Endoscopic Resection of Ampullary Tumours: Long-term Outcomes and Adverse Events

Abstract

Background The management of ampullary lesions has shifted from surgical approach to endoscopic resection. Previous reports were limited by small numbers of patients and short follow-up. The aim of this study is to describe short- and long-term outcomes in a large cohort of patients undergoing endoscopic ampullectomy. Methods Retrospective study of endoscopic ampullectomies performed at a tertiary center from January 1999 to October 2016. Information recorded includes patient demographics, clinical outcomes, lesion pathology, procedural events, adverse events and follow-up data. Results Overall, 103 patients underwent endoscopic resection of ampullary tumours (mean age 62.3 ± 14.3 years, 50.5% female, mean lesion size 20.9 mm; 94.9% adenomas, with a majority of lesions exhibiting low-grade dysplasia (72.7%). Complete endoscopic resection was achieved in 82.5% at initial procedure. Final complete endoscopic resection was achieved in all patients with benign pathology on follow-up procedures. Final pathology showed that 11% had previously undiagnosed invasive carcinoma. Delayed postprocedure bleeding occurred in 21.4%, all of which were managed successfully at endoscopy. Acute pancreatitis complicated 15.5% of procedures (mild in 93.8%). Perforation occurred in 5.8%, all treated conservatively except for one patient requiring surgery. Piecemeal resection was associated with significantly higher recurrence compared to en-bloc resection (54.3% versus 26.2%, respectively, P = 0.012). All recurrences were treated endoscopically. Conclusion Endoscopic ampullectomy appears both safe and effective in managing patients with ampullary tumours in experienced hands. Most adverse events can be managed conservatively. Many patients develop recurrence during long-term follow-up but can be managed endoscopically. Recurrence rates may be reduced by performing initial en-bloc resection.

Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

“…The rate of diagnostic overestimation, leading to potentially inadequate and risky treatment, has been prospectively evaluated to be 15 % overall, and 21 % for initial low grade dysplasia diagnosis [19]. Normal intestinal mucosa or inflammatory tissue were found in post-papillectomy histological analysis in 8 % and in 13.8 % in two large retrospective series [37,41].…”

“…In their abovementioned meta-analysis, Spadaccini et al [26] revealed a pooled rate of post-papillectomy bleeding of 10.6 % (95 %CI 5.2 %-13.6 %; I 2 = 61 %), with effective conservative management including endoscopic treatment for 149/156 events (95.5 %) for which data were available. In the more recent and largest retrospective studies, endoscopic treatments were performed in 69.1 % of cases (n = 56/81) and mostly successfully [20,39,41,88,89]. Reported endoscopic techniques included epinephrine injection, electrocoagulation, clip application, and APC.…”

Anticoagulation and antiplatelet management in gastrointestinal endoscopy: A review of current evidence

“…Endoscopic ampullectomy allows for a minimally invasive nonsurgical intervention option for the treatment of ampullary adenomas, however is associated with significant risk of PPB between 4.9% to 30%[ 72 - 79 ]. The considerably high incidence of PPB of 30% reported in the study by Hopper et al [ 72 ] was observed in resections of larger sized ampullary adenomas (between 40-60 mm).…”

Experimental Substantiation of Autoplasma Application as a Haemostatic Agent in Endoscopic Operations in the Digestive Tract

“…Any surgical intervention is associated with complications, among which the most frequent and threatening are perforation of the hollow organ and bleeding. At present, physical methods of haemostasis are widely used in endosurgery, creating comfortable conditions for performing the operation and obtaining, in general, positive results (1). However, it should be noted that 'cellular technologies' are gaining popularity in endosurgery of the digestive tract, including the use of blood components or blood cells with a haemostatic purpose.…”