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.

Keywords: Ampullary tumors; Endoscopic papillectomy; Endoscopic resection; Endoscopic ultrasound; Epidemiology; Staging; Surgical ampullectomy.

Figure 1

Endoscopic view of neuroendocrine tumor of the papilla with Fujinon intelligent chromo endoscopy. A: This picture show the depression in the center of the lesion; B: The picture shows the aspect of the papillary region after the “en bloc” resection.

Figure 2

Endoscopic ultrasound staging of the duodenal papilla. A: Patient of the Figure 1. Endoscopic ultrasound staging shows the regular and hypoechoic nodule (1.93 cm) in the papilla without infiltration of the duodenal wall and pancreatic gland. The staging was uT1N0Mx; B: This picture shows the papillary tumor with 1.72 cm with invasion of the common bile duct wall (blue arrows). NET: Neuroendocrine tumor; TU: Tumor; CBD: Common bile duct.

Figure 3

Endoscopic papillectomy immediately after endoscopic ultrasound for staging. A: En bloc resection of the tumor, after the snare is widely opened, duodenoscope is pushed in a craniocaudal direction; B: The endoscopic view of the common bile duct and main pancreatic duct (blue arrows) after a complete en bloc resection of the papillary tumor. CBD: Common bile duct; MPD: Main pancreatic duct.