Quality of life and outcomes in patients undergoing endoscopic papillectomy vs surgical treatment for duodenal papillary adenomas

Table 1 Demographics, baseline characteristics, risk factors, and clinical profile at the time of duodenal papillary adenoma diagnosis based on availability of long-term follow-up, mean ± SD/n (%)

Variable	EP (n = 155)	Surgery (n = 43)	P value
Age, years			0.051
mean ± SD	56.9 ± 10.4	60.1 ± 8.68
Range	28-81	39-75
≤ 39	7 (4.5)	1 (2.3)
40-49	29 (18.7)	3 (7.0)
50-59	60 (38.7)	17 (39.5)
60-69	43 (27.7)	16 (37.2)
≥ 70	16 (10.3)	6 (14.0)
Sex			0.162
Female	54 (38.4)	20 (46.5)
Male	101 (65.2)	23 (53.5)
BMI (kg/m2)			0.001
Normal/low (≤ 23.9)	74 (47.7)	33 (76.7)
Overweight (24-27.9)	66 (42.6)	9 (20.9)
Obese (≥ 28)	15 (9.7)	1 (2.3)
Comorbidities
History of hypertension	63 (40.6)	17 (39.5)	0.896
History of diabetes	26 (16.8)	8 (18.6)	0.778
History of hyperlipidemia	36 (23.2)	4 (9.3)	0.053
History of heart disease	27 (17.4)	3 (7.0)	0.195
History of liver disease	38 (24.5)	13 (30.2)	0.448
History of renal disease	31 (20.0)	10 (23.3)	0.641
History of other tumors	20 (12.9)	5 (11.6)	0.824
History of stroke	4 (2.6)	1 (2.3)	1.000
Current smoking	26 (16.8)	4 (9.3)	0.227
Current alcohol consumption	11 (7.1)	2 (4.7)	0.822
CEA (ng/mL), median (IQR)	1.0 (0.5-1.6)	1.1 (0.6-1.9)	0.299
CA-199 (U/mL), median (IQR)	9.5 (5.8-12.5)	15.0 (9.6-26.6)	< 0.001
TBil (μmol/L), median (IQR)	10.5 (7.1-13.7)	11.5 (9.0-15.8)	0.138
DBil (μmol/L), median (IQR)	2.4 (1.8-3.5)	3.1 (2.1-4.9)	0.020
ALT (U/L), median (IQR)	16.5 (12.6-22.4)	18.8 (11.7-56.0)	0.090
ALP (U/L), median (IQR)	66.7 (55.8-85.0)	74.4 (64.2-144.3)	0.003
GGT (U/L), median (IQR)	20.9 (15.9-30.7)	25.4 (19.2-459.6)	0.001
Hb (g/L), median (IQR)	137.0 (126.0-150.0)	128.0 (117.0-136.0)	< 0.001
WBC (× 109/L), median (IQR)	5.1 (4.4-6.3)	5.2 (4.1-6.6)	0.942
PLT (× 109/L), median (IQR)	186.0 (157.0-215.0)	201.0 (177.0-234.0)	0.029

EP: Endoscopic papillectomy; BMI: Body mass index; CEA: Carcinoembryonic antigen; CA-199: Carcinoma antigen-199; TBil: Total bilirubin; DBil: Direct bilirubin; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transferase; Hb: Hemoglobin; WBC: White blood cells; PLT: Platelets.

Table 2 Histopathologic findings of lesions and preoperative laboratory indices, n (%)

Variable	EP (n = 155)	Surgery (n = 43)	P value
Tumor size, median (IQR) (mm)
Length	14.0 (10.0-17.0)	30.0 (18.0-40.0)	< 0.001
Width	10.0 (7.0-14.0)	15.0 (13.0-30.0)	< 0.001
Bile duct invasion	14 (9.0)	12 (27.9)	0.001
Pancreatic duct invasion	3 (1.9)	1 (2.3)	1.000
Neurological invasion	0 (0.0)	1 (2.3)	0.217
Vascular invasion	0 (0.0)	1 (2.3)	0.217
Lymphatic metastasis	0 (0.0)	0 (0.0)
Duodenal diverticulum	8 (5.2)	0 (0.0)	0.279
Preoperative dilatation of the common bile duct	25 (16.1)	18 (41.9)	< 0.001
Preoperative dilatation of the pancreatic duct	0 (0.0)	10 (23.3)	< 0.001
Pathology			< 0.001
No dysplasia	32 (20.6)	0 (0.0)
Adenoma/LGD	98 (63.2)	14 (32.6)
Adenoma/HGD	6 (3.9)	5 (11.6)
Adenoma/LGD with focal HGD	14 (9.0)	10 (23.3)
Adenoma/HGD with focal adenocarcinoma	5 (3.2)	10 (23.3)
Adenocarcinoma	0 (0.0)	4 (9.3)

EP: Endoscopic papillectomy; IQR: Interquartile range; LGD: Low-grade dysplasia; HGD: High-grade dysplasia.

Table 3 Comparison of postoperative quality of life, occurrence of follow-up complications, adverse events, and long-term outcomes between endoscopic papillectomy and surgical treatment, n (%)

Variable	EP (n = 155)	Surgery (n = 43)	P value
Quality of life
PCS score, median (IQR)	54.2 (51.7-55.9)	53.0 (46.0-55.1)	0.008
≥ 50	129 (83.2)	29 (67.4)	0.023
MCS score, median (IQR)	55.9 (51.7-60.7)	48.6 (41.8-56.0)	< 0.001
≥ 50	124 (80.0)	20 (46.5)	< 0.001
Follow-up time, months, median (IQR)	37.0 (25.0-54.0)	46.0 (25.0-65.0)	0.451
Range	13-131	5-91	0.113
≤ 24	38 (24.5)	10 (23.3)
25-60	85 (54.8)	19 (44.2)
61-120	26 (16.8)	14 (32.5)
> 120	6 (3.9)	0 (0.0)
Follow-up pancreatitis	8 (5.2)	0 (0.0)	0.279
Follow-up cholangitis	6 (3.9)	2 (4.7)	1.000
Follow-up bile duct stones	12 (7.7)	1 (2.3)	0.357
Abdominal pain	32 (20.6)	14 (32.6)	0.102
Frequency of abdominal pain			0.001
Infrequent	25 (16.1)	9 (20.9)
Sometimes	7 (4.5)	5 (11.6)
Region of abdominal pain			< 0.001
Back	1 (0.6)	0 (0.0)
Epigastric region	14 (9.0)	10 (23.3)
Right upper abdomen	9 (5.8)	0 (0.0)
Right lower abdomen	1 (0.6)	0 (0.0)
Left upper abdomen	7 (4.5)	3 (7.0)
Left lower abdomen	0 (0.0)	1 (2.3)
Abdominal pain classification			< 0.001
Sting	2 (1.3)	0 (0.0)
Colic	2 (1.3)	1 (2.3)
Hidden anguish	22 (14.2)	10 (23.3)
Distending pain	6 (3.9)	3 (7.0)
Appetite decline	10 (6.5)	7 (16.3)	0.084
Weight loss	15 (9.7)	9 (20.9)	0.047
Poor sleep	26 (16.8)	9 (20.9)	0.527
Bleeding
Postoperative bleeding	9 (5.8)	1 (2.3)	0.597
Delayed bleeding	11 (7.1)	0 (0.0)	< 0.001
Pancreatitis	17 (11.0)	1 (2.3)	0.149
Cholangitis	2 (1.3)	0 (0.0)	1.000
Perforation	4 (2.6)	0 (0.0)	0.579
Papillary stricture	2 (1.3)	0 (0.0)	1.000
Pancreatic fistula	0 (0.0)	10 (23.3)	< 0.001
Biliary fistula	0 (0.0)	2 (4.7)	0.046
Chylous fistula	0 (0.0)	1 (2.3)
Abdominal infection	0 (0.0)	15 (34.9)	< 0.001
Infection of incisional wound	0 (0.0)	2 (4.7)	0.046
Regular review	133 (85.8)	41 (95.3)	0.090
Recurrence	8 (5.2)	1 (2.3)	0.176
Post-relapse treatment
Untreated	2 (25.0)	0 (0.0)
EMR	4 (50.0)	1 (100.0)
EMR with submucosal injection	2 (25.0)	0 (0.0)

EP: Endoscopic papillectomy; IQR: Interquartile range; PCS: Physical component summary; MCS: Mental component summary; EMR: Endoscopic mucosal resection.

Table 4 Unadjusted and multivariate adjusted coefficients and 95% confidence intervals for factors affecting quality of life, depending on treatment modality

Variable	PCS						MCS
	B	SE	β	t value	P value	95%CI	B	SE	β	t value	P value	95%CI
Group	-3.12	1.15	-0.19	-2.70	0.008	-5.400 to -0.838	-6.13	1.27	-0.33	-4.82	< 0.001	-8.633 to -3.619
Model 1	-2.66	1.19	-0.16	-2.23	0.027	-5.015 to -0.304	-5.695	1.28	-0.30	-4.46	< 0.001	-8.216 to -3.174
Model 1 + model 2	-2.68	1.69	-0.16	-1.59	0.114	-6.031 to 0.655	-5.34	1.79	-0.28	-2.98	0.003	-8.873 to -1.799
Model 1 + model 2 + model 3	-2.84	1.81	-0.17	-1.57	0.118	-6.405 to 0.725	-5.20	1.92	-0.28	-2.71	0.007	-8.985 to -1.409
Model 1 + model 2 + model 3 + model 4	-3.99	1.92	-0.25	-2.08	0.039	-7.780 to -0.199	-5.98	2.15	-0.33	-2.79	0.006	-10.218 to -1.748

PCS: Physical component summary; MCS: Mental component summary; CI: Confidence interval. The specific information of models 1-4 can be found in the supplementary materials.

Table 5 Physical component summary scores and mental component summary scores at long-term follow-up based on demographics and comorbidities of endoscopic papillectomy

Variable	PCS median (IQR)	Univariate analysis	Multivariate analysis			Adjusted R2	MCS median (IQR)	Univariate analysis	Multivariate analysis			Adjusted R2
		P value	Coefficient	95%CI	P value			P value	Coefficient	95%CI	P value
Sex		0.81				21.00%		0.02	-2.15	-4.474 to 0.184	0.071	12.40%
Female	54.3 (51.5-55.9)						55.8 (47.8-59.0)
Male	54.2 (51.7-55.9)						56.0 (53.5-60.7)
Coexistent hyperlipidemia		0.74						0.007	-2.05	-4.595 to 0.497	0.114
Yes	54.1 (50.9-55.9)						54.9 (47.6-57.6)
No	54.2 (51.7-55.9)						56.0 (53.3-60.7)
Coexistent hypertension		0.016	-0.9	-2.660 to 0.871	0.318			0.007	-3.02	-5.187 to -0.853	0.007
Yes	53.4 (50.8-55.3)						55.6 (49.4-60.7)
No	54.9 (52.7-55.9)						57.0 (54.0-60.7)
History of heart disease/stroke		0.005	-2.33	-4.688 to 0.021	0.052			0.64
Yes	51.5 (44.0-55.3)						55.9 (49.0-60.3)
No	54.3 (52.3-55.9)						56.0 (53.2-60.7)
History of liver disease		0.52						0.048	-1.58	-4.688 to 0.021	0.22
Yes	54.5 (52.0-55.9)						55.8 (49.8-57.0)
No	54.2 (51.3-55.9)						56.0 (53.3-60.7)
Follow-up time (months)		0.005	0.5	-0.648 to 1.646	0.391			0.136
≤ 24	52.8 (50.2-55.3)						55.9 (53.5-60.6)
25-60	55.2 (52.1-56.2)						55.9 (50.1-58.3)
61-120	53.6 (52.6-55.3)						58.9 (50.9-60.8)
> 120	53.0 (50.8-55.3)						57.7 (52.3-60.7)
Abdominal pain		< 0.001	-4.31	-6.500 to -2.115	< 0.001			0.08
Yes	51.0 (44.9-53.1)						54.1 (46.5-57.3)
No	55.3 (53.1-55.9)						56.0 (53.3-60.7)
Appetite decline		0.033	0.58	-2.993 to 4.146	0.75			0.07
Yes	50.9 (46.3-53.8)						52.4 (41.7-56.0)
No	54.3 (51.7-55.9)						56.0 (52.7-60.7)
Poor sleep		0.001	-3.8	-6.232 to -1.357	0.002			0.047	-0.72	-3.592 to 2.158	0.623
Yes	51.7 (43.3-55.3)						55.4 (46.5-59.4)
No	54.5 (52.1-55.9)						56.0 (53.2-60.7)
Weight loss		0.024	-1.13	-4.153 to 1.897	0.462			0.66
Yes	52.6 (46.6-53.5)						56.3 (49.1-60.5)
No	54.6 (51.7-55.9)						56.0 (52.6-60.7)
Smoking		0.32						0.029	1.73	-1.266 to 4.728	0.256
Yes	55.1 (53.6-55.9)						56.8 (53.3-60.7)
No	54.2 (51.3-55.9)						55.9 (50.9-59.9)
PEP		0.62						0.024	-3.76	-7.235 to -0.284	0.034
Yes	55.2 (51.2-56.6)						53.6 (44.8-56.3)
No	54.2 (51.7-55.9)						56.0 (53.0-60.7)

PCS: Physical component summary; MCS: Mental component summary; IQR: Interquartile range; CI: Confidence interval; PEP: Post-endoscopic retrograde cholangiopancreatography pancreatitis.