Value of endoscopic papillectomy combined with endobiliary radio frequency ablation for duodenal papilla tumor with intraductal biliary infiltration / 中华消化内镜杂志

Objective:To evaluate the efficacy and safety of endoscopic papillectomy (EP) combined with endobiliary radio frequency ablation (RFA) for duodenal papilla tumor with intraductal biliary infiltration.Methods:Data of 12 patients with histologically confirmed duodenal papilla tumor combined with intraductal biliary infiltration treated by EP with RFA from February 2013 to February 2019 were retrospectively analyzed. Clinical characteristics,endoscopic features, treatment efficacy and postoperative complications of patients were reviewed and recurrence was followed up.Results:The median diameter of lesions measured by endoscopic ultrasound was 18.5 mm×15.5 mm, and the length of intrabiliary invasion was 14.1±5.8 mm. EP combined with RFA was successfully performed in all patients with a technical success rate of 100%. Postoperative pathology showed adenocarcinoma in 5 patients, adenoma with high-grade intraepithelial neoplasia in 6 patients, and adenoma with low-grade intraepithelial neoplasia in 1 patient. Patients received mean 4.1±1.6 times of ERCP with intraductal biopsy during a mean follow-up period of 28.5±10.4 months. Recurrence occurred in 2 patients at 14 and 20 months respectively, both were adenocarcinoma.Conclusion:EP combined with RFA is effective and safe for duodenal papilla tumor with intraductal biliary infiltration. However, given the risk of recurrence, close surveillance is recommended.

Seguimento de longo prazo de pacientes com tumor neuroendócrino da papila duodenal submetidos à papilectomia endoscópica: série de casos e revisão da literatura / Long-term follow-up of patients undergoing endoscopic papillectomy for papillary neuroendocrine tumor: a case series and literature review

ABSTRACT BACKGROUND: Duodenal papilla neuroendocrine tumors (DP-NET) are rare. Surgical therapy may be recommended for their treatment. However, they have high rates of morbidity and mortality. Endoscopic papillectomy (EP) is safe and effective for complete resection of tumors at this site. OBJECTIVE: This study aimed to describe a case series of DP-NETs resected by EP and perform a literature review. METHODS: A series of patients with DP-NETs underwent EP as primary treatment between Jan/2008 and Mar/2020 at a tertiary referral center. A comprehensive search was made on the MEDLINE primary electronic database. The search strategy was designed to find all articles related to DP-NETs published in the literature. RESULTS: Six patients underwent EP for presenting DP-NETs, four of whom were women (mean age, 63 years). The mean diameter of DP-NETs was 1.6±0.3 cm. Four of six patients were followed up, one of whom suffered relapse at the resection site after 3 months and was referred to surgery (pT3n1b) and the remaining three patients experienced no endoscopic or histological recurrence during follow-up periods of 10, 7, and 4 years, respectively. Eighteen articles were found in the literature search in MEDLINE. The articles included case reports of endoscopically treated DP-NETs. CONCLUSION: EP is safe and effective for DP-NETs that are ≤20 mm, confined to the submucosal layer, well-differentiated, and without local or remote metastasis. Adequate endoscopic follow-up and definitive surgical treatment in the presence of relapse are necessary.

RESUMO CONTEXTO: Tumores neuroendócrinos da papila duodenal (TNE-PD) são raros. A cirurgia deve ser recomendada para o tratamento. No entanto, apresentam altas taxas de morbimortalidade. A papilectomia endoscópica (PE) é segura e eficaz para a ressecção completa de tumores nesta região. OBJETIVO: Descrever uma série de casos de TNEs-PD ressecados por PE e realizar uma revisão da literatura. MÉTODOS: Pacientes com TNEs-PD submetidos a PE como tratamento primário com intenção curativa entre jan/2008 e mar/2020 em um centro de referência terciário foram estudados. Uma pesquisa abrangente foi feita no MEDLINE. A estratégia de busca foi desenhada para encontrar todos os artigos relacionados a TNEs-PD publicados na literatura, que haviam sido submetidos a PE. RESULTADOS: Seis pacientes foram submetidos a PE por apresentar TNEs-PD, sendo quatro mulheres, com média de idade de 66 anos (22-96). O diâmetro médio dos TNEs-PD foi de 1,8±0,4 cm. Quatro dos seis pacientes foram acompanhados, um dos quais sofreu recidiva no local da ressecção após 3 meses e foi encaminhado para cirurgia (pT3n1b), e os três pacientes restantes não apresentaram recorrência endoscópica ou histológica durante os períodos de acompanhamento de 10, 7 e 4 anos, respectivamente. Dezoito artigos foram encontrados no MEDLINE. Os artigos incluíram relatos de casos de TNEs-PD tratados pela PE. CONCLUSÃO: A PE é segura e eficaz para TNEs-PD ≤20 mm, confinados à camada submucosa, bem diferenciados e sem metástases locais ou remotas. Acompanhamento endoscópico adequado e tratamento cirúrgico definitivo na vigência de recidiva são necessários.

Tratamiento endoscópico de adenomas de la papila menor: reporte de dos casos / Endoscopic treatment of minor papilla adenomas: Report on two cases

Resumen Existen numerosas publicaciones sobre resección endoscópica de lesiones de la papila mayor, pero solo se han presentado series de casos individuales de resección de lesiones de la papila menor. En el presente artículo se describe el éxito técnico y la seguridad de la resección endoscópica de dos lesiones adenomatosas de la papila menor.

Abstract There are various publications on endoscopic resection of major papilla lesions, but only individual case series of resection of minor papilla lesions have been reported. This article describes the technical success and safety of endoscopic resection of two adenomatous lesions of the minor papilla.

Characteristics of benign and malignant lesions of ampullary polyps and the accuracy of forceps biopsy / 北京大学学报(医学版)

OBJECTIVE@#To distinguish the endoscopic and clinical features of ampullary polyps, to investigate the endoscopic cancer risk factors of ampullary polyps based on the compared differences of benign lesions and adenocarcinoma, and to assess the accuracy of forceps biopsy.@*METHODS@#Authors retrospectively analyzed the data extracted from patients treated with endoscopic papillectomy (EP) from January 2009 to May 2019 in the Department of Gastroenterology, Peking University Third Hospital. Endoscopic pictures and pathology reports were reevaluated and analyzed. Differences between benign and cancer groups were conducted.@*RESULTS@#In the study, 42 cases were involved, 35 to 83 years old, containing 83.3% older than 50 years old patients. The histological types were as follows, 2 for inflammatory polyps (4.8%), 1 for neuroendocrine tumor (2.4%), 1 for hyperplastic polyp (2.4%), 5 for grade Ⅰ adenoma (11.9%), 10 for grade Ⅱ adenoma (23.8%), 4 for grade Ⅲ adenoma (9.5%) and 19 for adenocarcinoma (45.2%), and 90.5% were adenoma or adenocarcinoma. The average age of benign group (inflammatory polyps and adenomas) was (56.7±9.2), which was significantly younger than that of adenocarcinoma group [(66.0±9.8), P=0.004]. Tumor diameter in adenocarcinoma group[(2.3±0.8) cm] was significantly larger than that in benign group[(1.6±0.6) cm, P=0.002]. Benign lesions only showed Yamada type Ⅰ(57.1%)and type Ⅱ(42.9%). The percentage of Yamada type Ⅰ (36.8%)and type Ⅱ(31.6%) in adenocarcinoma group was lower than that in benign group. Moreover, Yamada type Ⅲ (31.5%) was only found in the adenocarcinoma group. Significant differences were observed between the two groups in Yamada types (P=0.046). Most of the benign lesions had clear boundary(18/21, 85.7%). The percentage of clear boundary in adenocarcinoma group (2/19, 10.5%) was significantly lower than that in the benign group (P < 0.001). No significant differences were investigated in color (P=0.353) and surface (P=0.324) between benign and adenocarcinoma lesions. Pooling age, lesion diameter, Yamada type and clear boundary into Logistic regression analysis, only age (OR=1.186, 95%CI 1.025-1.373, P=0.022) and clear boundary (OR=66.218, 95%CI 3.421-1 281.840, P=0.006) were the independent cancer risk factors. Only 2 (10.5%) in the 19 cancer patients had positive biopsy results before EP. As compared with post-EP, 55.3% (21/38) biopsies were under-estimated, including 17 (17/19, 89.5%) adenocarcinomas and 4 (4/10, 40%) grade Ⅱ adenomas.@*CONCLUSION@#adenoma and adenocarcinoma were the major histological type of ampullary po-lyps. Age and unclear boundary were the independent risk factors of ampullary adenocarcinoma. Forceps biopsy was not enough for ampullary polyp differentiation.

Efficacy of endoscopic papillectomy for tumors of major duodenal papilla and literature review / 中国内镜杂志

Objective To evaluate and analyze the efficacy and safety of endoscopic papillectomy for tumors of major duodenal papilla. Methods The clinical data of three patients with tumors of major duodenal papilla who were treated by endoscopic papillectomy were retrospectively reviewed, and the clinical outcome was summarized. Results The success rate of endoscopic papillectomy was 100.0% (3/3), and the complete resection was 100.0% (3/3). No short-term complication occurred in 3 cases. The recurrence rate was 0.0% (0/3). Conclusion Endoscopic papillectomy is an effective method for treating tumors of major duodenal papilla.

Two Cases of Endoscopic Papillectomy for Neuroendocrine Tumor Arising from Minor Papilla / 대한췌담도학회지

Most of neuroendocrine tumors are usually found in the gastrointestinal tract. Recently, the incidence of gastrointestinal neuroendocrine tumors seems to have increased. However, only a few cases of neuroendocrine tumor arising from the minor duodenal papilla have been reported. Currently, several options are available to treat the tumors of the minor duodenal papilla. Endoscopic papillectomy is increasingly performed as a minimally invasive alternative treatment to conventional surgical resection. We present two cases of neuroendocrine tumor arising from minor duodenal papilla, which were successfully resected by endoscopic papillectomy. Although surgical resection is considered to be a standard treatment for gastrointestinal neuroendocrine tumors, our experience suggests that endoscopic papillectomy can be a minimally invasive alternative treatment for neuroendocrine tumors arising from the minor duodenal papilla.

Two Cases of Endoscopic Papillectomy for Neuroendocrine Tumor Arising from Minor Papilla / 대한췌담도학회지

Most of neuroendocrine tumors are usually found in the gastrointestinal tract. Recently, the incidence of gastrointestinal neuroendocrine tumors seems to have increased. However, only a few cases of neuroendocrine tumor arising from the minor duodenal papilla have been reported. Currently, several options are available to treat the tumors of the minor duodenal papilla. Endoscopic papillectomy is increasingly performed as a minimally invasive alternative treatment to conventional surgical resection. We present two cases of neuroendocrine tumor arising from minor duodenal papilla, which were successfully resected by endoscopic papillectomy. Although surgical resection is considered to be a standard treatment for gastrointestinal neuroendocrine tumors, our experience suggests that endoscopic papillectomy can be a minimally invasive alternative treatment for neuroendocrine tumors arising from the minor duodenal papilla.

Tranexamic Acid-Induced Acute Renal Cortical Necrosis in Post-Endoscopic Papillectomy Bleeding

Acute renal failure can be the result of acute renal cortical necrosis (RCN), which commonly occurs from complications occurring during pregnancy. RCN is rarely caused by medications, although tranexamic acid, which is used in patients with acute bleeding for its antifibrinolytic effects, reportedly causes acute RCN in rare cases. An 82-year-old woman experienced gastrointestinal bleeding after endoscopic papillectomy of an ampullary adenoma. The bleeding was controlled with tranexamic acid administration; however, 4 days later, her urine volume decreased and she developed pulmonary edema and dyspnea. Serum creatinine levels increased from 0.8 to 3.9 mg/dL and dialysis was performed. Abdominal pelvic computed tomography with contrast enhancement revealed bilateral RCN with no renal cortex enhancement. Renal dysfunction and oliguria persisted and hemodialysis was continued. Clinicians must be aware that acute RCN can occur after tranexamic acid administration to control bleeding.

A Case of Intractable Vernal Keratoconjunctivitis Treated by Papillectomy and Amniotic Membrane Transplantation

PURPOSE: To report a successful case of intractable vernal keratoconjunctivitis treated by papillectomy and amniotic membrane transplantation. CASE SUMMARY: A 20-year-old female patient presented with repeated vernal keratoconjunctivitis in both eyes since the age of 14. Despite medical therapy, she developed severe itching, burning and foreign body sensations, and limbal nodules with mutiple giant papillae of the upper tarsal plate. Surgical resection of the giant papillae and amniotic membrane transplantation in her left eye was performed. One month later, the same procedure was performed in her right eye. The patient's symptoms then improved. Neither recurrence nor serious complication were observed during the 6 months follow up period after surgery. CONCLUSIONS: In intractable vernal keratoconjunctivitis, papillectomy with amniotic membrane transplantation may potentially be a good treatment option for better clinical outcome and low recurrence rates.

The Prevention of Pancreatitis after Endoscopic Papillectomy; Stent versus No Stent / 대한췌담도학회지

Endoscopic papillectomy (EP) has been considered to be a less invasive, alternative therapy to surgery for ampullary adenoma. However, complication rates after EP could not be ignored, when compared to endoscopic resection for gastrointestinal lesions. Among them, the prevalence of postpapillectomy pancreatitis is higher in EP than ERCP. The prophylactic placement of a pancreatic stent has been reported to decrease the risk of pancreatitis after EP. However, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, a prospective, randomized, controlled study with a larger number of patients is needed to assess the efficacy of pancreatic stent placement to prevent pancreatitis.

A Gangliocytic Paraganglioma of the Ampulla of Vater Removed by Endoscopic Resection / 대한췌담도학회지

Gangliocytic paraganglioma (GP) is an extremely rare tumor that mostly occurs in the periampullary area of the duodenum. It is characterized by benign behavior and favorable outcomes, but sometimes shows regional lymph node dissemination. GP consist of three characteristic histological components: epithelioid, spindle, and ganglion cells. Therefore, it is often misdiagnosed as a neuroendocrine tumor when only endoscopic forceps biopsy is performed. The clinical management of GP has not yet been standardized. This case report describes an asymptomatic patient who was initially diagnosed with a grade-1 neuroendocrine tumor, but was confirmed as having benign GP after endoscopic papillectomy. Complete en-bloc resection was performed for this patient, without any significant adverse events. At a 6-month follow-up assessment, the patient remained asymptomatic and there was no evidence of recurrence.

Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management / 대한소화기학회지

Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.

Clinical efficacy of endoscopic resection of duodenal papilla tumor (with video) / 中华消化内镜杂志

Objective To evaluate therapeutic effect of endoscopy on duodenal papilla tumor. Methods Clinical data of patients who underwent the endoscopic duodenal papilla tumor resection in Zhongshan Hospital were retrospectively studied from April 2007 to May 2014. Results A total of 21 patients underwent 28 procedures. Postoperative biliary stent were retained in 6 cases (6/28) , with no perforation or postoperative pancreatitis. Delayed bleeding occurred in 7 cases (7/28) and controlled by endoscopic hemostasis, and no death occurred. Mean follow-up was 31. 5 months. There were 6 recurrent cases, and mean recurrence time was 14. 1 months. All these recurrent cases are treated by endoscopy treatments or surgery. Conclusion Endoscopic treatment of duodenal papilla tumor is safe, effective and minimally invasive, but the occurrence of delayed bleeding is worth concern.

Recent Advances in Endoscopic Papillectomy for Ampulla of Vater Tumors: Endoscopic Ultrasonography, Intraductal Ultrasonography, and Pancreatic Stent Placement

Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.

Ampullary Adenoma Treated by Endoscopic Double-Snare Retracting Papillectomy

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.

The therapeutic value of endoscopic papillectomy for adenoma in major duodenal papilla / 中华消化内镜杂志

Objective To study the therapeutic value of the endoscopic papillectomy for adenoma in the major duodenal papilla.Methods All 3 1 cases with the major duodenal papilla undergoing endoscopic papillectomy from January 2008 to June 2013 were retrospectively reviewed.The clinical data,endoscopic treatment,complications and follow-up were analysed.Results Endoscopic papillectomy was performed successfully in 29 patients.Post-operative pathology showed adenoma with low-grade dysplasia in 25 cases and high-grade dysplasia in 4 cases.One patient (3. 4%,1/29 )bled during operation;and there was no bleeding after operation. There was no perforation during and after the operation. Seventeen patients (58. 6%,17/29)developed hyperamylasemia and 3 patients(10. 3%,3/29)got mild pancreatitis,which were cured by conservative treatment.During follow-up,2 patients (6. 9%,2/29)with high-grade dysplasia had tumor recurrence after 6 months and 2 years respectively.The 27 other patients had no recurrence during the follow-up period.The shortest follow-up was 1 1 months,the longest was 5 years,with a mean time of 33. 5 ±8. 5 months.Conclusion Endoscopic papillectomy is feasible and safe for early tumors of the major duodenal papilla.Although the postoperative recurrence rate is low,it still needs close follow-up.

Acute Acalculous Cholecystitis without Cholangitis As a Complication of Endoscopic Snare Papillectomy for Ampullary Adenoma / 대한췌담도학회지

Endoscopic snare papillectomy (ESP) for ampulla of Vater tumor (AVT) has been performed successfully instead of surgical ampullectomy (SA) because ESP is a less invasive procedure than SA. Hemorrhage, perforation and pancreatitis are relatively common complications of ESP and other rare complications such as cholangitis, liver abscess has been reported. Recently we encountered a case of acute acalculous cholecystitis after ESP for AVT, which was treated successfully with percutaneous cholecystostomy with intravenous antibiotics. We therefore report this case with a brief review of the literature.

Prophylactic Pancreatic Stent Placement for Endoscopic Duodenal Ampullectomy: A Single-Center Retrospective Study

BACKGROUND/AIMS: We investigated the efficacy of prophylactic pancreatic stent placement for preventing postprocedure pancreatitis in patients undergoing endoscopic papillectomy. METHODS: This retrospective study included 82 consecutive patients who underwent endoscopic papillectomy for benign ampullary neoplasm at Samsung Medical Center between August 2002 and June 2011. The patients were subdivided into two groups, namely, those who received prophylactic pancreatic stent placement and those who did not. Patient demographics, baseline blood test, tumor characteristics, and endoscopic treatment data were collected. The primary endpoint was postprocedure pancreatitis. RESULTS: There was no difference in the development of postprocedure pancreatitis between the stent group and the no stent group (6/54, 10.5% and 2/28, 7.14%, respectively; p=1.00). At baseline, there were no significant differences between the two groups in terms of their risk factors for pancreatitis except pancreatic duct dye injection. The stent group was more likely to have dye injection than the nonstent group (100% vs 42.8%, p<0.001). However, in a logistic regression analysis, no significant difference was observed in the risk factors for pancreatitis including dye injection. CONCLUSIONS: Our data suggest that routine prophylactic pancreatic duct stent placement in all patients undergoing endoscopic papillectomy may not be necessary and that large-scale prospective studies are required to identify the subgroup of patients who would benefit.

Clinicopathologic Characteristics Associated with Complications and Long-Term Outcomes of Endoscopic Papillectomy for Adenoma

PURPOSE: Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP. MATERIALS AND METHODS: Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11). RESULTS: The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months. CONCLUSION: If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.

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.