Endoscopic Resection of Tumor of Papilla Vater: Our Experiences

Endoscopic papillectomy has become common in recent years as a non‐invasive therapeutic procedure for tumor of the papilla of Vater, although the lesions, which indicate endoscopic papillectomy, are very rare. In order to decide the indication for this procedure, intraductal ultrasonography (IDUS) is useful to obtain the correct diagnosis. For the successful and safe procedure of papillectomy, it is important to use the cutting mode of generator. and it is sometimes useful to inject the saline into the submucosal layer of the duodenum and to place the plastic stent into the bilio‐pancreatic ducts.     

Current Status of Endoscopic Papillectomy for Ampullary Tumors

Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.     

内镜下十二指肠乳头切除术在乳头部肿瘤诊断中的价值

目的:评价内镜下十二指肠乳头切除术(endos-copic papillectomy,EP)在乳头部肿瘤诊断中的临床价值.方法:分析2008-01/2012-03来我院的16例经病理检查确诊的十二指肠乳头部肿瘤患者的相关资料,评价EP在十二指肠乳头部肿瘤诊断中的临床价值.结果:16例患者中,内镜活检诊断为腺瘤者12例,慢性炎症改变者4例.EP将乳头部肿瘤组织切除后整体送检行病理学检查确诊为低分化腺癌者2例,高分化腺癌1例,腺瘤13例(其中1例腺瘤恶变,4例常规内镜活检诊断为慢性炎症改变者术后均确诊为腺瘤),EP术后准确率明显高于内镜活检法(P<0.05).超声内镜(endoscopic ultrasonography,EUS)检查提示病变均起源于黏膜层,胰胆管扩张者9例,未见黏膜下层连续性中断及胰胆管受累者,无腹膜后淋巴结肿大者;12例高回声病变者术后病理检查结果均为腺瘤,1例高回声病变局部见低回声区者术后病理检查结果为腺瘤恶变,3例低回声病变者术后病理检查结果均为腺癌.EP术后2例低分化腺癌者、1例腺瘤恶变者及1例腺瘤者胆管开口处见病变残留,提示胆管受累,但术前EUS检查均未提示胆管受累;1例高分化腺癌及11例腺瘤者病灶均完整切除,术后切缘阴性.EP术后除2例出现黑便外,无急性胰腺炎、穿孔及其他并发症发生,无患者死亡.结论:EP术将乳头部肿瘤组织切除后整体送检行病理学检查可提高诊断准确率,为治疗方法的抉择提供科学依据.     

Endoscopic resection of carcinoid of the minor duodenal papilla

We encountered a 65-year-old man with a carcinoid tumor of the minor duodenal papilla. Since he had liver cirrhosis and completely refused surgery, we performed an endoscopic snare papillectomy. The papillectomy was performed successfully without procedure-related complication. The specimens revealed a carcinoid tumor showing that the margin of the tumor was positive. One week later, upper GI endoscopy was performed and the biopsy specimens obtained from base of ulcer showed no neoplastic cells. We performed a duodenoscopy and CT 3, 6 and 18 mo later, and there was no macroscopic or microscopic evidence of tumor recurrence after more than 4 years.     

Two Cases of Hemorrhagic Ampullary Lesions Successfully Treated by Endoscopic Papillectomy

We herein report two cases of hemorrhagic ampullary lesions in which endoscopic papillotomy was performed to control bleeding and resulted in successful treatment. Both patients were pathologically diagnosed with an underlying pathology characterized by inflammatory cell infiltration and capillary proliferation. They also had disposing factors for bleeding, such as antithrombotic therapy and idiopathic thrombocytopenic purpura. Endoscopic treatment was selected because the risk of surgical resection was high due to the patients'' hemorrhagic condition. Both patients were successfully treated without any serious adverse events and had an uneventful postoperative course with no relapse of bleeding.     

No Significant Correlation between Histologic Changes of the Papilla of Vater and Juxtapapillary Diverticulum: Special Reference to the Pathogenesis of Gallstones

The aim of this study was to investigate the significance of histologic changes of the papilla of Vater in cases with a juxtapapillary diverticulum, with special reference to the pathogenesis of gallstones. Three hundred and sixty-two autopsy cases, mainly of aged people, were analyzed. The incidence of both diverticulum and gallstone increased with age. The presence of diverticulum was associated with a significant increase of gallstones (49% versus 20%; P > 0.01). Analysis by the type of gallstones showed a significantly higher incidence of bilirubinate in cases with juxtapapillary diverticula. Stones both in the gallbladder and in the extrahepatic bile ducts were more prevalent in cases with diverticula as compared with the cases without diverticula. No significant relationship was found between juxtapapillary diverticula and the degree of histologic changes in the papilla of Vater, such as inflammatory cellular infiltration, fibrous proliferation, glandular proliferation, or muscular hypertrophy and proliferation of the sphincter of Oddi. These facts imply that juxtapapillary diverticula are not involved in the formation of gallstones via histologic changes of the papilla of Vater, whereas diverticula may play an important role in the pathogenesis of gallstones, especially of bilirubin stones.     

内镜下十二指肠乳头切除术对十二指肠乳头部腺瘤的治疗价值

目的评价内镜下十二指肠乳头切除术在十二指肠乳头部腺瘤治疗中的应用价值。方法回顾性分析31例因十二指肠乳头部腺瘤行内镜下十二指肠乳头切除术治疗患者的临床资料,总结内镜治疗完成情况、并发症发生情况以及术后随访情况。结果29例（93．5％,29／31）成功完成内镜下十二指肠乳头切除术治疗,术后病理提示腺瘤伴低级别上皮类瘤变25例、腺瘤伴上皮类瘤变4例。术中1例（3．4％,1／29）发生出血,无穿孔;术后无出血和穿孔,17例（58．6％,17／29）并发高淀粉酶血症、3例（10．3％,3／29）并发轻度胰腺炎,均经内科保守治疗痊愈。有2例（6．9％,2／29）伴有上皮类瘤变者分别在术后6个月及2年后复发;其余27例随访期间无复发,随访时间11个月至5年,平均（33．6±8．5）个月。结论内镜下十二指肠乳头切除术治疗十二指肠乳头部腺瘤安全可行,具有较好的临床应用价值,虽然术后复发率较低,但仍应注意密切随访。     

Endoscopic papillectomy: Is there room for this procedure in clinical practice?

It has been 20 years since the development of endoscopic papillectomy (snare excision of the papilla of Vater). The accepted indication for this procedure is adenoma of the duodenal papilla. As for the evaluation of tumor extent, there is room for improvement of the diagnostic accuracy. Due to the high incidence of coexistent cancer detected by histological examination of surgically resected specimens in biopsy‐proven adenoma of the papilla of Vater, ablation techniques should essentially be avoided in order to preserve a specimen that is amenable to reliable histological examination. Otherwise, there may be a risk of retained coexistent cancer. It is not always possible to leave a safety margin when removing a tumor of the papilla of Vater by the snare excision technique and careful follow up is mandatory after the treatment. Consensus has not been reached as to the interval and the method of biopsy during follow up. When endoscopic biopsy from the site of the papilla of Vater at follow‐up endoscopy proves malignancy, the remnant needs to be resected surgically. An adequate follow‐up interval should be determined before this technique is established as the treatment of choice for ampullary tumors.     

Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up

AIMS: To compare the efficacy and the complication rate between endoscopic snare resection of adenomas of Vater's papilla and endoscopic palliation. METHODS: In a retrospective, non randomized manner, we compared long-term results of our endoscopic strategies in 36 patients with histologically confirmed adenoma of Vater's papilla submitted either to local endoscopic snare resection (n=18) or to simple endoscopic palliation (n= 18), respectively. RESULTS: Between 1985 and 1998 results were reviewed. Median age was 76.5 (range 42-89) years in the palliation, and 64.0 (23-89) years in the endoscopic snare resection group. Median duration of follow-up was 33 (6-135) and 75.0 (27-123) months, respectively. The incidence of adenocarcinoma of Vater's papilla was 1 per 52.8 patient-years after endoscopic snare resection and 1 per 15.5 patient-years in the group treated with endoscopic palliation. Compared to the results of endoscopic palliation (prosthesis, sphincterotomy), we found a significant reduction of carcinoma-related death (p=0.0045, McNemar) and adenoma carcinoma-sequence (p=0.007, McNemar) after snare resection. CONCLUSIONS: This retrospective study suggests that complete endoscopic snare resection of adenomas of Vater's papilla will lead to a lower rate of adenoma-carcinoma sequence, to a lower carcinoma-related death rate and probably improves patient survival. These results should be proven prospectively.     

Carcinoma of the papilla of Vater following treatment of pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is frequently associated with biliary cancer due to reflux of pancreatic enzymes into the choledochus, and even after surgery to correct the PBM such patients still have a risk of residual bile duct cancer. Here, we report the case of a 59-year-old female with carcinoma of the papilla of Vater which developed 2.5 years after choledochoduodenostomy for PBM. During the postoperative follow-up period, computed tomography obtained 2 years after the first operation demonstrated a tumor in the distal end of the choledochus, although she did not have jaundice and laboratory tests showed no abnormalities caused by the previous operation. As a result, carcinoma of the papilla of Vater was diagnosed at an early stage, followed by surgical cure. For early detection of periampullary cancer in patients undergoing surgery for PBM, careful long-term followup is needed.     

Malignant carcinoid tumor in the papilla of Vater: case report and review of 25 cases reported in Japan

Carcinoid tumors in the papilla of Vater are rare. We describe a 48-year-old male who was diagnosed with a tumor consisting of atypical cells in the papilla of Vater. He underwent curative resection of the tumor by pancreatico-duodenectomy (PD), with dissection of the regional lymph nodes. Microscopic examination revealed a metastatic lymph node in the pancreatic region. Characteristic findings on histopathological and electron microscopic studies led to the final diagnosis of malignant carcinoid tumor. It is clear from the literature that carcinoid tumors in the papilla of Vater metastasize to the regional lymph nodes and the liver. However, it has been difficult to preoperatively diagnose carcinoid tumor in the papilla of Vater. Therefore, if we observe atypical cells in the papilla of Vater, malignant carcinoid tumor should be considered. If this tumor is suspected, PD or pylorus-preserving PD, together with dissection of the regional lymph nodes, at least along the hepatoduodenal ligament, should be considered as the treatment of first choice.     

Endosonographic criteria for assessment of the depth of duodenal invasion in carcinoma of the papilla of Vater

Background: Imaging criteria by endosonography for assessment of the depth of duodenal invasion of carcinoma of the papilla of Vater (papilla carcinoma) have not been established. Methods: Twelve patients with papilla carcinoma were studied. The endosonographic findings were described in each case and depths were evaluated based on endosonographic images of the normal papilla and by comparison with endosonographic images of gastric carcinoma. The information was compared with the histopathological findings of the resected specimens. Results: Imaging criteria were proposed as follows: In d0 or T1, the papilla swelled preserving the basic structure; in d1 or T2, the papilla presented as a tumor but the non‐thickened duodenal fourth (proper muscle) layer was traceable behind the tumor; in d2 or T2, the papilla presented as a tumor fused with the thickened duodenal fourth layer; in d3 or T3–4, the papilla presented as a tumor and the duodenal fourth layer was partially or entirely untraceable behind the tumor. Accuracy of endosonography was 75% by the Japanese classification and 83.3% by the TNM system. Conclusions: Proposed endosonographic criteria are suitable for clinical application for assessing the depth of duodenal invasion of papilla carcinoma.     

Endoscopic papillectomy: Indications,techniques, and results

Endoscopic papillectomy(EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size(up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings(ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound(EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a "high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early(pancreatitis, bleeding, perforation, and cholangitis) and late(papil-lary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis(FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.     

Myelodysplastic Syndrome Progresses Rapidly Into Erythroleukemia Associated With Synchronous Double Cancers of the Stomach and the Papilla of Vater

Patients with myelodysplastic syndrome (MDS) show a relatively high incidence of developing cancers. However, it is extremely rare that synchronous double cancers develop in an MDS patient. We report a case of MDS that progressed rapidly into erythroleukemia (M6 by French-American-British classification) complicated by gastric cancer and carcinoma of the papilla of Vater. A 66-year-old man was admitted because of pancytopenia with peripheral blasts. A diagnosis of MDS (with refractory anemia with excess of blasts in transformation [RAEB-T]) was made by bone marrow examination. Chromosome analysis revealed 46,XY. An early gastric cancer was also diagnosed by endoscopic examination. The peripheral blasts gradually proliferated and the disease progressed to M6. A chromosome abnormality 46,XY,del(1)(q42) was detected at the leukemic transformation. A CAG (low-dose cytarabine and aclarubicin in combination with granulocyte colony-stimulating factor) regimen was started as a remission-induction therapy. However, obstructive jaundice developed and a marked dilatation of bile ducts was observed by abdominal computed tomography (CT). A carcinoma of the papilla of Vater was detected by endoscopy. As remission was achieved and the pancytopenia improved, the patient subsequently underwent a surgical jejuno-choledochostomy to manage the jaundice. However, the leukemia relapsed thereafter and additional chromosome abnormalities including der(5)t(5;10)(p15:q11) were observed.     

The Safety of Radiofrequency Ablation Using a Novel Temperature-Controlled Probe for the Treatment of Residual Intraductal Lesions after Endoscopic Papillectomy

Background/AimsTreatment of residual intraductal lesions after endoscopic papillectomy for ampullary adenomas is relatively difficult. Few studies have been conducted using intraductal radiofrequency ablation (RFA) in the treatment of such lesions, and no study has aimed to reduce the side effects of excessive heat caused by RFA. Recently, a temperature-controlled RFA probe was developed to avoid excessive heat. This study aimed to investigate the safety of this new RFA probe in the treatment of intraductal lesions of ampullary adenoma.MethodsPatients who received RFA for residual intraductal lesions after endoscopic papillectomy between November 2017 and June 2019 were retrospectively reviewed. A novel temperature-controlled probe (ELRA) was used for intraductal RFA, and clinical data including adverse events were collected.ResultsTen patients were included in this study. Intraductal adenomas showed low-grade dysplasia in eight patients and high-grade dysplasia in two patients. The median diameter of intraductal adenomas was 9 mm (range, 5 to 10 mm) in the common bile duct and 5 mm (range, 4 to 11 mm) in the pancreatic duct. Adverse events occurred in three patients (30.0%), of which two were mild pancreatitis and one was asymptomatic biliary stricture. Over a median follow-up period of 253 days, only one patient underwent additional surgery, as the remainder showed no adenomatous lesions on follow-up biopsies.ConclusionsThe new temperature-controlled RFA probe can be used with acceptable safety for the treatment of residual intraductal lesions after endoscopic papillectomy. Further evaluation through future prospective studies is needed.     

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

BACKGROUND Ectopic pancreas is a rare developmental anomaly that results in a variety of clinical presentations. Patients with ectopic pancreas are mostly asymptomatic,and if symptomatic, symptoms are usually nonspecific and determined by the location of the lesion and the various complications arising from it. Ectopic pancreas at the ampulla of Vater(EPAV) is rare and typically diagnosed after highly morbid surgical procedures such as pancreaticoduodenectomy or ampullectomy. To our knowledge, we report the first case of confirmed EPAV with a minimally invasive intervention.CASE SUMMARY A 71-year-old male with coronary artery disease, presented to us with new-onset dyspepsia with imaging studies revealing a ‘double duct sign' secondary to a small subepithelial ampullary lesion. His hematological and biochemical investigations were normal. His age, comorbidity, poor diagnostic accuracy of endoscopy,biopsies and imaging techniques for subepithelial ampullary lesions, and suspicion of malignancy made us acquire histological diagnosis before morbid surgical intervention. We performed balloon-catheter-assisted endoscopic snare papillectomy which aided us to achieve en bloc resection of the ampulla for histopathological diagnosis and staging. The patient's post-procedure recovery was uneventful. The en bloc resected specimen revealed ectopic pancreatic tissue in the ampullary region. Thus, the benign histopathology avoided morbid surgical intervention in our patient. At 15 mo follow-up, the patient is asymptomatic.CONCLUSION EPAV is rare and remains challenging to diagnose. This rare entity should be included in the differential diagnosis of subepithelial ampullary lesions.Endoscopic en bloc resection of the papilla may play a vital role as a diagnostic and therapeutic option for preoperative histological diagnosis and staging to avoid morbid surgical procedures.     

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.     

An inflammatory myofibroblastic tumor of the ampulla of vater successfully managed with endoscopic papillectomy: report of a case

Inflammatory myofibroblastic tumors (IMTs) are solid neoplastic mesenchymal proliferations composed of myofibroblastic spindle cells admixed with inflammatory infiltrates. The documented sites in the gastrointestinal tract include the esophagus, small intestine, colon, appendix, rectum, pancreas, spleen, liver, and Meckel's diverticulum. Biliary IMTs are rare, and IMTs arising from the ampulla of Vater have not been reported previously. Herein we report the case of a 65-year-old woman with an extrahepatic biliary obstruction due to IMT of the ampulla of Vater, and a successful therapeutic approach using endoscopic ultrasonography and endoscopic papillectomy.     

Modes of spread in early ampullary cancer in terms of establishing proper indications for endoscopic papillectomy

Background: Endoscopic papillectomy for adenomas of the ampulla of Vater has been reported and is gaining acceptance as an alternative to surgery in the treatment of early ampullary cancer. However, whether endoscopic treatment is justified as a treatment of choice for early ampullary cancer remains controversial. The aim of the present study was to elucidate the possibility of endoscopic papillectomy as a treatment of early ampullary cancer from the review of pathology of cases treated by surgical resection. Patients and methods: Twenty‐three cases of early ampullary cancer (m—tumor limited to the mucosa of the ampulla 14; od—tumor that invades Oddi's sphincter, 9) treated by surgical resection from January 1984 to March 2003 were investigated as to the following: (i) macroscopic type, maximum size, and histological type of tumor; (ii) main location and extension of tumor; (iii) prevalence of extension into the lower bile duct or pancreatic duct, and relationship between ductal infiltration and macroscopic type, maximum size, main location, or depth of invasion of tumor; (iv) lymphatic permeation, vascular invasion, and lymph node metastasis; and (v) prognosis. Results: All cases were classified macroscopically as exposed‐tumor type or non‐exposed‐tumor type without ulceration. Extension into the lower bile duct or the pancreatic duct was observed in 43% of the cases. There was no correlation between ductal infiltration and macroscopic type, maximum tumor size, main tumor location, or tumor depth. No lymphatic permeation, vascular invasion, or lymph node metastasis were proven in cases with ampullary cancer confined to the mucosa. In the nine cases with involvement of Oddi's sphincter, lymphatic permeation and lymph node metastasis were observed in two cases and one case, respectively. Conclusion: Endoscopic treatment for early ampullary cancer confined to the mucosa without spread to the bile duct or pancreatic duct is justified as a treatment of choice if detailed histological examination of the resected specimen indicated no invasion beyond its margin.     

十二指肠乳头肿瘤的内镜下切除

随着内镜下逆行胰胆管造影(ERCP)的广泛应用,十二指肠乳头肿瘤越来越多地被发现。该病手术治疗创伤大,并发症和死亡率高,采用内镜下切除则创伤小、恢复快,且安全、疗效肯定。此文就内镜下对十二指肠乳头肿瘤的诊断、切除的适应证、技术、安全和有效性及并发症作一综述。