Therapeutic effect of endoscopy on early cancer of duodenal papilla / 中华消化内镜杂志

Objective:To evaluate the clinical efficacy of endoscopy for early cancer of duodenal papilla.Methods:A retrospective analysis was performed on data collected from 23 consecutive patients with early cancer of duodenal papilla, who underwent endoscopic treatment from January 2015 to January 2021 in Beijing Friendship Hospital. Baseline data, endoscopic and pathological data, occurrence and outcome of complications were studied.Results:Twenty-three patients successfully received endoscopic treatment. The maximal diameter of lesions evaluated under endoscopy was 1.90±0.83 cm. Among the 23 cases, 20 underwent endoscopic mucosal resection and 3 underwent endoscopic piecemeal mucosal resection. Delayed bleeding occurred in 5 cases (21.7%), 3 patients (13.0%) developed postoperative hyperamylasemia, 6 patients (26.1%) developed mild acute pancreatitis, and 1 patient (4.3%) had pancreatic duct stent displacement after the operation, which improved after medical or endoscopic treatment. No perforation occurred during the perioperative period. In terms of final pathology, the en bloc resection rate was 82.6% (19/23), and the complete resection rate was 78.3% (18/23). Preoperative endoscopic ultrasonography showed that 19 lesions were confined to the mucosal layer, which were all demonstrated by postoperative pathology. Four other cases were suspected to be involved in the submucosa or the end of the pancreaticobiliary duct under endoscopic ultrasonography, two of which were confined to the mucosal layer, and the other 2 cases involved the submucosal layer, so additional surgery was performed. A total of 18 patients were followed up, among whom 14 achieved complete resection of postoperative pathology, and 2 patients (14.3%, 2/14) were found to have recurrence at 12 and 51 months respectively after the treatment and did not relapse after surgical treatment and endoscopic treatment respectively. Among 4 other patients of follow-up whose pathology did not achieve complete resection, 1 had no recurrence, and the other 3 received additional surgical treatment without recurrence.Conclusion:Endoscopic treatment for early cancer of duodenal papilla is safe and effective. It is necessary to improve preoperative evaluation, stay alert to perioperative complications, and pay attention to regular postoperative endoscopic follow-up.

Diagnostic value of narrow-band imaging combined with endoscopic ultrasonography for ampullary tumors / 中华消化内镜杂志

Objective To study the diagnostic value of narrow-band imaging ( NBI) combined with endoscopic ultrasonography ( EUS) for ampullary tumors. Methods A total of 21 patients suspected with ampullary lesions by imaging or endoscopic examination from December 2015 to March 2017 were enrolled in this prospective study. All patients underwent NBI and EUS, and 20 patients underwent biopsy. The type of ampullary tumor was predicted by preoperative examination, and appropriate treatment methods were chosen. The final diagnosis was confirmed by biopsy, surgical pathology, and clinical follow-up for more than 6 months. The accuracy of NBI combined with EUS and biopsy in diagnosis of ampullary malignant tumors was calculated according to the gold standard. The Chi-square test was used to compare diagnostic accuracies. Results The sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of NBI combined with EUS in diagnosis of ampullary malignancies were 94. 1％ (16/17), 100. 0％ (4/4), 95. 2％ (20/21), 100. 0％ (16/16), and 80. 0％ (4/5), respectively. The corresponding indicators of preoperative biopsy were 41. 2％ ( 7/17) , 100. 0％ ( 3/3) , 50. 0％ ( 10/20) , 100. 0％ ( 7/7) , and 23. 1％( 3/13) , respectively. The accuracy of NBI combined with EUS in diagnosing ampullary malignant tumor was significantly higher compared with preoperative biopsy ( P=0. 004) . Conclusion NBI combined with EUS can more accurately predict benign or malignant ampullary tumor, and better guide the choice of surgical methods compared with preoperative biopsy.

Transduodenal ampullectomy for ampullary tumors - single center experience of consecutive 26 patients

PURPOSE: Transduodenal ampullectomy (TDA) has been reported in a limited number of cases and in a small number of case series. The aim of this study was to analyze perioperative and long-term oncological outcomes of patients with ampullary tumors who underwent TDA in a single large-volume center. METHODS: Through a retrospective review of data from 2004 to 2016, we identified 26 patients who underwent TDA at Asan Medical Center. RESULTS: Eleven of 26 patients underwent TDA for T1 and carcinoma in situ (high-grade dysplasia) cancer; these patients are still alive without recurrence. A major in-hospital complication (3.8%) occurred in 1 case, but there was no case of 90-day mortality. In addition, none of the patients was diagnosed as having newly developed diabetes mellitus after TDA. No significant differences were found between open and laparoscopic-TDA in terms of operation time, painkiller use, and hospital stay. CONCLUSION: TDA is a feasible and effective surgical procedure for the treatment of selected patients with ampullary tumors. It is an alternative treatment option in cases of ampullary tumors not amenable to endoscopic papillectomy or pancreaticoduodenectomy.

The Role of Endoscopy in Diagnosis and Treatment of Ampullary Tumor / 대한췌담도학회지

Tumors of the major duodenal papilla, also known as ampullary tumor, are rare with an approximate 5% incidence of all gastrointestinal neoplasm. These tumors seem to be detected more frequently with increasing performance of upper endoscopic examination and endoscopic retrograde cholangiopancreatography (ERCP). Adenoma, most common benign disease of ampullary tumor, is very important because of its potential to undergo malignant transformation to ampullary cancer. Especially, endoscopic ultrasound or transpapillary intraductal ultrasonography can provide more detailed and accurate information on the extent of ampullary tumors and proper treatment should be done after diagnosis. Considering perioperative morbidity and mortality of surgical resection, endoscopic papillectomy is regarded as a curative treatment of ampullary adenoma. However, the indication of the procedure is very strict and there are various complications related to the procedure. Therefore, it is important to understand the role of endoscopy in diagnosis and treatment of ampullary tumor. In this review, the diagnostic role of endoscopy for ampullary tumor and the treatment method of endoscopic papillectomy will be discussed.

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.

Endoscopic snare resection for tumors of the ampulla of Vater

Though surgical resection has been the traditional treatment for tumors of the ampulla of Vater, endoscopic maneuvers such as snare resection, laser photodestruction and electrofulguration have recently been introduced to avoid operation-related morbidity and mortality. From 1994 to 1996, 6 patients with ampullary tumor were managed by endoscopic snare resection and regularly followed. Endoscopic snare resection of the ampullary tumor was technically feasible in all patients and each procedure was performed in a single session. Histologic diagnoses of the resected specimens were adenoma in 4 patients and adenoma with coexistent adenocarcinoma in 2 patients. Resection margins were negative in all patients except 1 with coexistent adenocarcinoma and a radical pancreaticoduodenectomy was performed in that case. For the other patient with adenocarcinoma foci, no further treatment was persued since he was 72-year-old and refused operation. Acute pancreatitis developed in 2 patients after endoscopic therapy, but was resolved with conservative management. There was no procedure-related death. Surveillance duodenoscopy performed at 1 and 6 months after endoscopic resection revealed no evidence of recurrent tumor in 4 patients with adenoma. Among them, 3 patients are alive without evidence of recurrence at 16-37 months after resection, but 1 patient was lost after 9 months of follow-up. The patient with adenocarcinoma in whom a pancreaticoduodenectomy was performed, has been alive without recurrence for 12 months. Oral 5-fluorouracil was administered for the other patient with adenocarcinoma foci. Though he experienced local recurrence at 13 months after the procedure, he has been alive for 28 months after resection. In conclusion, endoscopic snare resection may be applied as a viable alternative to surgery in selected patients with small ampullary tumors.

Treatment of Ampullary Neoplasm, Diagnosed as Benign on Preoperative Endoscopic Biopsy

Adenoma of the ampulla of Vater is a rare disease, and there is no universal consensus on the management of this entity due to its rarity and unpredictable behavior. Because many of these tumors recur after local excision and because it is difficult to obtain a definitive diagnosis or to exclude malignancy before operation, local excision of ampullary tumors still remains controversial despite being a standard operation for nearly a century. Many surgeons resort to more radical resection, such as pancreatoduodenectomy for treatment of this troublesome disease. The author's report on the evaluation and treatment of 10 patients who underwent pancreatoduodenectomy for ampullatry tumors, diagnosed as benign adenoma on preoperative endoscopic biopsy. Endoscopic retrograde cholangiopancreaticography (ERCP) and computed tomography (CT) was performed in all cases. There were 6 men and 4 women, with a median age of 53 years (22-72 years). Postoperative histopathologic examination revealed that five of the ten patients had had cancerous change within adenoma. Four of the five ampullary adenocarninomas were confined to mucosa, but one had invaded the pancreatic parenchyma. No case was accompanied with lymphatic involvement. Reoperative pancreatoduodenectomy was perfomed in one patient with recurrent villotubular adenoma after local excision of ampulla. All patients are still alive and without any evidence of tumor recurrence after pancreatoduodenectomy (median follow up period 35 months, range 17-77 months). There was no postoperative death. Diagnosis of malignancy could not be ruled out based on a preoperative endoscopic biopsy in ampullary tumors. We conclude that pancreatoduodenectomy with regional lymph node dissection should be the standard treatment in circumstances without any contraindication to extensive surgery.