Can prophylactic argon plasma coagulation reduce delayed post‐papillectomy bleeding? A prospective multicenter trial

Abstract

Background and Aim Endoscopic post‐papillectomy bleeding occurs in 3% to 20% of the cases, and delayed bleeding is also problematic. However, there is no consensus on how to reduce delayed post‐papillectomy bleeding. The aim of this study was to evaluate the efficacy of prophylactic argon plasma coagulation (APC) to minimize delayed bleeding and reduce the persistence of residual tumors after endoscopic papillectomy. Methods In a prospective pilot study of patients with benign ampullary tumors, the prophylactic APC group underwent APC at the resection margin following a conventional snaring papillectomy. Then, 24 h later after the papillectomy, all patients underwent a follow‐up duodenoscopy to identify post‐papillectomy bleeding and were followed up until 12 months. The main outcomes were the delayed (≥24 h) post‐papillectomy bleeding rate and the tumor persistence rate. Results The delayed post‐papillectomy bleeding rate was 30.8% (8/26) in the prophylactic APC group and 21.4% (6/28) in the non‐APC group (P = 0.434). The post‐procedure pancreatitis rates were 23.1% (6/26) and 35.7% (10/28), respectively (P = 0.310). The rate of tumor persistence did not differ between the two groups at 1 month (12.5% vs 7.4%, P = 0.656), 3 months (4.2% vs 3.7%, P = 1.00), 6 months (8.3% vs 3.7%, P = 0.595), and 12 months (0% vs 3.7%, P = 1.00). There were no procedure‐related mortalities or serious complications. Conclusion Prophylactic APC may not be effective in reducing delayed post‐papillectomy bleeding or remnant tumor ablation immediately after conventional papillectomy (Clinical trial registration—http://cris.nih.go.kr; KCT0001955).

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

“…Our results showed that most adverse events caused by EP showed mild- to moderate-grade severity. The role of thermal ablation in bleeding remains controversial and studies have shown that the risk of pancreatitis increased with the size of the lesion and when hemostasis was performed[ 22 , 23 , 28 ]. Here, thermal ablation was not significantly associated with bleeding or recurrence although it increased the risk of pancreatitis.…”

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

“…The delayed bleeding rate was significantly lower in the APC group compared to the non-APC group (7.3 % vs. 31.7 %, OR 0.180, P < 0.01). However, there are conflicting data: a recent RCT including 54 patients failed to find any reduction in the rate of delayed postpapillectomy bleeding with APC (30.8 % in the prophylactic APC group vs. 21.4 % in the non-APC group; P = 0.434) [173]. Ismail et al [153] reported retrospectively that bleeding occurred post-papillectomy in 11/61 (18 %) despite prophylactic APC having been performed in 10/11 of those who bled.…”

Endoscopy in patients on antiplatelet or anticoagulant therapy: British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE) guideline update

“…A RCT has suggested that, compared with the Autocut mode, the Endocut mode may prevent immediate but not delayed bleeding in cases with tumors > 14 mm; it causes more frequent crush artifacts 118 . Prophylactic argon plasma coagulation has been reported as effective in a retrospective study (n = 82) and ineffective in a RCT (n = 54) to prevent post-ampullectomy bleeding 119 120 . Submucosal injection prior to ampullectomy did not prevent bleeding in a RCT (n = 50) and a retrospective matched cohort analysis (n = 50) 121 122 ; furthermore it was associated with higher tumor recurrence rate and a shorter recurrence-free survival in the retrospective study 121 .…”