Endoscopic Resection of Benign Tumors of the Papilla of Vater

Abstract

Most benign papillary tumors are adenomas which can potentially undergo the adenoma-carcinoma-sequence making complete removal mandatory for curative therapy. Endoscopic resection (papillectomy) of these lesions is being increasingly performed as a less traumatic alternative to surgery. Available data shows endoscopic papillectomy to be effective and safe in experienced hands with usually little morbidity and virtually no mortality. Success rates are around 80 % for lesions without intraductal involvement. Selected cases of limited distal intraductal involvement accessible after sphincterotomy may also be managed curatively by endoscopic resection. Endoscopic snare resection of entire lesions should be primarily regarded as a diagnostic procedure. It allows for an accurate histological diagnosis based on examination of the entire specimen rather than forceps biopsies and thus a reliable assessment of the need for surgical therapy. Subsequent surgery in operable patients is not precluded by previous endoscopic resection. Surgery is indicated in case of incomplete removal and if malignancy is present. The curative role of endoscopic papillectomy for early invasive carcinoma needs to be established. Histological features and individual risk for surgery are factors to be considered. Inoperable patients may still benefit from palliative endoscopic stenting. After endoscopic papillectomy has been completed, regular follow-up examinations including biopsies are warranted because of the risk of local recurrence. For benign looking papillary tumors, endoscopic papillectomy serves as a diagnostic tool and should be considered as first line procedure regardless of age. The following article details the approach to patients with benign papillary tumor and the technique of endoscopic papillectomy.

Indications and Outcome of Endoscopic Papillectomy of the Major and Minor Papilla—a Prospective 5-year Study

“…A surgical intervention as an emerging consequence was not required emphasizing the safety of the papillectomy in experienced hands (Bertoni et al 1997). Taken together, papillectomy is justifi ed for R0-resectable adenomas (Bohnacker et al 2006) and uT1 carcinomas in older high-risk patients (e.g.) 9.1 severe cardiopulmonary disorders) (group 1-3), which has to be controlled by histologic investigation of the resection margins and periodic EUS follow-up investigations.…”

“…]) in this study indicating a "contradiction between EUS fi nding (deeply infi ltrating tumor growth) and histologic finding (adenoma or unspecifi c infl ammation)" in several patients who could undergo diagnostic papillectomy according to the defi nition of patient group 2. A possible solution might be that the decision should usually based on the diagnosis after histologic investigation (Bohnacker et al 2006) of a (deep) biopsy (after former papillotomy) or even of a representative specimen obtained by endoscopic papillectomy including the preinterventional EUS (Ito et al 2007). …”

“…Neoplastic lesions of the papilla are divided into adenomas (70%) and carcinomas(Ca) (20%-25%). Adenomas possess a potential for malignant transformation according to the adenoma-carcinoma sequence (Bohnacker et al 2006;Catalano et al 2004;Stolte and Pscherer, 1996;Treitschke et al 2000). Interestingly, there are malignantly transformed cells in about 30% of cases; whereas in villous adenomas, the detection rate of malignant cells is 60% (Stolte and Pscherer, 1996).…”

“…Endoscopic papillectomy is a promising and challenging endoscopic intervention with diagnostic and therapeutic potential (Aiura et al 2003;Jung et al 2001;Lee et al 2002;Mc Cutcheon, 1997;Rollhauser and al-Kawas, 1997;Silvis, 1993;Sriram et al 2000), which is increasingly used (Bohnacker et al 2005;Bohnacker et al 2006).…”

Endoscopic papillectomy of minor papillar adenoma associated with pancreas divisum

“…With the development of endoscopic tools, the safety and the efficacy of endoscopic papillectomy has improved, and indications for endoscopic papillectomy have recently been expanded [2][3][4][5] . Recently, endoscopic papillectomy has been accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has yielded high success and low recurrence rates [5,6] . However adenoma of the minor papilla has been reported in only a few cases [7][8][9] .…”