Published online Nov 28, 2020. doi: 10.3748/wjg.v26.i44.7036
Peer-review started: August 20, 2020
First decision: September 12, 2020
Revised: September 24, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 28, 2020
Endoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. To drain bile and pancreatic juice away from the wound may help to prevent delayed perforation.
Although the application of an endoscopic nasobiliary drainage (ENBD) tube can achieve external drainage of bile, it is generally unable to drain pancreatic juice at the same time and may cause stress due to nasopharyngeal discomfort; while the conventional plastic biliary and pancreatic stents cannot drain bile and pancreatic juice a distance due to their limited length. These drainage methods cannot avoid erosion of the artificial ulcer by bile and/or pancreatic juice after EP. Therefore, we modified the ENBD tubes into overlength biliary and pancreatic stents to drain bile and pancreatic juice to the proximal jejunum.
The present study aimed to evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.
This is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an ENBD tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.
EP and overlength stents placement were technically feasible in all five patients, with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), en bloc excision and curative resection was achieved in four. The final histopathological diagnoses of the endoscopic specimens were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.
For patients with exposure or injury of muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.
Overlength biliary and pancreatic stents placement after EP is a feasible, useful and safe technique to prevent papillectomy-related complications, especially delayed perforation, in selected patients by experienced endoscopists. However, due to the unique physiology and intricate anatomy of the duodenum, it is often difficult and time-consuming to place the distal ends of overlength stents into the jejunum. In view of the limited number of patients and the short-term follow-up, a further larger prospective study with long-term follow-up is needed to confirm our results.