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

Abstract

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.

Expert consensus on endoscopic papillectomy using a Delphi process

“…Although generally considered safe, EP is not without risks, with serious adverse events occurring in 15-35% of patients and recurrence in up to 20% during surveillance. [3][4][5][6][7]26 It is therefore incumbent on those managing these patients to further refine and optimize the EP procedure to mitigate against these adverse events. However, high-level scientific knowledge to guide this process is largely absent because papillary adenomas are uncommon, and thus large prospective multicenter or randomized controlled studies have not been executed.…”

“…6,24,25 Furthermore, a recent series of patients who underwent EP showed that in only half of the lesions in which the resection specimen showed adenocarcinoma, malignancy was already suspected based on the endoscopic appearance, further questioning the accuracy of endoscopic assessment. 26 Advanced imaging techniques such as narrow-band imaging and chromoendoscopy have proven to be a valuable addition to white-light imaging in the diagnosis of colorectal lesions. 27 However, the possible benefit of narrowband imaging in the assessment of papillary lesions is only described in a small case series.…”

“…No consensus was reached on the standard placement of a stent inside the CBD (18%) (Supplementary Table 1) to, for example, prevent postintervention cholangitis, which has been described in 0% to 7% of cases. 3,5,26 Possible indications to place a CBD stent are concerns for a (micro)perforation (88%) or ongoing bleeding from the papillary region during the procedure (76%). In case of concerns for a (micro) perforation, a fully covered self-expanding metal stent (FCSEMS) is preferred over a plastic stent (88%) (Table 1).…”

“…Recent data on long-term follow-up after EP show that recurrence has been found even 5 years after the index procedure, confirming the need for consideration of longer follow-up. 7,26 Finally, there was consensus that patients should be admitted for observation after the procedure (82%) (Supplementary Table 2). However, participants could not agree on the length of necessary observation, 69% would observe at least 24 hours, and 44% at least 48 hours (Table 3).…”

Cold Snare Papillectomy for Re-redo Endoscopic Resection of a Defiant Adenoma Recurrence with a Unique Growth Pattern

“… 1 Recurrence remains the Achilles heel in endoscopic papillectomy due to the complex- related anatomy. 2 Cold snare papillectomy, albeit not systematically studied, represents a novel principle and may have a role in selected lesions and clinical settings. 3 …”