Recent advances in endoscopic papillectomy for ampulla of vater tumors: endoscopic ultrasonography, intraductal ultrasonography, and pancreatic stent placement

Abstract

Since it was first described nearly three decades ago, endoscopic papillectomy (EP) has been utilized as a less invasive, alternative therapy for adenoma of the major duodenal papilla. In this article, we review the recent advances in EP, especially those pertaining to endoscopic ultrasonography (EUS), intraductal ultrasonography (IDUS), and pancreatic stent placement for the prevention of postpapillectomy pancreatitis. Because EUS and IDUS have similar diagnostic accuracies, either modality can be used for the preprocedural evaluation of ampullary tumors. Nevertheless, further technical refinements are required for a more precise evaluation. Given the paucity of data on the usefulness of EUS and/or IDUS during follow-up after EP, a well-designed study is warranted. Furthermore, pancreatic stent placement appears to have a protective effect against postpapillectomy pancreatitis; however, a prospective, randomized, controlled study with a larger number of patients is needed to assess this finding. Moreover, since pancreatic stent placement after EP is not always successful, various novel techniques have been developed to ensure reliable stent placement. Despite the recent advances in EP, further technical refinements and studies are needed to confirm their efficacy.

Keywords: Ampulla of Vater; Ampullary tumors; Endoscopic papillectomy; Endoscopic resection.

Fig. 1

Pre-procedural evaluation of ampullary adenoma. (A) Endoscopic exam demonstrates a pale, granular lesion on the major duodenal papilla. (B) Endoscopic ultrasonography with radial echoendoscope shows that the adenoma is limited to mucosa.

Fig. 2

Another case of preprocedural evaluation of ampullary adenoma. (A) Endoscopic exam shows a protuberant, hyperemic lesion at the major duodenal papilla. (B) Intraductal ultrasonography reveals that the adenoma is limited to mucosa and muscularis propria is intact (Kindly provided by Drs. Jong Ho Moon and Hyun Jong Choi from SoonchunHyang University Bucheon Hospital).

Fig. 3

Endoscopic papillectomy of ampullary adenoma. (A) A pale, elongated lesion is seen on the major duodenal papilla. (B) The adenoma is grasped with a standard polypectomy snare. (C) The tumor is removed en bloc after application of electrosurgical current. (D) A 5 Fr, 3 cm pancreatic stent is placed. (E) Hemostasis is achieved with argon plasma coagulation. (F) Postpapillectomy ulcer is clear without bleeding.