Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla

BACKGROUND: Endoscopic excision for adenoma of the major duodenal papilla was introduced as an alternative to surgery, but postprocedure pancreatitis is a serious drawback. This study assessed the feasibility and the safety of endoscopic papillectomy with a guidewire and pancreatic-duct stent insertion to prevent pancreatitis. METHODS: Six patients were enrolled. The snare loop was passed over a guidewire that had been inserted into the pancreatic duct. Immediately after snare resection, a pancreatic stent was placed along the indwelling guidewire. RESULTS: En bloc papillectomy and pancreatic stent insertion were performed successfully in all patients. Pancreatitis did not develop acutely in any patient. Complications included cholangitis (n = 1) and late-onset pancreatitis owing to the pancreatic stent (n = 1). Scant residual adenomatous tissue was present at resection margins in two patients and was treated endoscopically. CONCLUSIONS: Wire-guided endoscopic snare papillectomy in selected patients is a useful technique that maintains pancreatic-duct access for stent placement. This appears to prevent pancreatitis and to improve the outcome for patients undergoing endoscopic resection of papillary tumors.     

Balloon-catheter-assisted endoscopic snare papillectomy for benign tumors of the major duodenal papilla

BACKGROUND: Adenomas of the major duodenal papilla are considered premalignant and should be resected completely. Endoscopic snare papillectomy has been recognized as a safe and feasible treatment. An endoscopic snare papillectomy technique was devised using a balloon catheter inserted into the common bile duct to more efficiently resect papillary tumors en bloc. METHODS: Two patients with benign adenoma of the major duodenal papilla were included in this study. A balloon catheter linked to a snare was inserted into the bile duct via the accessory channel of a duodenoscope, and snare resection was performed after pulling the expanded balloon toward the duodenal lumen. RESULTS: En bloc papillectomy was successfully performed, leaving the lateral margin free of tumor as confirmed microscopically. No complications were observed in either case. CONCLUSIONS: Given an appropriate indication, balloon-catheter-assisted endoscopic snare papillectomy is a useful technique for the treatment of tumors of the major duodenal papilla.     

经内镜十二指肠乳头切除术治疗乳头部肿瘤的临床价值

目的 探讨经内镜十二指肠乳头切除术(EP)治疗十二指肠乳头部肿瘤的临床价值.方法 前瞻性观察研究15例经EP治疗的十二指肠乳头部肿瘤患者的临床疗效、并发症及随访观察结果,评价其临床价值.结果 所有15例患者均顺利完成EP治疗,其中4例术前病检为慢性炎症者术后病理诊断为腺瘤;11例术前病检为腺瘤者中术后病理诊断为高分化腺癌1例、低分化腺癌2例、腺瘤恶变1例.EP术后8例合并胰胆管扩张者同时行胆管及胰管塑料支架引流术,1例确诊为低分化腺癌者、1例确诊为腺瘤恶变者及1例腺瘤部分残留者术后追加外科手术治疗,另1例低分化腺癌者因年龄较大拒绝追加手术治疗.EP术后除2例患者出现黑便,2例患者出现一过性血淀粉酶升高外,无急性胰腺炎、胆管炎及穿孔等并发症发生,无患者死亡.EP术后平均随访观察23.4个月,11例(11/15,73.3％)病变完整切除者中,10例腺瘤者均未见复发,另1例乳头部高分化腺癌者术后已随访5个月,多次复查病检均未见复发.结论 EP术不仅可提高十二指肠乳头部肿瘤诊断的准确率;对于十二指肠乳头部腺瘤,EP术可将腺瘤组织完整切除达到根治的目的,是一项安全、有效的微创治疗措施.     

十二指肠乳头肿瘤内镜下切除术34例疗效分析

目的 评价、分析十二指肠乳头肿瘤内镜下切除的疗效及安全性.方法 回顾性分析34例十二指肠乳头肿瘤内镜切除术患者的临床资料,总结其治疗效果及并发症情况.结果 内镜下肿瘤切除成功率为94.12％ (32/34),完全切除率为66.67％ (20/30).10例(29.41％,10/34)出现短期并发症,其中7例(20.59％,7/34)为术后消化道出血,3例(8.82％,3/34)为术后胰腺炎.术后转外科手术者5例(14.71％,5/34),其中2例术后病理回报肿瘤侵犯过深,2例病变侵犯胆管,1例因出血保守治疗无效.术后病理示低级别上皮内瘤变(LGIN) 13例(38.24％,13/34),高级别上皮内瘤变(HGIN)17例(50.00％,17/34),类癌1例(2.94％,1/34),腺癌3例(8.82％,3/34).7例复发,复发率为23.33％(7/30),HGIN组肿瘤复发率(42.86％,6/14)高于低级别上皮内瘤变LGIN组(10.00％,1/10),但差异无统计学意义(P=0.078).结论 十二指肠乳头肿瘤内镜下切除术是安全有效的方法,术后出血为主要并发症,HGIN患者术后复发率较高.     

Endoscopic snare papillectomy for adenoma of the ampulla of vater: Long-term results in 135 consecutive patients

BackgroundThe premalignant nature of ampullary adenomas justifies their radical excision.AimsAim of this study is to evaluate the long-term results of endoscopic snare papillectomy in a consecutive series of patients with ampullary adenomas.MethodsPatients who underwent endoscopic snare papillectomy between October 1999 and October 2017 were identified from an electronic database. Endoscopic snare papillectomy was performed en bloc, when possible; a pancreatic stent or a nasopancreatic drainage were inserted. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly.ResultsEndoscopic snare papillectomy was performed in 135 patients (70 M, mean age 60.5 years) by en bloc (83%) or piecemeal (17%) resection. Delayed bleeding occurred in 16 patients (11.8%), infected retroperitoneal collections in 6 patients (4.4%), pancreatitis in 4 patients (3%). One patient died (0.7%).Follow-up was available in 103/114 (90.3%) patients. In case of residual (24.3%) and recurrent (23.3%), adenomas endoscopic retreatment was successful in 42/49 cases (85.7%). After a mean follow-up of 40 months, 93.2% (96/103) of the patients were disease freeConclusionEndoscopic snare papillectomy of ampullary adenomas is effective with favorable long-term outcomes. Compliance to the scheduled follow-up is important for the early detection and re-treatment of recurrences.     

十二指肠乳头腺瘤的内镜治疗

目的 探讨十二指肠乳头内镜下切除术（EP）治疗十二指肠乳头腺瘤（AA）的临床应用价值.方法 回顾分析长海医院消化内镜中心EP治疗AA成功率、并发症发生率、术后残留率及局部复发率等.结果 2005年7月至2009年7月EP治疗经内镜及病理确诊的从19例：散发AA18例（94.7%）,其中十二指肠多发腺瘤合并AA 1例;家族性腺瘤性息肉病并AA 1例（5.3%）.EP治疗一次性整块切除11例（57.9%）,分片切除8例（42.1%）.平均随访24.5个月（7～48个月）,首次EP后残留4例（21.1%）,EP治疗成功率为89.5%（17/19）.近期并发症：出血3例,轻症急性胰腺炎3例,急性胆管炎2例;远期并发症：胆管下端开口狭窄合并急性胆管炎1例,长期胆管支架置入后合并胆总管多发结石及急性胆管炎各1例.未发生穿孔等严重并发症以及EP术中转手术或死亡.结论 EP是治疗AA及其早期癌变的一种安全、有效的方法.     

Endoscopic papillectomy and KRAS expression in the treatment of adenoma in the major duodenal papilla

Abstract

Objective. The use of endoscopic papillectomy for resecting adenomas in the major duodenal papilla is increasing. This study focuses on the following three issues: Can endoscopic papillectomy be performed as a safe diagnostic and/or therapeutic procedure in biopsy-verified or suspected ampullary adenoma? Does expression of mutated KRAS in resected adenomatous tissue predict long-term outcome? What other factors may affect long-term outcome and should, therefore, be considered in decision making prior to endoscopic papillectomy? Material and methods. Thirty-six prospectively collected patients who underwent endoscopic papillectomy at Karolinska University Hospital between 2005 and 2014 were analyzed. Results. The rate of exact agreement between the histomorphological grading of the endoscopic biopsies and the papillectomy specimens was low (48%). Obstructive jaundice at presentation increased the risk of undetected adenocarcinoma (RR = 3.98; 95% CI = 1.46–10.85, p = 0.007). Lesions with malignancies were significantly larger (mean 30.6 mm) than those where only adenomas were found (mean 14.4 mm, p = 0.001). Mutated KRAS was detected in 9 of the 36 post-papillectomy specimens, including 4 of the 5 cases of ampullary adenocarcinoma. Eighteen cases were endoscopically cured after a mean follow-up period of 47 months (range 16–92 months). Conclusions. Endoscopic papillectomy is a valuable staging tool because of the limitations of endoscopic biopsy. Endoscopic papillectomy concomitantly offers a curative treatment for most patients with adenoma in the major duodenal papilla. Jaundice at presentation and large adenomas may indicate the presence of more advanced disease. Determination of mutated KRAS seems to be of limited value in predicting long-term outcome.     

Treatment outcome after endoscopic papillectomy of tumors of the major duodenal papilla]

BACKGROUND/AIMS: Endoscopic papillectomy is reported to be relatively safe and reliable for complete resection of benign tumors of the major duodenal papilla. We evaluated methods and treatment outcome of the patients who have undergone endoscopic papillectomy. METHODS: Medical records of 22 consecutive patients with tumor of the major duodenal papilla (10 women, 12 men; mean age 55.8+/-2.8 yrs) who have undergone endoscopic papillectomy were reviewed retrospectively. Endoscopic papillectomy was defined the successful when complete excision of the tumor was achieved. RESULTS: Mean duration of follow-up was 8.4+/-2.4 months (range 1-43 months). Endoscopic papillectomy was successful in 16 patients (72.7%), but incomplete resection occurred in 6 patients. Only one patient showed recurrence. Histopathologic evaluation after endoscopic papillectomy revealed adenoma (n=11, 50%), high-grade dysplasia (n=3, 13.6%), adenocarcinoma (n=2, 9.1%), carcinoid (n=1), chronic inflammation (n=3, 13.6%), papillary adenomatous hyperplasia (n=1), and cavernous lymphangioma (n=1). The mean size of the resected lesions was 10.3+/-1.2 mm (range 2-20 mm). There was no factor which could predict the endoscopic success statistically. A pancreatic duct stent was placed in 11 patients (50.0%) and was removed after 3 to 39 days. There were 8 (36.8%) procedure-related complications: bleeding (n=4), papillary stenosis (n=1), perforation (n=1), cholangitis (n=1), and asymptomatic liver function abnormality (n=1). There was no pancreatitis or mortality. All the complications resolved with conservative management. CONCLUSIONS: Endoscopic papillectomy in selected patients seemed to be highly successful and safe. Longer follow-up is needed to assess the long-term efficacy.     

Endoscopic snare papillectomy for a solitary Peutz-Jeghers-type polyp in the duodenum with ingrowth into the common bile duct: Case report

Solitary duodenal Peutz-Jeghers (PJ)-type hamartomatous polyps are rare and considered a different disease entity than classic PJ syndrome. We describe the case of an 89-year-old man admitted to our emergency department with symptoms of acute cholangitis, liver dysfunction, and slight jaundice. Magnetic resonance imaging showed multiple signal voids, reflecting choledocholithiasis, and an oval-shaped tumor in the common bile duct (CBD). Following endoscopic retrograde cholangiopancreatography, the patient was diagnosed with a lower CBD tumor 20 mm in diameter. Endoscopic sphincterotomy was performed for choledocholithotomy, resulting in the expulsion of a large tumor with a stalk connected to the papilla of Vater. The tumor was successfully excised en bloc by endoscopic snare papillectomy. Histopathologic examination showed that the tumor was a PJ-type hamartomatous polyp. No mucocutaneous pigmentation of the skin was evident and the patient’s family history was negative. Solitary duodenal PJ-type hamartomatous polyps are usually diagnosed incidentally during endoscopy for other indications because most of these tumors are asymptomatic or have nonspecific presentations. To our knowledge, this is the first reported solitary PJ-type polyp with intra-CBD growth treated by endoscopic snare papillectomy.     

Endoscopic diagnosis and treatment of superficial nonampullary duodenal tumors

The diagnostic and treatment guidelines of superficial non-ampullary duodenal tumors have not been standardized due to their low prevalence.Previous reports suggested that a superficial adenocarcinoma(SAC) should be treated via local resection because of its low risk of lymph node metastasis,whereas a highgrade adenoma(HGA) should be resected because of its high risk of progression to adenocarcinoma.Therefore,pretreatment diagnosis of SAC or HGA is important to determine the appropriate treatment strategy.There are certain endoscopic features known to be associated with SAC or HGA,and current practice prioritizes the endoscopic and biopsy diagnosis of these conditions.Surgical treatment of these duodenal lesions is often related to high risk of morbidity,and therefore endoscopic resection has become increasingly common in recent years.Endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD) are the commonly performed endoscopic resection methods.EMR is preferred due to its lower risk of adverse events;however,it has a higher risk of recurrence than ESD.Recently,a new and safer endoscopic procedure that reduces adverse events from EMR or ESD has been reported.