Safety of Endoscopic Snare Ampullectomy for Adenomatous Ampullary Lesions: Focus on Pancreatic Stent Placement to Prevent Pancreatitis

Abstract

Background: Ampullary tumors, although relatively uncommon, are increasingly diagnosed due to ongoing progress in imaging technology and the diagnostic accuracy of endoscopic ultrasound and magnetic resonance cholangiopancreatography. Endoscopic ampullectomy (EA) has become the preferred treatment option over surgery due to its lower morbidity for benign ampullary adenomas. This study aims to evaluate the efficacy, safety, and outcome of EA in 30 patients with benign-appearing ampullary lesions with particular emphasis on the accuracy of preampullectomy histology and technical details of the pancreatic duct drainage to prevent postprocedural pancreatitis.Materials and Methods: Data from a cohort of 30 patients who underwent EA were retrospectively analyzed. Histologic characteristics of the ampullomas, accuracy of histology of pre-EA biopsy specimen, safety of the procedure, recurrence rate, as well as the clinical outcome of all patients, are analyzed and discussed.Results: Endoscopic resection was successful as a definitive treatment in 25 patients (83.3%). Five patients required additional surgery. In 8 patients, a definitive histologic specimen revealed an adenocarcinoma (3 in situ and 5 invasive). The diagnostic accuracy obtained by preresection biopsy specimen was low (0.70). Pancreatic duct stent placement after snare resection was unsuccessful in 9 patients, and 3 of them developed pancreatitis after EA.Conclusions: EA appears to be a relatively safe alternative to surgery as the first therapeutic option for selected patients with benignappearing ampullary adenomas. A correct preoperative evaluation by endoscopic ultrasound and magnetic resonance cholangiopancreatography can help to define the anatomy of the pancreatic duct to improve the success rate of pancreatic stent placement which seems to offer a protective role in the prevention of postprocedural pancreatitis.

Updates in endoscopic management of ampullary and duodenal adenomas

“…Thus, the best evidence to date suggests that routine submucosal injection is not warranted during endoscopic resection of ampullary adenomas. (2) Prophylactic pancreatic duct (PD) stents: In randomized trials, PD stent placement not only decreases the occurrence of post EP pancreatitis but also is lowers the rate of long-term papillary stenosis after ampullectomy [32][33][34]. An area of uncertainty is the optimal length and diameter of PD stents.…”

“…Prophylactic pancreatic duct (PD) stents: In randomized trials, PD stent placement not only decreases the occurrence of post EP pancreatitis but also is lowers the rate of long-term papillary stenosis after ampullectomy [32–34]. An area of uncertainty is the optimal length and diameter of PD stents.…”

Endoscopic papillectomy for ampullary adenomatous lesions: A literature review

“…Although prophylactic pancreatic stent placement is debated and failed to demonstrate a reduction in some studies[ 31 ], experts nevertheless recommend placement of prophylactic pancreatic stents for selected patients at high risk for post-ERCP pancreatitis (PEP)[ 32 , 33 ], especially those with insufficient pancreatic juice drainage after EP. A series of studies demonstrated that prophylactic pancreatic stent placement significantly decreased the risk of post-EP pancreatitis[ 34 , 35 ]. A meta-analysis showed that pancreatic stent placement decreased the odds of post-procedure pancreatitis and potentially reduced the risk of late post-procedure papillary stenosis[ 36 ].…”