Yonsei Med J.  2014 May;55(3):644-650. 10.3349/ymj.2014.55.3.644.

Clinicopathologic Characteristics Associated with Complications and Long-Term Outcomes of Endoscopic Papillectomy for Adenoma

• Shim CN
• Chung MJ
• Bang S
• Park SW
• Song SY
• Chung JB
• Park JY

• KMID: 2068673
• DOI: http://doi.org/10.3349/ymj.2014.55.3.644

Abstract

PURPOSE
Endoscopic papillectomy (EP) is currently employed for the treatment of ampullary adenoma. This study aimed to evaluate the clinical, endoscopic, and histologic characteristics related to complications and long-term outcomes of EP.
MATERIALS AND METHODS
Thirty-nine patients underwent EP for ampullary adenoma. Patients were grouped according to the occurrence of procedure-related complications: no complication group (n=28) and complication group (n=11).
RESULTS
The overall complication rate was 28.2%. The most common complication was EP-related pancreatitis (n=7). Amylase (p=0.006) and lipase levels (p=0.007), 24 hours after EP, were significantly higher in the complication group, however, these levels did not differ at earlier times. As the tumor progressed from adenoma to cancer, the complete resection was significantly lessened (p=0.032). The duration of antiprotease injection during the hospital stay was significantly longer (p=0.017) and the transfusion requirements were significantly higher (p=0.018) in the complication group. During a median follow-up of 15 months, three lesions (10.3%) recurred among patients with complete resection (n=29) and five lesions (12.8%) recurred among enrolled patients. One patient with progressive recurrence from low-grade dysplasia to adenocarcinoma was noted during a follow-up of 22 months.
CONCLUSION
If symptoms are present, amylase and lipase levels, 24 hours after EP, could help predict possible EP-related pancreatitis. Histologic diagnosis through resected specimens may result in complete resection. Patients with complications need a longer duration of antiprotease injection during their hospital stay and more transfusions. The recurrence rate was not significantly high in completely resected cases, however, there was a possibility of progressive recurrence.

Keyword

Ampullary adenoma; endoscopic papillectomy; endoscopic retrograde cholangiopancreatography; complication

MeSH Terms

Adenoma/*surgery
Adult
Aged
Aged, 80 and over
Common Bile Duct Neoplasms/*surgery
Endoscopy/*methods
Female
Humans
Male
Middle Aged
Neoplasm Recurrence, Local
Retrospective Studies

Reference

1. Rosenberg J, Welch JP, Pyrtek LJ, Walker M, Trowbridge P. Benign villous adenomas of the ampulla of Vater. Cancer. 1986; 58:1563–1568.

2. Arvanitis ML, Jagelman DG, Fazio VW, Lavery IC, McGannon E. Mortality in patients with familial adenomatous polyposis. Dis Colon Rectum. 1990; 33:639–642.

3. Stolte M, Pscherer C. Adenoma-carcinoma sequence in the papilla of Vater. Scand J Gastroenterol. 1996; 31:376–382.

4. Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol. 1992; 87:37–42.

5. Yamaguchi K, Enjoji M, Kitamura K. Endoscopic biopsy has limited accuracy in diagnosis of ampullary tumors. Gastrointest Endosc. 1990; 36:588–592.

6. Hernandez LV, Catalano MF. Endoscopic papillectomy. Curr Opin Gastroenterol. 2008; 24:617–622.

7. Yamao T, Isomoto H, Kohno S, Mizuta Y, Yamakawa M, Nakao K, et al. Endoscopic snare papillectomy with biliary and pancreatic stent placement for tumors of the major duodenal papilla. Surg Endosc. 2010; 24:119–124.

8. Desilets DJ, Dy RM, Ku PM, Hanson BL, Elton E, Mattia A, et al. Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications. Gastrointest Endosc. 2001; 54:202–208.

9. Norton ID, Gostout CJ, Baron TH, Geller A, Petersen BT, Wiersema MJ. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc. 2002; 56:239–243.

10. Bohnacker S, Soehendra N, Maguchi H, Chung JB, Howell DA. Endoscopic resection of benign tumors of the papilla of vater. Endoscopy. 2006; 38:521–525.

11. Patel R, Davitte J, Varadarajulu S, Wilcox CM. Endoscopic resection of ampullary adenomas: complications and outcomes. Dig Dis Sci. 2011; 56:3235–3240.

12. Boix J, Lorenzo-Zúñiga V, Moreno de Vega V, Domènech E, Gassull MA. Endoscopic resection of ampullary tumors: 12-year review of 21 cases. Surg Endosc. 2009; 23:45–49.

13. Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, et al. ASGE Standards of Practice Committee. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009; 70:1060–1070.

14. Dixon MF. Gastrointestinal epithelial neoplasia: Vienna revisited. Gut. 2002; 51:130–131.

15. Cotton PB, Lehman G, Vennes J, Geenen JE, Russell RC, Meyers WC, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc. 1991; 37:383–393.

16. Catalano MF, Linder JD, Chak A, Sivak MV Jr, Raijman I, Geenen JE, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc. 2004; 59:225–232.

17. Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive review. Gastrointest Endosc. 2004; 59:845–864.

18. Elmunzer BJ, Scheiman JM, Lehman GA, Chak A, Mosler P, Higgins PD, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012; 366:1414–1422.

19. Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc. 2006; 63:292–301.

20. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc. 2005; 62:367–370.

21. Eswaran SL, Sanders M, Bernadino KP, Ansari A, Lawrence C, Stefan A, et al. Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series. Gastrointest Endosc. 2006; 64:925–932.

22. Irani S, Arai A, Ayub K, Biehl T, Brandabur JJ, Dorer R, et al. Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period. Gastrointest Endosc. 2009; 70:923–932.