Therapeutic outcomes of endoscopic papillectomy for ampullary neoplasms: retrospective analysis of a multicenter study

Abstract

BackgroundEndoscopic papillectomy (EP) is reported to be a relatively safe and reliable procedure for complete resection of ampullary neoplasms. The aim of this study was to evaluate the therapeutic outcomes and complications of EP for ampullary neoplasms.MethodsA retrospective multicenter study was conducted with 5 participating centers from January 2007 to July 2014. A total of 104 patients who underwent EP for ampullary neoplasms were reviewed retrospectively. EP was performed by snare resection with or without submucosal lifting of the lesion.ResultsThe mean age of patients was 60.5 ± 12.1 years, and the male-to-female ratio was 2.0:1. En bloc resection was possible in 94 patients (90.3%). A biliary and a pancreatic stent were placed after EP in 42 patients and in 60 patients, respectively. A pathologically incomplete resection was noted in 11 cases (10.6%), and 5 of these patients were treated with additional endoscopic procedure. Histology of resected specimens was as follows: low grade adenoma (43.2%), high grade adenoma (14.4%), adenocarcinoma (16.3%), hyperplastic polyp (7.7%), and others (18.4%). Of the 75 cases with low grade adenoma on biopsy specimen, 21.3% turned out to have high grade adenoma (12%) or adenocarcinoma (9.3%). Procedure-related complications occurred in 33 patients (31.7%); bleeding (18 cases, 17.3%), pancreatitis (16 cases, 15.4%), and perforation (8 cases, 7.7%). Pre-EP ERCP, saline lifting, sphincterotomy, biliary stenting, pancreatic stenting, specimen size, and cauterization were not related to post EP complications. Surgery was performed in 6 cases with pathological incomplete resection and 2 cases with complications after EP, and there were 2 cases of mortality due to complications. During follow-up endoscopy after initial success of EP, remnant tumors were found in 7 patients, one of whom underwent surgery and the others were treated endoscopically. Consequently, the overall endoscopic success rate of EP was 89.4%.ConclusionsEndoscopic papillectomy appears to be an effective treatment for ampullary neoplasms, and can be considered as an alternative to surgery. However, relatively high risk of procedure related complications is a problem that must be considered.

Effect of preventive closure of the frenulum after endoscopic papillectomy: A prospective pilot study

“…Delayed bleeding at a frequency in the range of 4-25% has been reported. 10,[16][17][18][19][20][21][22][23] Although there are no reports on which sites are most likely to bleed after EP, the frenulum area of the ampulla of Vater has a rich blood supply 3 and is regarded as a frequent site of bleeding, as attested by our data shown in Figure 4. The following three factors made frenulum to be vulnerable for bleeding.…”

“…However, the risk of bleeding could depend on the anatomical complexity and vascularity of the tumor site . Large tumors over 20 mm in diameter extending to frenulum tend to bleed and would need clipping . Some smaller tumors could also potentially bleed; therefore, preemptive closure for EP is expected to be beneficial.…”

“…4 Large tumors over 20 mm in diameter extending to frenulum tend to bleed and would need clipping. 10,[16][17][18][19][20][21][22][23] Some smaller tumors could also potentially bleed; therefore, preemptive closure for EP is expected to be beneficial.…”

Unsolved problems in endoscopic papillectomy

“…4,7,8,60,61 Some investigators showed that the adoption of the prophylactic PS placement after EP did not correlate with the subsequent development of post-procedural pancreatitis. 9,62,63 Although prophylactic PS is moderately recommended during EP by American Society for Gastrointestinal Endoscopy, studies published to date have not reached consistent consensus regarding whether prophylactic PS should be routinely adopted for EP. 64 Recently published a systemic review and meta-analysis 65 reported that prophylactic PS decreased the odds of post-procedure pancreatitis (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.36-1.40; P = 0.325) as well as late papillary stenosis (OR, 0.35; 95% CI, 0.07-1.75; P = 0.200; I 2 = 0%), increased the odds of bleeding (OR, 1.32; 95% CI, 0.50-3.46; P = 0.572; I 2 = 0%), and perforation (OR, 2.25; 95% CI, 0.33-15.50; P = 0.412; I 2 = 0%), but not significantly.…”

Management of Remnant or Recurrent Lesions after Endoscopic Papillectomy

“…Focal carcinoma can be missed by endoscopic biopsy sampling, and is found only in resected specimens in 6% to 26% of the adenomas in patients undergoing papillectomy. 1,2 Recently, endoscopic papillectomy (EP) has become a popular therapeutic option for the management of AOV adenomas because it is less invasive com-pared with surgical resection. Endoscopic treatment of AOV adenomas achieves cure rates ranging from 76% to 90% in patients without intraductal extension.…”