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.

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.

Triple-Tissue Sampling during Endoscopic Retrograde Cholangiopancreatography Increases the Overall Diagnostic Sensitivity for Cholangiocarcinoma

BACKGROUND/AIMS: There are several methods for obtaining tissue samples to diagnose malignant biliary strictures during endoscopic retrograde cholangiopancreatography (ERCP). However, each method has only limited sensitivity. This study aimed to evaluate the diagnostic accuracy of a combined triple-tissue sampling (TTS) method (on-site bile aspiration cytology, brush cytology, and forceps biopsy). METHODS: We retrospectively reviewed 168 patients with suspicious malignant biliary strictures who underwent double-tissue sampling (DTS; n=121) or TTS (n=47) via ERCP at our institution from 2004 to 2011. RESULTS: Among the 168 patients reviewed, 117 patients (69.6%) were eventually diagnosed with malignancies. The diagnostic sensitivity for cancer was significantly higher in the TTS group than the DTS group (85.0% vs 64.9%, respectively; p=0.022). Furthermore, the combination of brush cytology and forceps biopsy was superior to the other method combinations in the DTS group. With respect to cancer type (cholangiocarcinoma vs noncholangiocarcinoma), interestingly, the diagnostic sensitivity was higher for cholangiocarcinoma in the TTS group than the DTS group (100% vs 69.4%, respectively; p<0.001) but not for the non-cholangiocarcinoma patients (57.1% vs 57.1%, respectively). CONCLUSIONS: TTS can provide an improved diagnostic accuracy in suspicious malignant biliary strictures, particularly for cholangiocarcinoma.

Endoscopic Resection as a Possible Radical Treatment for Duodenal Gangliocytic Paraganglioma: A Report of Four Cases / 대한소화기학회지

Gangliocytic paraganglioma (GP) is a rare, benign tumor which is usually found in the duodenum. We here report four recent cases of GP, with successful endoscopic resection in three cases, including a lesion on the ampulla of Vater. In all cases, each lesion had a stalk that facilitated removal using an endoscopic approach. Endoscopic mucosal resection is a feasible and safe treatment if the location, depth, and lymph node status are all favorable and is also helpful for definite diagnosis of unknown duodenal mass. To avoid morbidity resulting from open surgical resection, careful inspection for the peduncle of the GP will help determine the feasibility of endoscopic resection.

Necessity of Histologic Confirmation for Adequate Management in Ampullary Tumors / 대한소화기학회지

No abstract available.

Necessity of Histologic Confirmation for Adequate Management in Ampullary Tumors / 대한소화기학회지

No abstract available.

Clinical, Pathological, and Immunohistochemical Features of Adenomyoma in the Ampulla of Vater / 대한소화기학회지

BACKGROUND/AIMS: Ampullary adenomyoma is a benign lesion whose malignant potential has yet to be confirmed. Despite its benign nature, adenomyoma is frequently misdiagnosed as a carcinoma or adenoma and is overtreated by extensive surgery. This study was performed to analyze the clinical, pathological, and immunohistochemical features of adenomyomas in the ampulla of Vater. METHODS: Nine cases of adenomyoma in the ampulla of Vater, diagnosed in Chungbuk National University Hospital between 2008 and 2011, were enrolled in this study. We reviewed the clinical data on the symptoms, laboratory data, and radiologic findings of the abdominal computed tomography and endoscopic retrograde cholangiopancreatography. For pathological analysis, all the slides were reviewed by one pathologist, and immunohistochemical stainings with antibodies against cytokeratin 7 (CK7), cytokeratin 20 (CK20), alpha-smooth muscle actin (alpha-SMA), and Ki-67 antigen were performed. RESULTS: All the cases were CK7 positive and CK20 negative. A strong cytoplasmic expression of alpha-SMA was confirmed in all cases. The Ki-67 index was less than 1% in eight cases and 5% in one case. Four cases underwent endoscopic papillectomy, and one case received surgical ampullectomy during colorectal cancer surgery. Five cases that underwent endoscopic or surgical treatment remained symptom-free for three years. Four cases that were closely observed with repeated endoscopic examinations exhibited no interval changes in the papillary lesions. CONCLUSIONS: Endoscopic biopsy and immunohistochemistry can aid in the diagnosis of ampullary adenomyomas. Endoscopic papillectomy or surgical ampullectomy is adequate for the treatment of symptomatic ampullary adenomyomas.

Resección endoscópica de adenoma gigante de la ampolla de Vater con crecimiento intraductal: a propósito de un caso / Endoscopic resection of a giant adenoma of the ampulla of vater with intraductal growth: report of a case

Los tumores ampulares representan un grupo diverso aunque infrecuente de lesiones ubicadas en la confluencia de los conductos pancreático y biliar. Representan el 1-2% de los tumores del tracto digestivo, estos pueden ser benignos y malignos. Entre los tumores benignos, el adenoma es el más frecuente y su incidencia oscila entre 0,04 y 0,12%. Pueden ser sésiles o pediculados e histológicamente diferenciarse en tubulares, túbulo-vellosos y vellosos. Debido a su potencial maligno, el tratamiento recomendado es la resección bien sea quirúrgica o endoscópica; esta última indicada en tumores menores de 4,5cm. Se reporta el caso de paciente masculino de 78 años quien consultó por ictericia, dolor abdominal y pérdida de peso de 2 meses de evolución. Se realizó ultrasonido y tomografía abdominal que reportan imagen sólida en confluente biliopancreático. Se realizó duodenoscopia encontrando tumoración ampular de 6 centímetros de diámetro de aspecto velloso. Dada la edad y comorbilidades del paciente se decidió ampulectomía endoscópica parcelar. En la colangiografía retrograda endoscópica se observó imagen de defecto en tercio distal de colédoco por lo que se procedió a extraer con balón de Fogarty, obteniéndose masa tumoral de aspecto velloso pediculada la cual es resecada sin complicaciones. El hallazgo histopatológico reportó adenoma túbulo-velloso con displasia de bajo grado y en controles endoscópicos e histológicos de seguimiento a los 10 meses del procedimiento no se ha evidenciado recidiva tumoral y clínicamente el paciente se encuentra asintomático y en buenas condiciones generales

Ampullary tumors represent a various group but uncommon lesions located at the confluence of the pancreatic and bile ducts. They account for 1 to 2% of the digestive tract tumors, they may be benign and malignant. Among benign tumors, the adenoma is the most common and its incidence ranges from 0.04 a 0.12%. They can be sessile or pedunculated and histologically differentiated tubular, tubulo villous and villous. Because of its malignant potential, the recommended treatment is surgical resection or endoscopic either, the latter indicated in tumors less 4.5 cm. A case of 78 years old male patient who consulted with jaundice, abdominal pain and two months weight loss. It performed abdominal ultrasound and CT reporting in confluent biliopancreatic solid image. Duodenoscopy was performed finding ampullary tumor six inches diameter appearance fluffy. Considering patient age and comorbidities, it decided parcel endoscopic ampullectomy. In endoscopic retrograde cholangiography, defect image was observed in distal choledochal, so we proceeded to extract with Fogarty Balloon, giving pedunculated villous tumor, which is removed without complications. The histopathological finding was tubule villous adenoma, with low grade dysplasia. In endoscopic and histologycal controls up to procedure ten months, is not clinically evidence tumor recurrence and the patient is asymptomatic in good general conditions

Periampullary carcinoid: An uncommon tumor at an unusual site.

Gastrointestinal carcinoid tumors represent a group of well-differentiated tumors originating from various neuroendocrine cells located in the gastrointestinal mucosa and submucosa. Consequently, there is diversity in their clinical presentation, incidence at specific anatomic sites, biological behavior, hormone production, morphologic characteristics, and immunophenotype. Periampullary carcinoids are extremely rare and less then 100 patients have been reported in the world literature, that too mostly as case reports. We are reporting two cases of periampullary carcinoids, one of which presented with rare manifestation as gastrointestinal bleed and both are doing well after successful pancreatoduodenectomy.

Resultados actuales de la pancreatoduodenectomía para el tratamiento de los tumores periampulares y análisis de factores pronósticos de sobrevida / Results of pancreaticoduodenectomy in the treatment of periampullary tumors

Background: The diagnosis and treatment of periampullary tumors represents a challenge for current medicine. Aim: To review the results of pancreaticoduodenectomy (PDD) in the treatment of periampullary tumors and to identify risk factors that impact the long-term survival. Patients and Methods: We performed a retrospective study of patients who underwent a PDD for periampullary tumors between 1993 and 2009. We reviewed perioperative results and long term survival. We performed a multivariate analysis for long-term survival. Results: A PDD was performed in 181 patients aged 58 ± 12 years (98 females). Piloric preservation was done in 53 percent and a pancreatogastric anastomosis was used in 94 percent of cases. Morbidity was 62 percent and postoperative mortality was 5.5 percent. Pancreatic cancer was the most frequent pathological finding in 41 percent, followed by ampullary cancer in 28 percent and distal bile duct cancer in 16 percent. Median survival was 17 months, with a five years survival of 24 percent. Survival for ampullary tumors was 28 months with a five years survival of 32 percent. The median and five years survival were 14 months and 16 percent for bile duct cancer and 11 months and 14 percent for pancreatic cancer. Multivariate analysis identified tumor type (pancreas /bile duct) and lymph node dissemination as independent predictors of mortality. Conclusions: One quarter of patients experienced long term survival. Mortality predictors were tumor type and lymph node dissemination.

Ampuloma: ¿terapia endoscópica o quirúrgica? / Ampullary neoplasms: endoscopic or surgical treatment?

Ampullary neoplasms may correspond to adenoma or adenocarcinoma. The study of its staging is performed by means of computed tomography, magnetic resonance imaging and endosonography. The appropriate classification of the stages allows for a better planning of treatment. In benign tumors and small selected carcinoma, ampullectomy (endoscopic or surgical) is an alternative. In patients with ampullary neoplasms invading deep extension or showing high risk of recurrence, without evidence of metastasis, pancreatodudodenectomy is the treatment of choice. In those cases with distant metastasis, palliative treatment is indicated.

Las neoplasias ampulares pueden corresponder a adenomas o adenocarcinomas. El estudio de etapificación se realiza con tomografía computada, resonancia magnética y endosonografía. La correcta clasificación en estadíos, permite planificar de mejor forma el tratamiento. En tumores benignos y seleccionados carcinomas pequeños, la ampulectomía (endoscópica o quirúrgica) es una alternativa. En pacientes con neoplasias ampulares que presentan extensión en profundidad o alto riesgo de recurrencia, sin evidencia de metástasis a distancia, estaría indicada la pancreatoduodenectomía. En aquellos casos con metástasis a distancia, se aplican técnicas paliativas.

Ampullary tumours (ampullomas) in the elderly – an interdisciplinary problem.

Background & objectives: Ampullary cancer is one of the periampullary tumours with better prognosis, but relapses occur early in some patients. This study was carried out to assess whether pancreatoduodenectomy (PDE, Whipple operation) could be a safe therapeutic procedure for elderly patients with periampullary tumours. Methods: Between 2005 and 2007, 19 patients (12 male, 7 female) aged over 65 yr (range 66 and 83 yr) with diagnosis of ampulloma were operated. Results: Of the 19 patients, 6 underwent local surgical ampullectomy with reinsertion of ductus choledochus and Wirsungi’s duct for benign or early cancer lesion and 13 underwent PDE (Whipple operation). Of these 13, only one was in T1 stage, one was in T4 stage, two patients were T3 and the rest in T2 stage. Lesion of lymphatic system had 40 per cent of patients in T2 stage and all in T3 and T4 stages. One patient died of pulmonary embolism several days after operation. Post-operative complications occurred in 3 cases: 1 patient with partial dehiscence of gastroenteroanastomosis – treated by conservative approach, 2 patients with dehiscence of pancreatojejunoanastomosis. Interpretation & conclusions: Diagnosis and therapy of ampullary tumours is multimodal. With careful patient selection, PDE can be performed in elderly people (>65 yr) safely. The post-operative morbidity in this group is essentially influenced by their multi-morbidity.

Successful Resection of Locally Advanced Gastrointestinal Stromal Tumor of the Ampulla of Vater after Treatment with Imatinib / 대한소화기학회지

Gastrointestinal stromal tumor (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract arising from Cajal's cells, expressing CD 117. The standard treatment for primary GIST is complete surgical resection. Imatinib mesylate, a specific tyrosine kinase inhibitor, is effective against locally advanced and metastatic GIST. There are several reports of the effect of preoperative imatinib in patients with unresectable and locally advanced primary GIST. We report a case of unresectable primary GIST of the ampulla of Vater, which we were able to completely resect after treatment with a dosage of imatinib 400 mg daily for 5 months. Twelve months later, the patient was treated with imatinib and doing well with no evidence of recurrence.

Hepatectomía derecha tras extirpación de tumor de la ampolla de Vater / Right hepatectomy after excision of a carcinoma of the ampulla of Vater: report of one case

Occasionally hepatectomy for metastases of ampulla of Vater carcinoma can result in a better survival and quality of life of patients. We report a 67 years old male subjected to a duodenopancreatectomy for a carcinoma of the ampulla of Vater that required afterwards a right hepatectomy for metastases. Twenty one months after the second operation and 42 months after the first operation, that patient is asymptomatic and without evidences of relapse.

El tratamiento quirúrgico del carcinoma de ampolla de Vater presenta mejores resultados oncológicos que los del resto de los tumores periampulares. En casos seleccionados, la resección hepática por metástasis de carcinoma de ampolla de Vater extirpado previamente, puede proporcionar supervivencias prolongadas y con buena calidad de vida. Presentamos un paciente de 67 años tratado con duodenopancreatectomía por cáncer de la ampolla de Vater y posteriormente con hepatectomía derecha por metástasis. A los 42 y 21 meses de la primera y segunda intervención respectivamente, permanece asintomático y sin evidencia de enfermedad.

Hepaticocholecystoduodenostomy compared with Roux-en-y choledochojejunostomy for decompression of the biliary tract

The nature of palliative decompressive surgery for unresectable periampullary tumor is usually determined by the experience of the surgeon. We compared hepaticocholecystoduodenostomy [HCD], a new palliative decompressive anastomotic technique, to Roux-en-y choledochojejunostomy [CDJ] in this prospective, randomized study. Twenty patients who were to undergo surgery for palliative bypass were randomized into two groups: group I was subjected to HCD [10 patients] and group II to CDJ [10 patients]. Pre- and postoperative liver function tests, operative time, operative blood loss, onset of postoperative enteral feeding, length of hospital stay and survival rates were compared into the two groups. Effective surgical decompression was observed clinically as well as on analysis of pre- and postoperative liver function tests in both the groups. The results were statistically significant in favor of patients in group I when compared to those of group II with respect to operative time 84.7 [10.3] min vs 133.6 [8.9] min; P=<.0001], operative blood loss 137.8 [37.2] mL vs 201.6 [23.4] mL; P=/001], postoperative enteral feeding 3.3 [0.5] days vs 5.0 [0.7] days; P=<.0001] and length of hospital stay 7.5 [0.7] days vs 9.7 [1.2] days; P=<.0001]. During follow-up, recurrent jaundice was observed in one patient in group I and two patients in group II, while duodenal obstruction developed in one patient in the group I series. Gastrointestinal hemorrhage occurred in one patient belonging to group II. The difference in mean survival time was not statistically significant. Based on this small series, HCD seems to be a better palliative surgical procedure than the routinely performed CDJ

Ampullary carcinoma in Iraqi patients: single center experience

The aim of this paper is to report the pattern of ampullary carcinoma in Iraqi patients. During the period 1995-2000, 106 patients with ampullary carcinoma were admitted to Gastroenterology tertiary center accounting fort 2% of the total admission and 9% of gastrointestinal malignancies. 64 [60.4%] were male and 42 [39.6%] were females. 97 [87%] male are affected 1.5 times more than female with male: female ratio = 1.5. Age peak incidence bet [50-59] Patients came mainly from Baghdad 46% .Presenting symptom were jaundice in 78.3% Duration of illness the peak is 1-2 months mean period is [45 days] for lab investigations. Of the 85 patients. who undergone operation, resection was performed in 56 patients [66%]. Thirty patients had radical resection [Whipple procedure: pancreaticoduodenectomy] and 26 patients had local resection. The tumor was adenocarcinoma in all the cases. Only one case was undifferentiated carcinoma. The pattern of ampullary carcinoma is slightly different from the previous reports

Metachronous Four Primary Malignancies in Gastro-intestinal Tract / 대한소화기학회지

Multiple primary malignancy was reported firstly by Billroth in 1889. Recently, multiple primary malignancies are considered to increase due to improved survival rate of cancer patients, advanced diagnostic tools, and increased use of chemotherapy and radiotherapy. In Korea, several cases of triple primary malignancies were reported. However, four primary malignancies in gastro-intestinal tract was rarely reported. Recently, we experienced a 70 year-old male who was diagnosed with metachronous four primary malignancies in rectum, ascending colon, stomach, and ampulla of Vater. We report this rare case of metachronous four primary malignancies with a review of literature.

Tumores ampulares: comunicación de un caso y revisión de la literatura / Ampullary tumors: a case report and review of the literature

Los tumores ampulares corresponden a aquellos ubicados en la unión de los segmentos terminales del conducto pancreático y colédoco. Son poco frecuentes, constituyendo entre un 1 a 2 por ciento de los tumores del tracto digestivo. Se caracterizan por su lento crecimiento y por corresponder a los tumores periampulares de mejor pronóstico. Actualmente está en discusión el enfrentamiento terapéutico, en cuanto al tipo de resección para cada tumor y cada paciente. La postura previa ha sido la resección quirúrgica clásica, no obstante está en boga un manejo conservador. Se da a conocer el caso clínico de un hombre de 53 años, que consulta por cuadro de ictericia progresiva, coluria, acolia y dolor abdominal. La ecotomografía y TC de abdomen son sugerentes de neoplasia periampular. La colangiografia endoscópica retrógrada confirmó un tumor ampular de aproximadamente 3 cm. de diámetro. Se realiza papilotomía, instalación de endoprótesis biliar y biopsia de papila. El estudio histopatológico no descarta una neoplasia invasora, por lo que se realiza ampulectomía endoscópica. La biopsia concluye adenoma túbulopapilar.

Nd: YAG laser photoblation and palliation for peri-ampullary tumour

The current analysis was undertaken to determine the effect of Nd: YAG laser in treatment of different stages of periampullary tumours, whether benign or malignant. Patients, In a retrospective study of 26 patients with a histological diagnosis of primary periampullary adenocarcinoma [8 patients], metastatic adenocrcinoma into periampullary region [8 patients] and adenoma with or without dysplasia [10 patients] which were classified into 3 groups A, B and C respectively. All patients treated in two main hospitals in Glasgow between 1988 and 1998, with Nd: YAG laser with different number of sessions [1-8], without any major complications. Group A, treatment was successful in ablating and relieving symptoms in 5 patients but failed in 3 patients. Group B, Nd: YAG laser succeeded to relieve symptoms but not increase survival, [median survival time was 5 months]. Group C, Nd: YAG Laser succeeded in relieving symptoms in all ten patients and completely ablated the tumour in most of them 9/10, median survival time 60 months. Nd: YAG laser appears to be an effective treatment for benign and early malignant primary periampullary tumours as well as for the palliation of advanced malignant tumours with the main advantages it can be used in patients unfit for surgery and it is associated with less complications than other surgical procedures. Although these results are encouraging, the sample is relatively small and further follow up is required in order to recommend Nd: YAG laser photoablation as additive modalities for these patients

Carcinoid of ampulla of Vater.

Carcinoid tumors of ampulla are rare clinical entities. They form 0.35% of all the gastrointestinal carcinoids. So far, only 109 cases have been reported in the literature, mostly as individual case reports. Since the metastatic potential and the tumor size have no correlation, unlike in duodenal carcinoids, pancreatoduodenectomy is considered the treatment of choice. Here we present a case of carcinoid of ampulla presenting to our department.