No abstract

Adenomas arising in a choledochocele are usually resected surgically because they are difficult to completely remove endo− scopically and they are associated with a high malignancy potential [1 ± 2]. We successfully performed an endoscopic snare resection for choledochocele−asso− ciated villous adenoma with high−grade dysplasia.A 76−year−old woman was admitted com− plaining of epigastric pain lasting for sev− eral days. Duodenoscopy revealed a soft cystic−mass−like lesion covered with nor− mal mucosa above the ampulla of Vater (l " Fig. 1). Intraductal ultrasound showed an an− echogenic cystic mass with diffuse wall thickening and preserved wall layer (l " Fig. 2). Magnetic resonance cholangiopancrea− tography showed an oval−shaped cystic mass above the ampulla of Vater. A major endoscopic sphincterotomy was conduct− ed. Following sphincterotomy, duodenos− copy revealed mucosal nodules on the in− ner surface of the choledochocele (l " Fig. 3). Histopathologic findings of the biopsy specimen showed an adenoma with high−grade dysplasia (l " Fig. 4). Because the patient wanted to undergo an endoscopic treatment, we performed a wire−guided endoscopic snare resection for the choledochocele with the adenoma (l " Fig. 5, l " Video 1).During the 1−year follow−up duodenosco− py, no remnant or recurrence of the ade− noma was found. The surgical approach may be too inva− sive for a choledochocele with adenoma. Itoi et al.[3] performed a balloon−cathe− ter−assisted endoscopic snare resection using a double−channel duodenoscope for choledochocele. We attempted to per− form a wire−guided endoscopic snare re− section using the previously reported method for adenomas of the major papil− la [4]. En bloc resection was successfully achieved without any procedure−related complications or residual tumor. In con− clusion, endoscopic snare resection may be a feasible and effective solution for se− lected patients with choledochocele asso− ciated with a villous adenoma. Endoscopy_UCTN_Code_CCL_1AZ_2AK Endoscopy_UCTN_Code_TTT_1AR_2AKWire−guided endoscopic snare resection of a choledochocele−associated villous adenoma Video 1Wire−guided endoscopic snare resection. The guide wire was inserted into the main pancre− atic duct. An electrosurgical snare was then inserted along the guide wire. The snare was manipulated to grasp the base of the chole− dochocele before en bloc resection was con− ducted. After the excision had been complet− ed, a pancreatic stent was immediately placed along the indwelling guide wire. Histopatholo− gic examination of the resected specimen showed a villous adenoma with a clear resec− tion margin (l " Fig. 6). This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. UCTN ± Unusual cases and technical notes