An ampullary adenoma presenting with jaundice caused by duodenal intussusception: a case report.

BACKGROUND: Ampullary adenomas are premalignant lesions. However, biliary obstruction causing jaundice is rare. Duodenal intussusception secondary to an ampullary adenoma rarely occurs because of the fixed position of the duodenum in the retroperitoneum. Herein, we have described a rare case of ampullary adenoma with jaundice caused by duodenal intussusception. CASE PRESENTATION: A 40-year-old woman presenting with vomiting and yellowish discoloration of the skin was admitted to another hospital. The patient had experienced recurrent epigastric pain and vomiting for the past 18 months. Blood test results showed elevated levels of bilirubin (3.9 mg/dL), and abdominal computed tomography (CT) showed a 60-mm hypovascular mass in the third part of the duodenum and a left lateral shift of the dilated common bile duct. The patient was referred to our hospital for further evaluation. She recovered from hyperbilirubinemia spontaneously (levels of bilirubin, 1.0 mg/dL), and the CT showed a tumor shift from the third part of the duodenum to the second part and improvement of the dilated common bile duct. Hypotonic duodenography revealed a tumor that moved easily from the second to the third portion of the patient's position. Upper gastrointestinal endoscopy revealed a large papillary tumor occupying the second part of the duodenum, which was diagnosed as an adenoma through biopsy. The possibility of malignancy could not be negated owing to the presence of jaundice and an elevated carbohydrate antigen 19-9 level (76.0 U/mL). Pancreaticoduodenectomy was performed. The resected specimen showed a 60 × 40 × 40-mm pedunculated ampullary mass with submucosal elongation. The pathological examination indicated that the ampullary tumor was a high-grade intestinal adenoma. The postoperative course was uneventful, and the patient was discharged 26 days postoperatively. CONCLUSIONS: This report describes a rare case of a patient with an ampullary adenoma presenting with jaundice resulting from duodenal intussusception. Owing to the possibility of a postoperative cancer diagnosis which may have caused the biliary obstruction and the difficulty in making an accurate preoperative diagnosis, it is imperative to choose the appropriate surgical procedure such as a pancreaticoduodenectomy.

The timing of recurrence after endoscopic papillectomy.

BACKGROUND: Endoscopic papillectomy (EP) offers a safe and effective method for resection of ampullary adenomas. Data regarding the long-term resolution of adenoma following EP are limited. The aim of this study therefore was to examine the timing of recurrence after EP of ampullary adenomas. METHODS: This was a single-center retrospective study including patients who received EP for ampullary adenomas from 8/2000 to 1/2018. Patients with confirmed complete eradication of adenoma were included in the recurrence analysis with recurrence defined as finding adenomatous histology after 1 negative surveillance endoscopy. Kaplan-Meier estimates were calculated to determine recurrence rates. RESULTS: Of the 165 patients who underwent EP, 136 patients (mean age 61.9, 51.5% female) had adenomatous histology with a mean lesion size of 21.2 mm. A total of 124 (91.2%) achieved complete eradication with a follow-up of 345.8 person-years. Recurrence occurred in 20 (16.1%) patients at a mean of 3.2 (± 3) years (range 0.5-9.75 years) for a recurrence rate of 5.8 (95% CI 3.6-8.8) per 100 person-years. Nine (45%) recurrences occurred after the 1st 2 years of surveillance. Recurrence rate did not differ by baseline pathology [low-grade dysplasia: 5.2 (95% CI 3.0-9.0), high-grade dysplasia: 6.9 (95% CI 2.3-15.5), adenocarcinoma: 7.7 (95% CI 0.9-25.1)]. CONCLUSION: Recurrence remains a significant concern after EP. Given the timing of recurrence, long surveillance periods may be necessary. Larger multicenter studies are needed, however, to determine appropriate surveillance intervals.

The Significance of Histopathological Findings on Clinical Outcomes in Endoscopic Papillectomy with Endocut.

This study aimed to evaluate primary clinical outcomes in patients who underwent endoscopic papillectomy (EP) using the Endocut mode while examining the pathological characteristics of the margin of the resected specimen. To this end, 70 patients who underwent Endocut EP were included. Resection margins were classified according to pathological findings as "negative", "positive", or "uncertain (difficult pathological evaluation)". The effect of pathological resection margins on residual tumor recurrence rates was evaluated. The median follow-up was 47 months (range, 22-84). Eleven patients (15.7%) were diagnosed with residual tumors, ten of whom were diagnosed within 6 months after EP. The resection margins were pathologically negative in 27 patients, positive in 15, and uncertain in 28; residual tumors occurred in 5 patients (33.3%) in the positive group, 5 (17.9%) in the uncertain group, and 1 (3.7%) in the negative group. The patient in the negative group had familial adenomatous polyposis (FAP). Female sex, FAP, and uncertain or positive resection margins were significantly more common in residual patients (p = 0.009, 0.044, and 0.041, respectively). Pathological resection margins can be used to infer the residual tumor incidence, leading to early post-treatment of residual tumors.

Incidence and risk factors for recurrence of ampullary adenomas after endoscopic papillectomy: Comparative analysis of familial adenomatous polyposis and sporadic ampullary adenomas in an international multicenter cohort.

OBJECTIVES: Endoscopic papillectomy (EP) is a minimally invasive therapy for the management of ampullary adenomas (AA). We conducted this multicenter study to assess the incidence of and factors related to the recurrence of AA after EP in patients with familial adenomatous polyposis (FAP) compared to sporadic AA. METHODS: We included patients who underwent EP for AA at 10 tertiary hospitals. Adenomatous tissue at the resection site at the time of surveillance endoscopies was considered recurrent disease. RESULTS: In all, 257 patients, 100 (38.9%) with FAP and 157 (61%) patients with sporadic AA, were included. Over a median of 31 (range, 11-61) months, recurrence occurred in 48/100 (48%) of patients with FAP and 58/157 (36.9%) with sporadic AA (P = 0.07). Two (2%) FAP patients and 10 (6.3%) patients with sporadic AA underwent surgery for recurrence. On multivariable regression analysis, the recurrence in FAP was higher than in sporadic patients after the first year of follow-up. AA size (hazard ratio [HR] 1.03, 95% confidence interval [CI] 1.001, 1.056), periampullary extension (HR 2.5, 95% CI 1.5, 4.01), and biliary duct dilation (HR 2.04, 95% CI 1.2, 3.4) increased the risk, while en bloc resection (HR 0.6, 95% CI 0.41, 0.9) decreased the risk of recurrence. CONCLUSION: Recurrence rates are high after EP. Most recurrences in sporadic patients occur within the first year of follow-up, but after the first year of follow-up in patients with FAP. Recurrences are higher with larger adenomas, biliary duct dilation, and periampullary extensions, and may be mitigated by en bloc resection. These factors should be considered in decision-making with the patients.

Long-term recurrence after endoscopic versus surgical ampullectomy of sporadic ampullary adenomas: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Ampullary adenomas are treated both surgically and endoscopically, however, data comparing both techniques are lacking. We aimed to compare long-term recurrence of benign sporadic adenomas after endoscopic (EA) and surgical ampullectomy (SA). METHODS: A comprehensive literature search of multiple databases (until December 29, 2020) was performed to identify studies reporting outcomes of EA or SA of benign sporadic ampullary adenomas. The outcome was recurrence rate at 1 year, 2-year, 3 year and 5 years after EA and SA. RESULTS: A total of 39 studies with 1753 patients (1468 EA [age 61.1 ± 4.0 years, size 16.1 ± 4.0 mm], 285 SA [mean age 61.6 ± 4.48 years, size 22.7 ± 5.4 mm]) were included in the analysis. At year 1, pooled recurrence rate of EA was 13.0% (95% confidence interval [CI] 10.5-15.9], I2 = 31%) as compared to SA 14.1% (95% CI 9.5-20.3 I2 = 15.8%) (p = 0.82). Two (12.5%, [95% CI, 8.9-17.2] vs. 14.3 [95% CI, 9.1-21.6], p = 0.63), three (13.3%, [95% CI, 7.3-21.6] vs. 12.9 [95% CI, 7.3-21.6], p = 0.94) and 5 years (15.7%, [95% CI, 7.8-29.1] vs. 17.6% [95% CI, 6.2-40.8], p = 0.85) recurrence rate were comparable after EA and SA. On meta-regression, age, size of lesion or enbloc and complete resection were not significant predictors of recurrence. CONCLUSION: EA and SA of sporadic adenomas have similar recurrence rates at 1, 2, 3 and 5 years of follow up.

Radiation-free endoscopic papillectomy for ampullary adenoma: experience from a Chinese tertiary hospital.

BACKGROUND: Conventional endoscopic papillectomy (ESP) for ampullary adenoma is performed as a hybrid endoscopy and fluoroscopy guided procedure. In this study, we report our preliminary experience of non-radiation ESP. METHODS: The present method includes endoscopic snare resection, non-radiation endoscopic biliary and pancreatic stenting and endoclipping. Data from ten patients who underwent non-radiation ESP due to ampullary adenoma were collected. Procedure details, adverse events and follow-up were analyzed. RESULTS: Complete resection was accomplished in all patients, with en bloc resection and piecemeal resection in nine and one patient(s), respectively. Both biliary and pancreatic stenting and biliary stenting alone were achieved in eight and two patients, respectively. Endoclipping was performed in all patients. Hyperleukocytosis and hyperamylasemia occurred in two and one patient(s), respectively. No other complications occurred. No lesion residual or recurrence occurred during follow-up. CONCLUSIONS: Radiation-free ESP can be technically feasible and safely executed by experienced endoscopists. Our study provides a novel strategy for endoscopic resection of major papilla adenoma.

Acute cholecystitis associated with a novel integrated biliary stent and nasobiliary drainage catheter system.

A novel biliary drainage system consisting of an integrated biliary stent and nasobiliary drainage catheter system is expected to be clinically useful. However, Yamamoto and colleagues report two cases of acute cholecystitis after use of the system, suggesting that there are risks of adverse events associated with its unique design.

Underwater versus conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumors ≤20mm: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Underwater endoscopic mucosal resection (UEMR) is an emerging technique for endoscopic resection of superficial non-ampullary duodenal epithelial tumors (SNADETs). However, compared to conventional EMR, its efficacy and safety has not been widely explored. METHODS: We conducted a comprehensive search using the Pubmed, Embase, and Cochrane Library databases to identify studies comparing the efficacy and safety of UEMR versus EMR for SNADETs. The main outcomes examined included en bloc resection rate, R0 resection rate, recurrence rate, procedure time, and adverse events. RESULTS: A total of 5 studies comprising 635 patients were included. All the literature included duodenal lesions smaller than 20 mm. The pooled analysis showed that UEMR could achieve a higher en bloc resection rate (OR 1.78, 95%CI: 1.17 to 2.71, P = 0.007) and shorter procedure time (MD -4.08, 95%CI: -6.44 to -1.73, P = 0.0007) than EMR. However, the pooled results did not support a superiority of UEMR over EMR for R0 resection rate (OR 1.27; 95% CI: 0.90 to 1.81, P = 0.18) or recurrence rate (OR 0.49; 95% CI: 0.15 to 1.67, P = 0.26). The occurrence of adverse events, including postoperative bleeding, intraoperative perforation, and delayed perforation, was very low in included studies. CONCLUSION: Compared to EMR, UEMR is an effective and safe technique for SNADETs ≤20 mm.

Novel self-assembling hemostatic agent with a supportive role in hemostatic procedures for delayed bleeding after endoscopic papillectomy.

PuraStat is a newly developed self-assembling hemostatic gel which is expected to be applied to bleeding from various lesions of the gastrointestinal tract. Yamamoto and colleagues describe the practical use of this hemostatic gel for delayed bleeding after endoscopic papillectomy, with accompanying video.

Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study.

BACKGROUND: Ampullary adenoma is a rare premalignant lesion, but its incidence is increasing. Endoscopic papillectomy has become the first treatment of choice for ampullary adenomas due to its safety and effectiveness, thereby replacing surgical resection. However, recurrence rates and adverse events after endoscopic papillectomy were reported in up to 30% of cases. AIM: To review the long-term outcomes of endoscopic papillectomy and investigate the factors that affect these outcomes. METHODS: We retrospectively analyzed the data of patients who underwent endoscopic papillectomy for ampullary adenoma at five tertiary hospitals between 2013 and 2020. We evaluated clinical outcomes and their risk factors. The definitions of outcomes were as follow: (1) curative resection: complete endoscopic resection without recurrence; (2) endoscopic success: treatment of ampullary adenoma with endoscopy without surgical intervention; (3) early recurrence: reconfirmed adenoma at the first endoscopic surveillance; and (4) late recurrence: reconfirmed adenoma after the first endoscopic surveillance. RESULTS: A total of 106 patients were included for analysis. Of the included patients, 81 (76.4%) underwent curative resection, 99 (93.4%) had endoscopic success, showing that most patients with non-curative resection were successfully managed with endoscopy. Sixteen patients (15.1%) had piecemeal resection, 22 patients (20.8%) had shown positive/uncertain resection margin, 11 patients (16.1%) had an early recurrence, 13 patients (10.4%) had a late recurrence, and 6 patients (5.7%) had a re-recurrence. In multivariate analysis, a positive/uncertain margin [Odds ratio (OR) = 4.023, P = 0.048] and piecemeal resection (OR = 6.610, P = 0.005) were significant risk factors for early and late recurrence, respectively. Piecemeal resection was also a significant risk factor for non-curative resection (OR = 5.424, P = 0.007). Twenty-six patients experienced adverse events (24.5%). CONCLUSION: Endoscopic papillectomy is a safe and effective treatment for ampullary adenomas. Careful selection and follow-up of patients is mandatory, particularly in cases with positive/uncertain margin and piecemeal resection.

Impact of 5-Year Endoscopic Surveillance Intervals with Biopsy following Endoscopic Papillectomy for Ampullary Adenoma.

Background: Endoscopic snare papillectomy (ESP) has been established as a safe and effective treatment for ampullary adenomas. However, little is known about the optimal post-procedure follow-up period and the role of routine endoscopic surveillance biopsy following ESP. We aimed to evaluate patient adherence to a 5-year endoscopic surveillance and routine biopsy protocol after ESP of ampullary adenoma. Methods: We reviewed our prospectively collected database (n = 98), all members of which underwent ESP for ampullary lesions from January 2011 to December 2016, for the evaluation of long-term outcomes. The primary outcome was the rate of patient adherence to 5-year endoscopic surveillance following ESP. The secondary outcomes were the diagnostic yield of routine endoscopic biopsy, recurrence rate, and adverse events after endoscopic surveillance in the 5-year follow-up (3-month, 6-month, and every 1 year). Results: A total of 19 patients (19.4%) experienced recurrence during follow-up, all of these patients experienced recurrence within 3 years of the procedure (median 217 days, range 69-1083). The adherence rate for patients with sporadic ampullary adenoma were 100%, 93.5%, and 33.6% at 1, 3, and 5 years after ESP, respectively. The diagnostic yield of routine endoscopic biopsy without macroscopic abnormality was 0.54%. Pancreatitis occurred in four patients (4%, 3 mild, 1 moderate) after surveillance endoscopic biopsy without macroscopic abnormality. Conclusions: Given the low 5-year adherence rate and diagnostic yield of routine endoscopic biopsy with risk of pancreatitis, optimal surveillance intervals according to risk stratification (low grade vs. high grade adenoma/intramucosal adenocarcinoma) may be required to improve patient adherence, and routine biopsy without macroscopic abnormality may not be recommended.

Intraductal radiofrequency ablation therapy for eradication of intraductal residual lesions after endoscopic papillectomy for ampullary adenoma.

Yamamoto et al. report a case of intraductal residual lesions after endoscopic papillectomy successfully treated with endoscopic radiofrequency ablation therapy. This report provides readers with images and videos of precise intraductal radiofrequency ablation therapy methods for safe and effective eradication of intraductal residual lesions.

Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection?

BACKGROUND: Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions. MATERIALS AND METHODS: Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen. RESULTS: In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma. CONCLUSIONS: In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.

Efficacy and safety of underwater endoscopic mucosal resection for ≤20 mm superficial non-ampullary duodenal epithelial tumors: Systematic review and meta-analysis.

Background and aims: Superficial non-ampullary duodenal epithelial tumors (SNADETs) as a rare disease have gradually increased in recent years. Underwater endoscopic mucosal resection (UEMR) has emerged as a newly available option for the endoscopic resection of SNADETs. This study aimed to evaluate the efficacy and safety of UEMR for ≤20 mm SNADETs. Methods: A literature search was performed across multiple databases, including PubMed, Embase, Scopus, and Clinical trials for studies containing tumors ≤20 mm published from January 1, 2012, to August 8, 2022. Outcomes examined were the pooled rates of en bloc resection, R0 resection, adverse events, and recurrence. Subgroup analyses of the resection rate were conducted stratified by sample size and polyp size. Results: A total of 10 studies with UEMR performed in a total of 648 tumors were included for analysis. The pooled rate of en bloc resection and R0 resection was 88.2% (95% confidence interval (CI): 82.1-93.2) and 69.1% (95% CI: 62.2-76.1), respectively. The results showed pooled rate of intraoperative bleeding rate was 2.9% (95% CI: 0-9.0), delayed bleeding rate was 0.9% (95% CI: 0.1-2), recurrence rate was 1.5% (95% CI: 0-4.9). In the subgroup analysis, R0 and en-bloc resection rates were significantly higher in <10 mm than 10-20 mm SNADETs subgroups (R0 resection rate 83.1 vs. 48.6%; en bloc resection rate 100.0 vs. 84.0%, P < 0.05). Conclusion: Underwater endoscopic mucosal resection was an effective and safe technique for the optional treatment for ≤20 mm SNADETs, especially of <10 mm. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022340578.

[Ampullary neoplasms: surgical management]. / Papillentumoren: chirurgische Therapie.

BACKGROUND: Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth. OBJECTIVE: Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors. MATERIAL AND METHODS: A review of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. RESULTS AND CONCLUSION: Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry a risk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and level II dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.

Cold Snare Papillectomy for Re-redo Endoscopic Resection of a Defiant Adenoma Recurrence with a Unique Growth Pattern.

Endoscopic papillectomy has become the mainstay treatment in early papillary neoplasia. However, local recurrence remains the Achilles heel of the procedure due to the complex anatomy and limited ductal involvement unappreciated on endoscopic ultrasound (EUS) and/or endoscopic retrograde cholangiopancreatography (ERCP). While re-do papillectomy is, in general, technically feasible and widely accepted to treat recurrent adenoma, re-redo procedures to this end have rarely been reported. Likewise, utilization of cold snare technology is rarely considered in papillectomy and has, in fact, only once been reported in the literature before. We present a unique clinical case with a highly atypical growth pattern with a bonnet-like pedunculated lesion with a small insertion point just at the pancreatic duct orifice treated by re-redo cold snare papillectomy. How to cite this article: Zimmer V, Emrich K. Cold Snare Papillectomy for Re-redo Endoscopic Resection of a Defiant Adenoma Recurrence with a Unique Growth Pattern. Euroasian J Hepato-Gastroenterol 2021;11(1):43-44.

Predictive factor of recurrence after endoscopic papillectomy for ampullary neoplasms.

BACKGROUND/PURPOSE: Recurrence of ampullary neoplasms after endoscopic papillectomy (EP) has not been well elucidated. This study aimed to clarify the predictive factors for recurrences after EP. We also aimed to investigate the retreatment of the recurrent lesions and their outcomes. METHODS: This multicenter, retrospective cohort study included 96 patients with ampullary neoplasms who underwent EP at four tertiary centers between January 2000 and October 2018. RESULTS: The pathological diagnoses of resected specimens confirmed adenoma in 62 and adenocarcinoma in 34 patients (six Tis, 24 T1a, three T1b, one inconclusive). Complete resection was confirmed for 79 patients (82.3%). Recurrent lesions were observed in 13 patients (13.5%) during a median follow-up of 3 months (1-36 months) after EP. The predictive factors of recurrence were piecemeal resection, and non-negative horizontal or vertical margin in univariate analysis. Non-negative vertical margin was the only independent predictive factor of recurrence in the multivariate analysis. The recurrent lesions were treated endoscopically in 11 patients. Recurrence after the endoscopic retreatments was observed in one patient. CONCLUSIONS: Complete resection with negative vertical margin is an important factor in preventing the recurrence of ampullary neoplasms after EP. Endoscopic retreatments are also feasible for recurrent lesions.