. Data of FAP associated AL are limited and showed, at least in part, inconclusive results. We retrospectively analyzed the outcomes of EP in matched cohorts of FAP-related and sporadic ampullary lesions (SAL). Methods: The ESAP study included 1422 EPs. A propensity-score matching (nearest-neighbor-method) including age, gender, comorbidity, histologic subtype and size was performed. Main outcomes were complete resection (R0), technical success, complications and recurrence. Results: Propensity-score-based matching identified 202 patients (101 FAP, 101 SAL) with comparable baseline characteristics. FAP-patients were mainly asymptomatic (79.2% [95%CI 71.2-87.3] vs. 46.5% [95%CI 36.6-56.4]), p<0.001). The initial R0-rate was significantly lower in FAP-patients (63.4% [95%CI 53.8-72.9] vs. 83.2% [95%CI 75.8-90.6], p=0.001). After repeated (mean: 1.30 per patient) interventions, R0 was comparable (FAP 93.1% [95%CI 88.0-98.1] vs. SAL 97.0% [95%CI 93.7-100], p=0.194). The overall complication rate was 28.7%. Pancreatitis and bleeding were most common adverse events in both groups. Severe complications were very rare (3.5%). Twenty-one patients in the FAP-group (20.8% [95%CI 12.7-28.8]) and sixteen patients in the SAL-group (15.8% [95%CI 8.6-23.1], p=0.363) had a reccurence . Recurrences occurred later in FAP-patients (25 [95%CI 18.3-31.7] vs. 2 [95%CI CI 0.06-3.9] months). Conclusions: EP is safe and effective in FAP-related ampullary lesions Criteria for endoscopic resection of AL can be extended to FAP-patients. FAP-patients have a life-time risk to relapse even after complete resection and require long-time-surveillance.

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Section: Discussionmentioning

confidence: 99%

Endoscopic papillectomy for ampullary lesions in patients with familial adenomatous polyposis compared with sporadic lesions: a propensity score-matched cohort

et al. 2023

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“…On the other hand, a concern with submucosal injection is the possibility of creating a ''dome effect,'' making effective snare placement difficult during resection. At least two studies published in the last few years found that en bloc resection rates were lower with submucosal injection, without any significant differences in complication rates [25,26]. Thus, the best evidence to date suggests that routine submucosal injection is not warranted during endoscopic resection of ampullary adenomas.…”

Section: Management Ampullary Adenomasmentioning

confidence: 99%

Updates in endoscopic management of ampullary and duodenal adenomas

Chadalavada,

Shah

2023

Current Opinion in Gastroenterology

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Purpose of review Adenomas are the most common benign lesions of the gastrointestinal tract. The current review aims to summarize recent literature regarding risk factors, natural history, diagnostic and staging technique, and management strategies for ampullary and nonampullary duodenal adenomas. Recent findings Recent studies identified several possible risks factors for duodenal adenomas (e.g., cholecystectomy, proton pump inhibitor use), although these associations require corroboration. Chromoendoscopy and endocystoscopy may offer accuracy comparable to biopsies in expert hands. Recent publications underscore the reduction in morbidity with endoscopic resection for lesions without signs of malignancy with submucosal invasion. Submucosal injection did not improve safety of endoscopic ampullectomy. Summary Surveillance may be a reasonable strategy for sub-centimeter ampullary adenomas occurring in familial adenomatous polyposis, as they carry a relatively low risk of malignancy. Endoscopic resection is the preferred strategy over surgery in patients without lesions suggestive of invasive malignancy. For nonampullary duodenal adenomas, several endoscopic resection techniques are available, each with their unique advantages and trade-offs. In patients who are not operative candidates but have intraductal extension, endoscopic ablation is an emerging option.

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“…Delayed (>24 h) bleeding is also not uncommon after endoscopic papillectomy due to the thermal effect that lags behind and exposes the blood vessels to the risk of delayed bleeding. Although the vasoconstrictive effect of epinephrine injection wears off within 10-30 minutes and could therefore potentially underestimate the bleeding risk, no significant increase in delayed bleeding was observed in the study by Okano et al [ 6 ]. Several technical interventions to prevent late bleeding have been studied.…”

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confidence: 98%

“…In this issue of Clinical Endoscopy , Okano et al modified the submucosal injection technique so that it does not hinder endoscopic resection [ 6 ]. Instead of injecting into the entire papillary area, the authors only injected epinephrine around the distal part of the papilla where most of the blood vessels are located and bleeding is common.…”

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confidence: 99%

“…Several technical interventions to prevent late bleeding have been studied. Prophylactic clip placement on the frenulum, similar to that in the injection site in the study by Okano et al [ 6 ], compresses the local blood vessels and thus prevents bleeding without the risk of accidentally blocking the bile or pancreatic duct. A retrospective, monocentric study showed a lower incidence (5%) of delayed bleeding in 40 patients with a prophylactic clip compared to 23% in a historical cohort of 40 patients without clip placement [ 7 ].…”

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confidence: 99%

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