Endoscopic papillectomy: The limits of the indication, technique and results

Abstract

In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy (EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.

Effect of submucosal injection in endoscopic papillectomy of ampullary tumor: Propensity‐score matching analysis

“…3,16,[21][22][23] This study showed that SI was related to more frequent residual tumor and shorter recurrence-free survival. Theoretically, SI lifts the tumor from the wall to secure a wider resection margin and prevent perforation and bleeding.…”

Analysis of risk factors associated with acute pancreatitis after endoscopic papillectomy

“…This helped us with information for the positioning of the polypectomy snare to enable en bloc resection of the papilla. EUS also allowed evaluation of lymph nodes, which were observed in one of our patients with a tumor staged as uT1N1 whose final diagnosis was somatostatinoma with the presence of 2 lymph nodes detected by EUS, in whom EUS-guided fine needle aspiration was performed in the same EP session 9 .…”

“…Although EP compares favorably with surgical treatment, the risk of EP-related adverse events (AEs) is not negligible. Even in experienced hands, AEs occur in approximately 20% of cases [3][4][5][6][7][8][9][10] . Acute pancreatitis (AP) is one of the most feared complications, occurring in approximately 10 to 15% of cases.…”

Endoscopic and surgical ampullectomy for non-invasive ampullary tumors: Short-term outcomes

“…In case of non-invasive tumor, EA would be first considered given its lower morbidity, as confirmed by the present results. Nonetheless, SA is an alternative after EA failure or if EA is not amenable (8,15,18,19). The EA failure rate is indeed substantial, both in this series and in the literature.…”

“…This may be achieved either by ERCP/EGD or by EUS. The latter demonstrated a high sensitivity and is particularly accurate for the T staging which is key element since it determines the therapeutic modality (1,(16)(17)(18). Further investigation with an abdominal CT-scan, should be performed if the preoperative biopsies reveal an invasive carcinoma and/or if macroscopic malignant characteristics are observed during EGD/ERCP/EUS.…”