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Demirci NS, Cavdar E, Ozdemir NY, Yuksel S, Iriagac Y, Erdem GU, Odabas H, Hacibekiroglu I, Karaagac M, Ucar M, Ozturk B, Bozkaya Y. Clinicopathologic Analysis and Prognostic Factors for Survival in Patients with Operable Ampullary Carcinoma: A Multi-Institutional Retrospective Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:818. [PMID: 38793001 PMCID: PMC11122928 DOI: 10.3390/medicina60050818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/10/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: In ampullary cancer, 5-year survival rates are 30-50%, even with optimal resection and perioperative systemic therapies. We sought to determine the important clinicopathological features and adjuvant treatments in terms of the prognosis of patients with operable-stage ampullary carcinomas. Materials and Methods: We included 197 patients who underwent pancreaticoduodenectomy to treat ampullary carcinomas between December 2003 and May 2019. Demographics, clinical features, treatments, and outcomes/survival were analyzed. Results: The median disease-free survival (mDFS) and median overall survival (mOS) were 40.9 vs. 63.4 months, respectively. The mDFS was significantly lower in patients with lymphovascular invasion (p < 0.001) and lymph node involvement (p = 0.027). Potential predictors of decreased OS on univariate analysis included age ≥ 50 years (p = 0.045), poor performance status (p = 0.048), weight loss (p = 0.045), T3-T4 tumors (p = 0.018), surgical margin positivity (p = 0.01), lymph node involvement (p = 0.001), lymphovascular invasion (p < 0.001), perineural invasion (p = 0.007), and poor histological grade (p = 0.042). For the multivariate analysis, only nodal status (hazard ratio [HR]1.98; 95% confidence interval [CI], 1.08-3.65; p = 0.027) and surgical margin status (HR 2.61; 95% CI, 1.09-6.24; p = 0.03) were associated with OS. Conclusions: Nodal status and a positive surgical margin were independent predictors of a poor mOS for patients with ampullary carcinomas. Additional studies are required to explore the role of adjuvant therapy in patients with ampullary carcinomas.
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Affiliation(s)
- Nebi Serkan Demirci
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Eyyup Cavdar
- Department of Medical Oncology, Adiyaman Training and Research Hospital, Adiyaman University, 02000 Adiyaman, Türkiye
| | - Nuriye Yildirim Ozdemir
- Department of Medical Oncology, Faculty of Medicine, Yıldırım Beyazıt University, 06010 Ankara, Türkiye
| | - Sinemis Yuksel
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Yakup Iriagac
- Department of Medical Oncology, Balikesir Ataturk City Hospital, 10100 Balikesir, Türkiye
| | - Gokmen Umut Erdem
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Hatice Odabas
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Ilhan Hacibekiroglu
- Department of Medical Oncology, Faculty of Medicine, Sakarya University, 54050 Sakarya, Türkiye
| | - Mustafa Karaagac
- Department of Medical Oncology, Meram Medical Faculty, Necmettin Erbakan University, 42090 Konya, Türkiye;
| | - Mahmut Ucar
- Department of Medical Oncology, Faculty of Medicine, Erciyes University, 38039 Kayseri, Türkiye
| | - Banu Ozturk
- Department of Medical Oncology, Akdeniz University, 07058 Antalya, Türkiye;
| | - Yakup Bozkaya
- Department of Medical Oncology, Yeniyuzyil University-Gaziosmanpasa Hospital, 34098 Istanbul, Türkiye;
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WEO Newsletter. Dig Endosc 2023; 35:799-803. [PMID: 37678909 DOI: 10.1111/den.14647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
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Kim GE, Siddiqui UD. Endoscopic Resection Techniques for Duodenal and Ampullary Adenomas. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2023; 8:330-335. [PMID: 37575136 PMCID: PMC10422085 DOI: 10.1016/j.vgie.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Background and Aims Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10 mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques. Methods The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk. Results The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video. Conclusions A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.
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Affiliation(s)
- Grace E Kim
- Section of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, University of Chicago, Chicago, Illinois
| | - Uzma D Siddiqui
- Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, Illinois
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Cho KB. Endoscopic Papillectomy for Ampullary Tumors. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2022. [DOI: 10.7704/kjhugr.2022.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Ampullary tumors originate from the ampulla of Vater and are often discovered incidentally during an upper endoscopy. These tumors usually occur sporadically and may be benign or malignant in nature. Tumor growth clinically presents with cholestasis, pancreatitis, and bleeding. Patients with ampullary adenomas are often asymptomatic; however, removal of these lesions is recommended in view of their malignant potential. Following advances in endoscopic techniques and the accumulation of experience, considering high recurrence, mortality, and morbidity rates associated with surgery, endoscopic papillectomy may be useful as first-line treatment for adenomatous lesions with ambiguous malignant changes or focal intraepithelial carcinoma. Although it is relatively safe and easy to perform, the operation is a high-level procedure that may be associated with serious complications. It should be performed by an experienced endoscopist at a well-equipped hospital/center with emergency facilities and support personnel. Accurate resection is associated with high treatment success rates. Most complications are mild and can be treated medically. Pancreatitis is the most common complication, and pancreatic duct stenting is useful for prophylaxis. Recurrence may occur, and is more frequently observed during segmental resection; therefore, close periodic follow-up is essential. Although there are no unified indications or guidelines for endoscopic papillectomy, endoscopic papillectomy may be safe and effective for management of ampullary adenomas. Careful patient selection and follow-up are mandatory.
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Takada Y, Kawashima H, Ohno E, Ishikawa T, Mizutani Y, Iida T, Yamamura T, Kakushima N, Furukawa K, Nakamura M, Honda T, Ishigami M, Ito A, Hirooka Y. The impact of the age-adjusted Charlson comorbidity index as a prognostic factor for endoscopic papillectomy in ampullary tumors. J Gastroenterol 2022; 57:199-207. [PMID: 35098349 DOI: 10.1007/s00535-022-01853-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 01/15/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognostic nutritional index (PNI) and Charlson comorbidity index (CCI) have been useful for predicting the prognosis based on nutritional condition and comorbidities in surgery and endoscopic mucosal dissection. The age-adjusted CCI (ACCI) has also been reported to be useful in surgery, but it has not been applied to endoscopic treatment. We therefore clarified the prognostic factors associated with ampullary tumors treated with endoscopic papillectomy (EP). METHODS From January 2003 to December 2020, 236 patients who underwent EP for sporadic ampullary tumors at Nagoya University Hospital were included in this study. The 5-year survival and ability to predict the prognosis were evaluated in terms of the sex, PNI, ACCI, final pathological diagnosis, and intraductal extension. RESULTS During a median follow-up period of 1558 days, 17 patients died. No patient died of the primary disease. The 5-year survival rate was 91.1%. In a univariate analysis, only a high ACCI (≥ 5) was extracted as a significant prognostic factor (Odds ratio, 12.2; 95% confidence interval, 3.81-39.3; p < 0.001). The 5-year survival rates for a low ACCI (≤ 4) and high ACCI were 96.6% and 73.5%, respectively (p < 0.001). CONCLUSIONS A high ACCI is an important prognostic factor associated with the 5-year survival and a risk of death from other illness. Ampullary tumors suitable for EP are less likely to be a prognostic factor, and treatment-free follow-up may be acceptable in patients with a high ACCI.
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Affiliation(s)
- Yoshihisa Takada
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroki Kawashima
- Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan.
- Department of Endoscopy, Nagoya University Graduate School of Medicine, 65, Tsurumai-cho, Showa-ku, Nagoya, Aichi, 466-8560, Japan.
| | - Eizaburo Ohno
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takuya Ishikawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yasuyuki Mizutani
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Tadashi Iida
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takeshi Yamamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Naomi Kakushima
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazuhiro Furukawa
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masanao Nakamura
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Honda
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masatoshi Ishigami
- Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Ito
- Nishinoho Ito Medical Clinic, Kitanagoya, Japan
| | - Yoshiki Hirooka
- Department of Gastroenterology and Hepatology, Fujita Health University, Toyoake, Japan
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Logarajah S, Cho EE, Deleeuw P, Osman H, Jeyarajah DR. Transduodenal Resection for Duodenal Adenomas May Be An Under Utilized Tool – A Single Institution Experience. Heliyon 2022; 8:e09187. [PMID: 35434393 PMCID: PMC9006647 DOI: 10.1016/j.heliyon.2022.e09187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/10/2022] [Accepted: 03/21/2022] [Indexed: 11/03/2022] Open
Abstract
Background Methods Results Conclusion
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Itoi T, Ryozawa S, Katanuma A, Kawashima H, Iwasaki E, Hashimoto S, Yamamoto K, Ueki T, Igarashi Y, Inui K, Fujita N, Fujimoto K. Clinical practice guidelines for endoscopic papillectomy. Dig Endosc 2022; 34:394-411. [PMID: 35000226 DOI: 10.1111/den.14233] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 12/24/2022]
Abstract
The Japan Gastroenterological Endoscopy Society has developed the "Clinical Practice Guidelines for Endoscopic Papillectomy (EP)" as a fundamental guideline using scientific approach. EP is a recently spreading therapeutic modality for ampullary tumors ranked as high risk endoscopic technique. Because of the paucity of high level of evidence, strength of recommendations had to be determined by a consensus among specialists. These guidelines, shed light on the following five issues: Indications, Preoperative/intraoperative preparations and techniques, Early adverse events, Therapeutic outcomes and remnants/recurrences, and Follow-up and late adverse events, to guide current clinical practice on EP.
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Affiliation(s)
- Takao Itoi
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Shomei Ryozawa
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Akio Katanuma
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Eisuke Iwasaki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | | | - Toshiharu Ueki
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | | | - Kazuo Inui
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
| | - Naotaka Fujita
- Japan Gastroenterological Endoscopy Society, Tokyo, Japan
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Scroggie DL, Mavroeidis VK. Surgical ampullectomy: A comprehensive review. World J Gastrointest Surg 2021; 13:1338-1350. [PMID: 34950424 PMCID: PMC8649570 DOI: 10.4240/wjgs.v13.i11.1338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/29/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system. They are typically diagnosed at an earlier stage than other types of tumours in this region, due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct. Consequently, many are potentially curable by excision. Surgical ampullectomy (SA) (or transduodenal ampullectomy) for an ampullary tumour was first described in 1899, but was soon surpassed by pancreatoduodenectomy (PD), which offered a more extensive resection resulting in a lower risk of recurrence. Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy (EP), particularly for adenomas and even early cancers. The vast majority of resectable ampullary tumours are now treated using either PD or EP. However, SA continues to play a role in specific circumstances. Many authors have suggested specific indications for SA based on their own data, practices, or interpretations of the literature. However, certain issues have attracted controversy, such as its use for early ampullary cancers. Consequently, there has been a lack of clarity regarding indications for SA, and no evidence-based consensus guidelines have been produced. All studies reporting SA have employed observational designs, and have been heterogeneous in their methodologies. Accordingly, characteristics of patients and their tumours have differed substantially across treatment groups. Therefore, meaningful comparisons of clinical outcomes between SA, PD and EP have been elusive. Nevertheless, it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival, hence its role in this setting warrants further clarification, while it can also be useful in the management of specific benign entities. Whilst the commissioning of a randomised controlled trial seems unlikely, well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA, potentially informing the eventual development of consensus guidelines. In this comprehensive review, we explore the role of SA in the modern management of ampullary lesions.
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Affiliation(s)
- Darren L Scroggie
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol Medical School, Bristol BS8 2PS, United Kingdom
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
- Department of Surgery, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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Zheng X, Sun QJ, Zhou B, Jin M, Yan S. Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature. World J Clin Cases 2021; 9:4844-4851. [PMID: 34222457 PMCID: PMC8223850 DOI: 10.12998/wjcc.v9.i18.4844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.
CASE SUMMARY A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.
CONCLUSION Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.
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Affiliation(s)
- Xiang Zheng
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Qing-Jing Sun
- The Affiliated Hospital of Stomatology, School of Stomatology, Zhejiang University School of Medicine, and Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
| | - Bo Zhou
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Ming Jin
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Sheng Yan
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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A Comprehensive Approach to the Management of Benign and Malignant Ampullary Lesions: Management in Hereditary and Sporadic Settings. Curr Gastroenterol Rep 2020; 22:46. [PMID: 32654103 DOI: 10.1007/s11894-020-00784-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to examine the historical roots of endoscopic management of ampullary lesions and explore emerging data on improved techniques, technologies, and outcomes. Of specific interest was answering whether there exists a reasonable body of data to support one resection technique or strategy above others. RECENT FINDINGS Review of recent literature suggests the continued use of endoscopic ampullectomy is a safe and effective means of curative treatment of ampullary adenomas. Complications are relatively infrequent and complete endoscopic resection is possible in a majority of cases, with proper patient and lesion selection. Greater than 2 decades of experience with endoscopic ampullectomy have shown this to be a viable, well-tolerated, and highly effective means of treating ampullary adenomas. While few concrete guidelines exist to advise endoscopists on the ideal technique for resection, experience, patient selection, and prior planning can greatly influence the technical and clinical success of endoscopic ampullectomy.
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Ödemiş B, Durak MB, Cengiz M. Endoscopic Ampullectomy of Benign Ampullary Lesions: Outcomes From a Single Center Study. Surg Laparosc Endosc Percutan Tech 2020; 30:270-275. [PMID: 32150118 DOI: 10.1097/sle.0000000000000775] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Endoscopic ampullectomy (EA) offers an insignificantly intrusive strategy for viably treating mucosal and occasionally submucosal lesions of the ampulla of Vater and encompassing periampullary area with high achievement and is more secure. The aim of this study was to present safety, efficacy, and outcomes of EA in the treatment of benign lesions of ampulla Vater performed by single experienced endoscopists in a high volume center. METHODS This retrospective study was conducted in patients referred to our hospital (Turkey High Speciality Training and Research Hospital, Turkey) for endoscopic evaluation of ampullary benign lesions over an 8-year period (between October 2011 and September 2019). Success rate was defined as complete resection of lesions. RESULTS Twenty-nine patients with a median age of 64 years were included. Twenty-five patients had lesions confined to the ampulla vateri (86.2%). Accordingly, 2 lesions had intraductal extension adenoma (IDA) (6.9%) and 2 were lateral spreading adenoma (6.9%). The median size of the lesion was 17.5 mm (10 to 36 mm). Nineteen lesions (65.5%) were resected en bloc and 10 lesions (34.5%) were resected in piecemeal manner. Complete resection was achieved in 21 of 23 patients with benign ampullary lesions. The procedure success rate was 91.3%. Complications occurred in 6 patients (20.6%) of these 3 had (10.3%) bleeding, 2 (6.8%) had pancreatitis, and 1 had (3.4%) perforation. Four patients (13.7%) had a recurrence. CONCLUSIONS Deep resection of the benign ampullary lesions increases the complete resection rate, cannulation rate of the pancreatic duct, and stenting rate of the pancreatic duct. EA is a safe and successful procedure in patients with benign lesions of ampulla vater.
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Affiliation(s)
- Bülent Ödemiş
- Department of Gastroenterology, Turkey High Speciality Training and Research Hospital
| | - Muhammed B Durak
- Department of Gastroenterology, Turkey High Speciality Training and Research Hospital
| | - Mustafa Cengiz
- Department of Gastroenterology, Dr. A. Y. Ankara Oncology Training and Research Hospital, Ankara, Turkey
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Kim NH, Kim HJ. Unsolved problems in endoscopic papillectomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2020. [DOI: 10.18528/ijgii190018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Nam Hee Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hong Joo Kim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
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Diagnosis, risk stratification, and management of ampullary dysplasia by DNA flow cytometric analysis of paraffin-embedded tissue. Mod Pathol 2019; 32:1291-1302. [PMID: 30976103 PMCID: PMC8549479 DOI: 10.1038/s41379-019-0272-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/27/2019] [Accepted: 03/06/2019] [Indexed: 12/20/2022]
Abstract
The limited accuracy of endoscopic biopsy in detecting high-grade dysplasia or adenocarcinoma within ampullary adenoma or dysplasia has been reported. The natural history of ampullary dysplasia is also unclear, and there are no established guidelines to determine which patients with ampullary dysplasia require resection versus surveillance endoscopy. DNA flow cytometry was performed on 47 ampullary biopsies with low-grade dysplasia, 18 high-grade dysplasia, and 23 negative for dysplasia, as well as 11 cases of ampullary adenocarcinoma. Abnormal DNA content (aneuploidy or elevated 4N fraction > 6%) was identified in 9 (82%) of adenocarcinoma, 13 (72%) of high-grade dysplasia, 7 (15%) of low-grade dysplasia, and none (0%) of non-dysplastic mucosa. One-, 2-, and 7-year detection rates of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with abnormal DNA content were 57%, 86%, and 88%, respectively, whereas low-grade dysplasia patients in the setting of normal DNA content had 1-, 2-, and 7-year detection rates of 10%, 10%, and 10%, respectively. The univariate and multivariate hazard ratios (HRs) for subsequent detection of high-grade dysplasia or adenocarcinoma in low-grade dysplasia patients with DNA content abnormality were 16.8 (p = <0.01) and 9.8 (p = <0.01), respectively. Among the 13 high-grade dysplasia patients with DNA content abnormality, 5 patients (38%) were subsequently found to have adenocarcinoma within a mean follow-up time of 3 months, whereas only 1 (20%) of the remaining 5 patients in the setting of normal DNA content developed adenocarcinoma in a month (HR = 2.6, p = 0.39). The overall 1- and 2-year detection rates of adenocarcinoma in all high-grade dysplasia patients (regardless of flow cytometric results) were 34% (95% confidence interval = 16-63%) and 47% (95% confidence interval = 23-79%), respectively. In conclusion, the majority of low-grade dysplasia patients (86%) in the setting of abnormal DNA content developed high-grade dysplasia or adenocarcinoma within 2 years and thus may benefit from resection, whereas those with normal DNA content may be followed with surveillance endoscopy. The presence of DNA content abnormality can also confirm a morphologic suspicion of high-grade dysplasia, which should be managed with resection, as nearly 50% of the high-grade dysplasia patients were found to have adenocarcinoma within 2 years.
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Khan AS, Siddiqui I, Affleck A, Cochran A, Baker E, Iannitti D, Vrochides D, Martinie JB. Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum. Am Surg 2019. [DOI: 10.1177/000313481908500434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010–2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3–21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.
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Affiliation(s)
- Adeel S. Khan
- Division of Hepatopancreatobiliary (HPB) and Transplant Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri and
| | - Imran Siddiqui
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Arthur Affleck
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Allyson Cochran
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Erin Baker
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - David Iannitti
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - Dionisios Vrochides
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
| | - John B. Martinie
- Division of Hepatobiliary and Pancreatic Surgery, Department of General Surgery, Carolinas Medical Center, Charlotte, North Carolina
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Attila T, Parlak E, Alper E, Dişibeyaz S, Çiçek B, Ödemiş B. Endoscopic papillectomy of benign ampullary lesions: Outcomes from a multicenter study. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:325-334. [PMID: 29755017 DOI: 10.5152/tjg.2018.17378] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND/AIMS Endoscopic papillectomy (EP) has emerged as an alternative to surgery in the management of ampullary lesions. The aim of this study is to evaluate feasibility, efficacy, safety, outcome, and impact of EP in the management of benign ampullary lesions. MATERIALS AND METHODS This is a multicenter, retrospective study of 44 patients who had EP of benign ampullary lesions. RESULTS Over the 11-year period, 44 (55.7%) of 79 patients underwent EP for benign ampullary lesions. Complete resection was achieved in 40 patients (91%). An underlying adenocarcinoma was the only risk factor for incomplete resection. Twenty-eight lesions (63.6%) were resected en-bloc and 16 lesions (36.4%) were resected in piecemeal fashion. Post-papillectomy histopathologic diagnoses were tubular adenoma in 14 patients (32%), invasive adenocarcinoma in 9 patients (20.5%), tubullovillous adenoma in 7 patients (16%), tubullovillous adenoma with carcinoma limited to the mucosal layer in 5 patients (11.3%), adenoma with high-grade dysplasia in 4 patients (9%), neuroendocrine tumor in 1 patient (2.3%), ganglioneuroma in 1 patient (2.3%), hamartomatous polyp in 1 patient (2.3%), adenofibroma in 1 patients (2.3%), and Brunner gland hyperplasia in 1 patient (2.3%). Seven (15.9%) procedure-related complications occurred: 3 (6.8%) bleeding, 2 (4.5%) pancreatitis, 1 (2.3%) abdominal pain, and 1 (2.3%) stent migration to the pancreatic duct. Seven patients (17%) had recurrence. CONCLUSION Endoscopic papillectomy is a safe and effective method and can be considered as a first-line approach in patients with benign ampullary lesions with intent for cure. It also allows for correct histological diagnosis and staging.
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Affiliation(s)
- Tan Attila
- Division of Gastroenterology and Hepatology, Koç University School of Medicine, İstanbul, Turkey; Division of Gastroenterology and Hepatology, American Hospital, İstanbul, Turkey
| | - Erkan Parlak
- Division of Gastroenterology and Hepatology, Sakarya University School of Medicine, Sakarya, Turkey; Division of Gastroenterology and Hepatology, Ankara High Speciality Training and Research Hospital, Ankara, Turkey
| | - Emrah Alper
- Division of Gastroenterology and Hepatology, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - Selçuk Dişibeyaz
- Division of Gastroenterology and Hepatology, Ankara High Speciality Training and Research Hospital, Ankara, Turkey
| | - Bahattin Çiçek
- Division of Gastroenterology and Hepatology, Acıbadem University School of Medicine, İstanbul, Turkey
| | - Bülent Ödemiş
- Division of Gastroenterology and Hepatology, Ankara High Speciality Training and Research Hospital, Ankara, Turkey
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Endoscopic resection of advanced ampullary adenomas: a single-center 14-year retrospective cohort study. Surg Endosc 2018; 33:1180-1188. [PMID: 30167949 PMCID: PMC6430826 DOI: 10.1007/s00464-018-6392-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 08/20/2018] [Indexed: 12/13/2022]
Abstract
Background Endoscopic ampullectomy has been recognized as a safe and reliable means to resect selective tumors of the ampulla of Vater and is associated with lower morbidity and mortality rates compared to surgical resection. Success rates range from 42 to 92%, with recurrences reported in up to 33%. Studies on endoscopic resection of advanced lesions such as those with intraductal extension of adenoma (IEA) and lateral spreading adenomas (LSA) are limited. We aimed to evaluate the technical success, complications, and recurrence of endoscopic resection of ampullary adenomas, including advanced lesions. Methods All patients referred to the Erasmus Medical Center for endoscopic resection of an ampullary lesion were retrospectively identified between 2002 and 2016. Endoscopic success was defined as complete excision of the adenoma, irrespective of the number of attempts, in the absence of recurrence. Results We included 87 patients with a median age of 65 years. Of these, 56 patients (64%) had an adenoma confined to the ampulla (ACA), 20 patients (23%) had an LSA, and 11 patients (13%) were treated for an IEA. The median lesion sizes were 24.6 mm, 41.4 mm, and 16.3 mm, respectively (P < 0.001). Complications occurred in 22 patients (25.3%), of which hemorrhage was most prevalent (12.6%), followed by perforation (8.1%). Complications were equally divided (P = 0.874). The median follow-up duration was 21.1 months (12–45.9) for ACA, 14.7 months (4.2–34.5) for LSA, and 5.8 months (3.7–22.0) for IEA (P = 0.051). Endoscopic resection was curative in 87.5% of patients with an ACA, 85% in patients with an LSA, and in only one patient with an IEA (P < 0.001). Recurrence occurred in 10 patients (11.5%) (P = 0.733). Conclusion Endoscopic ampullectomy is safe and highly successful in selected patients with an adenoma with or without lateral spreading. Outcomes of endoscopic treatment adenomas with an intraductal extension are less favorable and in these cases surgery should be considered.
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Rustagi T, Irani S, Reddy DN, Abu Dayyeh BK, Baron TH, Gostout CJ, Levy MJ, Martin J, Petersen BT, Ross A, Topazian MD. Radiofrequency ablation for intraductal extension of ampullary neoplasms. Gastrointest Endosc 2017; 86:170-176. [PMID: 27866907 DOI: 10.1016/j.gie.2016.11.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 11/02/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Extension of ampullary adenomas into the common bile duct (CBD) or pancreatic duct (PD) may be difficult to treat endoscopically. We evaluated the feasibility, safety, and efficacy of endoscopic radiofrequency ablation (RFA) in the management of ampullary neoplasms with intraductal extension. METHODS This was a multicenter, retrospective analysis of all patients with intraductal extension of ampullary neoplasms treated with endoscopic RFA between February 2012 and June 2015. Treatment success was defined as the absence of detectable intraductal polyps by ductography, visual inspection, and biopsy sampling. RESULTS Fourteen patients with adenoma extension into the CBD (13 ± 7 mm, n = 14) and PD (7 ± 2 mm, n = 3) underwent a median of 1 RFA sessions (range, 1-5). Additional modalities (thermal probes, argon plasma coagulation, and/or photodynamic therapy) were also used in 7 patients, and prophylactic stents were routinely placed. Thirteen assessable patients underwent a median of 2 surveillance ERCPs after completion of treatment over a median follow-up of 16 months (range, 5-46), with intraductal biopsy specimens showing no neoplasm in 12 patients at the conclusion of endoscopic treatment. Treatment success was achieved in 92%, including 100% of those treated with RFA alone. Adverse events occurred in 43% and included ductal strictures (5 patients) and retroduodenal abscess (1 patient), all of which were successfully treated endoscopically. CONCLUSIONS Endoscopic RFA, alone or in combination with other modalities, may effectively treat intraductal extension of ampullary neoplasms. Ductal strictures were common after RFA but responded to endoscopic stent therapy. RFA may be appropriate in selected patients, particularly when the main treatment alternative is pancreaticoduodenectomy.
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Affiliation(s)
- Tarun Rustagi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - D Nageshwar Reddy
- Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Somajiguda, Hyderabad, India
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | | | - Michael J Levy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - John Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Bret T Petersen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Mark D Topazian
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Espinel J, Pinedo E, Ojeda V, Guerra Del Río M. Endoscopic ampullectomy: a technical review. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 108:271-8. [PMID: 27187501 DOI: 10.17235/reed.2016.3867/2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM This article provides a practical review to undertaking safe endoscopic ampullectomy and highlights some of the common difficulties with this technique as well as offering strategies to deal with these challenges. METHODS We conducted a review of studies regarding endoscopic ampullectomy for ampullary neoplasms with special focus on techniques. RESULTS Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. The optimal technique for endoscopic ampullectomy is dependent on the lesions size. En bloc resection is recommended for lesions confined to the papilla. There is no significant evidence to support the submucosal injection before ampullectomy. There is no consensus regarding the optimal current and power output for endoscopic ampulectomy. The benefits of a thermal adjunctive therapy remain controversial. A prophylactic pancreatic stent reduces the incidence and severity of pancreatitis post-ampullectomy. CONCLUSIONS Endoscopic ampullectomy is a safe and efficacious therapeutic procedure for papillary adenomas in experienced endoscopist and it can avoid the need for surgical intervention.
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Affiliation(s)
| | | | - Vanesa Ojeda
- Digestivo, Hospital Universitario Dr. Negrín. Las Palmas de Gran Canaria, España
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Mendonça EQ, Bernardo WM, de Moura EGH, Chaves DM, Kondo A, Pu LZCT, Baracat FI. Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis. Clinics (Sao Paulo) 2016; 71:28-35. [PMID: 26872081 PMCID: PMC4732405 DOI: 10.6061/clinics/2016(01)06] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Accepted: 11/09/2015] [Indexed: 12/16/2022] Open
Abstract
The aim of this study is to address the outcomes of endoscopic resection compared with surgery in the treatment of ampullary adenomas. A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. For this purpose, the Medline, Embase, Cochrane, Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scopus and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were scanned. Studies included patients with ampullary adenomas and data considering endoscopic treatment compared with surgery. The entire analysis was based on a fixed-effects model. Five retrospective cohort studies were selected (466 patients). All five studies (466 patients) had complete primary resection data available and showed a difference that favored surgical treatment (risk difference [RD] = -0.24, 95% confidence interval [CI] = -0.44 to -0.04). Primary success data were identified in all five studies as well. Analysis showed that the surgical approach outperformed endoscopic treatment for this outcome (RD = -0.37, 95% CI = -0.50 to -0.24). Recurrence data were found in all studies (466 patients), with a benefit indicated for surgical treatment (RD = 0.10, 95% CI = -0.01 to 0.19). Three studies (252 patients) presented complication data, but analysis showed no difference between the approaches for this parameter (RD = -0.15, 95% CI = -0.53 to 0.23). Considering complete primary resection, primary success and recurrence outcomes, the surgical approach achieves significantly better results. Regarding complication data, this systematic review concludes that rates are not significantly different.
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Affiliation(s)
- Ernesto Quaresma Mendonça
- Faculdade de Medicina da Universidade de São Paulo, Gastroenterologia, Unidade de Endoscopia Gastrointestinal, São Paulo/SP, Brazil
- corresponding author E-mail:
| | - Wanderley Marques Bernardo
- CEDEM - Centro de Desenvolvimento de Educação Médica, São Paulo/, SP, Brazil
- Brazilian Medical Association - Guidelines Developing, São Paulo/, SP, Brazil
| | | | - Dalton Marques Chaves
- Faculdade de Medicina da Universidade de São Paulo, Gastroenterologia, Unidade de Endoscopia Gastrointestinal, São Paulo/SP, Brazil
| | - André Kondo
- Faculdade de Medicina da Universidade de São Paulo, Gastroenterologia, Unidade de Endoscopia Gastrointestinal, São Paulo/SP, Brazil
| | - Leonardo Zorrón Cheng Tao Pu
- Faculdade de Medicina da Universidade de São Paulo, Gastroenterologia, Unidade de Endoscopia Gastrointestinal, São Paulo/SP, Brazil
| | - Felipe Iankelevich Baracat
- Faculdade de Medicina da Universidade de São Paulo, Gastroenterologia, Unidade de Endoscopia Gastrointestinal, São Paulo/SP, Brazil
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The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2015; 82:773-81. [PMID: 26260385 DOI: 10.1016/j.gie.2015.06.027] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 02/08/2023]
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Espinel J, Pinedo E, Ojeda V, Rio MGD. Endoscopic management of adenomatous ampullary lesions. World J Methodol 2015; 5:127-135. [PMID: 26413485 PMCID: PMC4572025 DOI: 10.5662/wjm.v5.i3.127] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Revised: 03/30/2015] [Accepted: 06/19/2015] [Indexed: 02/06/2023] Open
Abstract
Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.
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Panzeri F, Crippa S, Castelli P, Aleotti F, Pucci A, Partelli S, Zamboni G, Falconi M. Management of ampullary neoplasms: A tailored approach between endoscopy and surgery. World J Gastroenterol 2015; 21:7970-7987. [PMID: 26185369 PMCID: PMC4499340 DOI: 10.3748/wjg.v21.i26.7970] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Revised: 03/27/2015] [Accepted: 05/04/2015] [Indexed: 02/07/2023] Open
Abstract
Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.
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Abstract
INTRODUCTION Benign duodenal and periampullary tumors are uncommon lesions requiring careful attention to their complex anatomic relationships with the major and minor papillae as well as the gastric outlet during surgical intervention. While endoscopy is less morbid than open resection, many lesions are not amenable to endoscopic removal. Robotic surgery offers technical advantages above traditional laparoscopy, and we demonstrate the safety and feasibility of this approach for a variety of duodenal lesions. METHODS We performed a retrospective review of all robotic duodenal resections between April 2010 and December 2013 from two institutions. Demographic, clinicopathologic, and operative details were recorded with special attention to the post-operative course. RESULTS Twenty-six patients underwent robotic duodenal resection for a variety of diagnoses. The majority (88 %) were symptomatic at presentation. Nine patients underwent transduodenal ampullectomy, seven patients underwent duodenal resection, six patients underwent transduodenal resection of a mass, and four patients underwent segmental duodenal resection. Median operative time was 4 h with a median estimated blood loss of 50 cm(3) and no conversions to an open operation. The rate of major Clavien-Dindo grades 3-4 complications was 15 % at post-operative days 30 and 90 without mortality. Final pathology demonstrated a median tumor size of 2.9 cm with a final histologic diagnoses of adenoma (n = 13), neuroendocrine tumor (n = 6), gastrointestinal stromal tumor (GIST) (n = 2), lipoma (n = 2), Brunner's gland hamartoma (n = 1), leiomyoma (n = 1), and gangliocytic paraganglioma (n = 1). CONCLUSION Robotic duodenal resection is safe and feasible for benign and premalignant duodenal tumors not amenable to endoscopic resection.
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Abstract
Introduction Lesions of the ampulla of Vater are rare histological entities with an incidence of between 0.1 and 0.2% of gastrointestinal tumors. Until recently the main response to this kind of lesion was duodenopancreatectomy, regardless of the cellular atypia and local edema. In this study, we propose the application of transduodenal local excision of the ampulla of Vater especially in recognized cases of nonmalignant adenomas. Case presentation In this case report we analyze the case of a 78-year-old Greek man who revealed symptoms such as icterus, abdominal pain without constipation and bloody stools. A physical examination showed painless swelling of the gallbladder (Courvoisier sign). No previous abdominal operations or hernias were identified. Blood tests, computed tomography scan analysis, gastroscopy and endoscopic retrograde cholangiopancreatography along with biopsies and cytological tests diagnosed nonmalignant adenoma of the ampulla of Vater with high-grade dysplasia. The treatment we followed was transduodenal local excision of his ampulla of Vater. Conclusions Transduodenal local excision of the ampulla of Vater has limited side effects and postoperative complications, suggesting this particular technique to be the proper treatment for nonmalignant cases of adenomas.
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Shah KN, Clary BM. Endoscopic and Percutaneous Approaches to the Treatment of Biliary Tract and Primary Liver Tumors. Surg Oncol Clin N Am 2014; 23:207-30. [DOI: 10.1016/j.soc.2013.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Rafiullah, Tanimu S. Adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis. BMJ Case Rep 2014; 2014:bcr-2013-203151. [PMID: 24604802 DOI: 10.1136/bcr-2013-203151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
We report an interesting and rare case of a man with adenomyomatous hyperplasia of the ampulla of Vater presenting as acute pancreatitis, which to our knowledge, is only the second reported case in the English literature. The patient presented with an acute onset of abdominal pain, nausea and vomiting, without fever, chills or rigours. CT of the abdomen revealed changes of acute pancreatitis with a peripancreatic adenopathy, and abdominal ultrasound revealed a slightly hyperechoic and oedematous head of the pancreas, consistent with acute pancreatitis. Endoscopic retrograde cholangiopancreaticography revealed an ampullary lesion. Pathology of the ampullary lesion revealed an inflammatory polyp. Endoscopic ultrasound with endoscopic mucosal resection of the lesion revealed an adenomyomatous hyperplasia. The patient recovered well postendoscopic resection without recurrent pancreatitis or cholestasis.
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Affiliation(s)
- Rafiullah
- Department of Internal Medicine, Saint Clair's Hospital, Weston, Wisconsin, USA
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Askew J, Connor S. Review of the investigation and surgical management of resectable ampullary adenocarcinoma. HPB (Oxford) 2013; 15:829-38. [PMID: 23458317 PMCID: PMC4503279 DOI: 10.1111/hpb.12038] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 11/24/2012] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ampullary adenocarcinoma is considered to have a better prognosis than either pancreatic or bile duct adenocarcinoma. Pancreaticoduodenectomy is associated with significant mortality and morbidity. Some recent publications have advocated the use of endoscopic papillectomy for the treatment of early ampullary adenocarcinoma. This article reviews investigations and surgical treatment options of ampullary tumours. METHODS A systematic review of English-language articles was carried out using an electronic search of the Ovid MEDLINE (from 1996 onwards), PubMed and Cochrane Database of Systematic Reviews databases to identify studies related to the investigation and management of ampullary tumours. RESULTS Distinguishing between ampullary adenoma and adenocarcinoma is challenging given the inaccuracy of endoscopic biopsy, for which high false negative rates of 25-50% have been reported. Endoscopic ultrasound is the most accurate method for local staging of ampullary lesions, but distinguishing between T1 and T2 adenocarcinomas is difficult. Lymph node metastasis occurs early in the disease process; it is lowest for T1 tumours, but the risk is still high at 8-45%. Case reports of successful endoscopic resection and transduodenal ampullectomy of T1 adenocarcinomas have been published, but their duration of follow-up is limited. CONCLUSIONS Optimal staging should be used to distinguish between ampullary adenoma and adenocarcinoma. Pancreaticoduodenectomy remains the treatment of choice for all ampullary adenocarcinomas.
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Affiliation(s)
- James Askew
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
| | - Saxon Connor
- Department of Surgery, Christchurch HospitalChristchurch, New Zealand
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Zhang RC, Xu XW, Wu D, Zhou YC, Ajoodhea H, Chen K, Mou YP. Laparoscopic transduodenal local resection of periampullary neuroendocrine tumor: A case report. World J Gastroenterol 2013; 19:6693-6698. [PMID: 24151401 PMCID: PMC3801388 DOI: 10.3748/wjg.v19.i39.6693] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Revised: 08/30/2013] [Accepted: 09/05/2013] [Indexed: 02/06/2023] Open
Abstract
Studies on laparoscopic transduodenal local resection have not been readily available. Only three cases have been reported in the English-language literature. We describe herein a case of 25-year-old woman with periampullary neuroendocrine tumor (NET). Endoscopic ultrasonography revealed a duodenal papilla mass originated from the submucosa and close to the ampulla. The periampullary tumor was successfully managed with laparoscopic transduodenal local resection without any procedure-related complications. Pathological examination showed a NET (Grade 2) with negative margin. The patient was followed up for six months without signs of recurrence. This case suggests that laparoscopic transduodenal local resection is a feasible procedure in selected patients with periampullary tumor.
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Hoshino A, Nakamura Y, Suzuki H, Mizutani S, Ishii H, Watanabe M, Bou H, Yoshino M, Komine O, Uchida E. Adenocarcinoma of the minor duodenal papilla: report of a case. J NIPPON MED SCH 2013; 80:165-70. [PMID: 23657071 DOI: 10.1272/jnms.80.165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We report a rare case of adenocarcinoma of the minor papilla of the duodenum treated with transduodenal minor papillectomy. A 64-year-old woman was treated for an asymptomatic duodenal tumor detected on gastroduodenoscopy. Endoscopy showed a 15-mm sessile mass in the descending duodenum proximal to the major papilla. The major papilla was a villous 24-mm-diameter polypoid tumor. Histopathologic examination of the biopsy specimen showed tubular adenoma with moderate epithelial atypia. Transduodenal major and minor papillectomies were performed. The orifice of the duct of Santorini and the pancreatic duct were re-approximated to the duodenal wall to prevent acute pancreatitis caused by scarring and stenosis of the duct orifice. Histological findings were consistent with well-differentiated adenocarcinoma limited to the minor duodenal papilla, without infiltration of the duodenal wall submucosa, and confirmed complete resection. The patient had an uneventful postoperative course and has remained asymptomatic, without evidence of tumor recurrence or stenosis of the pancreatic duct orifice, for 4 years.
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Affiliation(s)
- Arichika Hoshino
- Institute of Gastroenterology, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Kanagawa, Japan.
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Meyer J, Rossetti A, Scheffler M, Morel P, Majno P. Ampullectomy for an unexpected ampullary hamartoma in a heterotaxic patient. Int J Surg Case Rep 2013; 4:544-546. [PMID: 23608516 PMCID: PMC3650259 DOI: 10.1016/j.ijscr.2013.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 03/01/2013] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Heterotaxy designates rare congenital disorders of organ positioning in the thoracic and abdominal cavities, which can be associated with numerous anomalies, complicating the surgical management because of the loss of conventional anatomic landmarks. PRESENTATION OF CASE A 72-year-old man was found to have asymptomatic cholestasis. Further workup included computed tomography and magnetic resonance cholangiopancreatography that revealed anomalies of lateralization of digestive organs associated with intestinal malrotation and polysplenia, and a stone-like element in the main bile duct. Endoscopic retrograde cholangiopancreatography failed to extract the lesion. Laparotomy found no stone, but a polypoid tumor with ampullary implantation. Pancreaticoduodenectomy was judged unreasonable due to the presence of macroscopic cirrhosis and a complete ampullectomy was performed. Histopathological examination revealed a hamartomatous polyp. DISCUSSION The unusual angle of the duodenoscope in a left-sided duodenum may have contributed to the improper pre-operative diagnosis. Endosonography could have recognized the tissular origin of the lesion and prompted a more detailed preoperative planning. It was fortunate that the patient ended up receiving the appropriate treatment despite the absence of an adequate pre-operative diagnosis, as the option of performing an extended resection was ruled out due to the presence of cirrhosis. CONCLUSION Although heterotaxy leads to increased technical difficulties in performing usual endoscopic and surgical procedures, it can be safely managed by experienced surgeons as illustrated by the present case. Imaging modalities have limited sensitivity in the diagnosis of small ampullary tumors. As false-negatives are likely to occur, this possibility should guide the choice of the best operation.
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Affiliation(s)
- Jeremy Meyer
- Divisions of Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, SwitzerlandDivisions of Visceral and Transplantation Surgery, University Hospitals of GenevaRue Gabrielle-Perret-Gentil 4Genève 141211Switzerland
| | - Andrea Rossetti
- Divisions of Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, SwitzerlandDivisions of Visceral and Transplantation Surgery, University Hospitals of GenevaRue Gabrielle-Perret-Gentil 4Genève 141211Switzerland
| | - Max Scheffler
- Division of Radiology, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, SwitzerlandDivision of Radiology, University Hospitals of GenevaRue Gabrielle-Perret-Gentil 4Genève 141211Switzerland
| | - Philippe Morel
- Divisions of Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, SwitzerlandDivisions of Visceral and Transplantation Surgery, University Hospitals of GenevaRue Gabrielle-Perret-Gentil 4Genève 141211Switzerland
| | - Pietro Majno
- Divisions of Visceral and Transplantation Surgery, University Hospitals of Geneva, Rue Gabrielle-Perret-Gentil 4, 1211 Genève 14, SwitzerlandDivisions of Visceral and Transplantation Surgery, University Hospitals of GenevaRue Gabrielle-Perret-Gentil 4Genève 141211Switzerland
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Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg 2013; 257:315-22. [PMID: 23059497 DOI: 10.1097/sla.0b013e318269d010] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). BACKGROUND The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. METHODS Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. RESULTS After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. CONCLUSIONS In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.
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Azih LC, Broussard BL, Phadnis MA, Heslin MJ, Eloubeidi MA, Varadarajulu S, Arnoletti JP. Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas. World J Gastroenterol 2013; 19:511-5. [PMID: 23382629 PMCID: PMC3558574 DOI: 10.3748/wjg.v19.i4.511] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2012] [Revised: 09/28/2012] [Accepted: 10/22/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate endoscopic ultrasound (EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.
METHODS: Records of 111 patients seen at our institution from November 1999 to July 2011 with the post-operative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed. Records of patients who underwent preoperative EUS for diagnostic purposes were identified. The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results. In addition, the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome (recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded, compared and analyzed.
RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions. In addition, computed tomography was performed in 18 patients, endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients. There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis (FAP)/other polyposis syndromes. In 38 (81%, P < 0.05) patients, EUS reliably identified absence of submucosal and muscularis invasion. In 4 cases, EUS underestimated submucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90% (P < 0.05). Types of resection performed included endoscopic resection in 22 cases, partial duodenectomy in 9 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 8), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2). Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intra-abdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. After median follow-up of 20 mo there were 6 local recurrences (13%, median follow-up = 20 mo) 4 of which were in patients with FAP.
CONCLUSION: EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection.
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Heinzow HS, Meister T, Domagk D. Endoskopische Papillenresektion: Indikation und Grenzen. Visc Med 2012. [DOI: 10.1159/000345869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
<b><i>Hintergrund: </i></b>Adenome der Papilla Vateri sind selten. Prävalenzen von 0,04–0,12% werden beschrieben. Eine maligne Transformation von benignen Adenomen zu Papillenkarzinomen ist möglich und folgt der Adenom-Karzinom-Sequenz. Die meisten Papillenadenome treten sporadisch auf, können jedoch z.B. bei Patienten mit familiärer adenomatöser Polyposis genetisch häufiger vorkommen. <b><i>Methode: </i></b>Es erfolgte eine aktuelle PubMed-Recherche zum Thema endoskopische Papillenresektion. <b><i>Ergebnisse/Schlussfolgerung: </i></b>Eine endoskopische Papillektomie kann bei Adenomen ohne duktale Infiltration durchgeführt werden, während es in Hinblick auf das papilläre Adenokarzinom noch keinen Konsens gibt. Jedoch konnten neuere Studien zeigen, dass Patienten mit hochgradiger intraepithelialer Neoplasie der Papilla Vateri keine lymphovaskuläre Invasion oder Lymphknotenmetastasen aufweisen, sodass eine endoskopische Papillektomie gerechtfertigt erscheint. Da papilläre Adenome in bis zu 30% der Fälle das Risiko für fokale karzinomatöse Areale beherbergen können, sollte jede Papillektomie «en bloc» durchgeführt werden.
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Kim J, Choi SH, Choi DW, Heo JS, Jang KT. Role of transduodenal ampullectomy for tumors of the ampulla of Vater. JOURNAL OF THE KOREAN SURGICAL SOCIETY 2011; 81:250-6. [PMID: 22111080 PMCID: PMC3219850 DOI: 10.4174/jkss.2011.81.4.250] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 06/07/2011] [Accepted: 06/27/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE Tumors arising from the ampulla of Vater can be benign or malignant. Recently, endoscopic papillectomy has been employed in the management of benign ampulla of Vater tumors; however, surgical resection is the treatment of choice. The aim of this study was to define indications and suggest a role for transduodenal ampullectomy in the management of ampulla of Vater tumors. METHODS We retrospectively reviewed the medical records of 54 patients treated for ampulla of Vater tumors between January 1999 and December 2008. RESULTS Twenty-two endoscopic papillectomies and 21 transduodenal ampullectomies were performed. Four patients underwent transduodenal ampullectomy after endoscopic papillectomy due to a recurrent or remnant tumor. Recurrence or a remnant tumor was found in one patient after transduodenal ampullectomy compared to six patients after endoscopic papillectomy. Immediate intraoperative conversion from transduodenal ampullectomy to pancreaticoduodenectomy was performed in five patients based on intraoperative frozen biopsy analysis. CONCLUSION Transduodenal ampullectomy should be performed to treat ampulla of Vater tumors that are unsuitable for endoscopic papillectomy. Transduodenal ampullectomy can serve as an intermediate treatment option between endoscopic papillectomy and pancreaticoduodenectomy in the management of ampulla of Vater tumors.
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Affiliation(s)
- Jieun Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Ho Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Wook Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Seok Heo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kee-Taek Jang
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Parc Y, Mabrut JY, Shields C. Surgical management of the duodenal manifestations of familial adenomatous polyposis. Br J Surg 2011; 98:480-4. [PMID: 21656714 DOI: 10.1002/bjs.7374] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2010] [Indexed: 01/13/2023]
Abstract
BACKGROUND Duodenal adenomas develop in patients with familial adenomatous polyposis, incurring a risk of carcinoma. When this risk is high, surgery is indicated. The choice of surgical treatment can be difficult as evidence-based data are lacking. METHODS This is a systematic review of the literature on the non-medical management of duodenal lesions arising in the setting of familial adenomatous polyposis. Studies were identified through searching MEDLINE. Studies published between January 1965 and October 2009 were included. Data regarding number of subjects, complications, length of follow-up, recurrence rate and outcome were extracted. RESULTS Transduodenal resection does not differ from an endoscopic approach in terms of recurrence. Ampullectomy has limited application as only papillary lesions are amenable to treatment in this manner. Duodenectomy with pancreas preservation is preferable to pancreaticoduodenectomy unless malignancy is present, or cannot be excluded. CONCLUSION Surgery should be reserved for advanced or malignant polyps.
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Affiliation(s)
- Y Parc
- Department of Digestive Surgery, Hôpital Saint-Antoine, Université Pierre et Marie Curie, Paris, France.
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Shiba H, Misawa T, Wakiyama S, Iida T, Ishida Y, Yanaga K. Pedunculated early ampullary carcinoma treated by ampullectomy: report of a case. J Gastrointest Cancer 2010; 41:138-40. [PMID: 20012229 DOI: 10.1007/s12029-009-9099-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
CASE REPORT A 30-year-old woman was admitted to our hospital for treatment of an ampullary tumor. Upper gastrointestinal endoscopy revealed a pedunculated tumor in the ampulla of Vater with a diameter of 50 mm, which was biopsied and diagnosed as tubulovillous adenoma with moderate atypia. Endoscopic ultrasonography demonstrated a hypoechoic tumor limited to the mucosa and without evidence of lymph node metastasis. Since endoscopic resection was not indicated because of the large size and pedunculated morphology with a long stalk, the patient underwent ampullectomy and papilloplasty. Histological examination revealed well-differentiated tubular adenocarcinoma in tubular adenoma with severe atypia limited to the mucosa. The patient remains well with no evidence of recurrence 10 months after resection. DISCUSSION Ampullectomy is an established method for ampullary tumor, but such a tumor with a long stalk is rare.
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Affiliation(s)
- Hiroaki Shiba
- Department of Surgery, Jikei University School of Medicine, 3-25-8, Nishi-Shinbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Ahn KS, Han HS, Yoon YS, Cho JY, Khalikulov K. Laparoscopic transduodenal ampullectomy for benign ampullary tumors. J Laparoendosc Adv Surg Tech A 2010; 20:59-63. [PMID: 19792863 DOI: 10.1089/lap.2009.0243] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Transduodenal ampullectomy (TDA) can be performed for benign and premalignant tumors of the ampulla of Vater (AOV) as an alternative to pancreaticoduodenectomy. However, the laparoscopic approach has rarely been attempted. In this report 2 cases of benign ampullary tumor that were treated by totally laparoscopic TDA. PATIENTS AND METHODS Case 1 was of a 75-year-old female who was admitted with left knee pain and underwent arthroscopic debridement. On postoperative day 6, she showed elevated levels of alkaline phosphatase, aspirate aminotransferase, alanine transaminase, and gamma-glutamyl transpeptidase, without any other laboratory test abnormality. She had no complaint of abdominal pain, and physical examinations were unremarkable. Computed tomography (CT), magnetic resonance cholangiography (MRCP), and endoscopy revealed a 2-cm-sized polypoid mass at the AOV. Subsequent endoscopic biopsy showed a pathologic finding of tubular adenoma. Case 2 was of a 55-year-old man who was admitted with an duodenal mass incidentally detected by screening endoscopy in a community hospital. Abdominal CT, endoscopy, and endoscopic ultrasonography revealed a 2.5-cm-sized tumor located at the duodenal papilla with possible extension to the ampullary sphincter. Endoscopic biopsy revealed gangliocytic paraganglioma. Both patients underwent laparoscopic transduodenal ampullectomy. RESULTS Operative times were 200 and 250 minutes, respectively, and estimated blood loss during both operations was about 50 mL. Patients were discharged on the postoperative days 9 and 8, respectively, without any complication. Postoperative histologic examinations revealed tubular adenoma with low-grade dysplasia in 1 patient and gangliocystic paraganglioma in the other. CONCLUSIONS These 2 cases demonstrate that laparoscopic TDA is a feasible operative procedure in selective patients with a benign or premalignant tumor at the AOV.
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Affiliation(s)
- Keun Soo Ahn
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam-si, Bundang-gu, Korea
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Wiedmann M, Witzigmann H, Mössner J. Malignant Tumors. CLINICAL HEPATOLOGY 2010:1519-1566. [DOI: 10.1007/978-3-642-04519-6_62] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Irani S, Arai A, Ayub K, Biehl T, Brandabur JJ, Dorer R, Gluck M, Jiranek G, Patterson D, Schembre D, Traverso LW, Kozarek RA. Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period. Gastrointest Endosc 2009; 70:923-932. [PMID: 19608181 DOI: 10.1016/j.gie.2009.04.015] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 04/10/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified. OBJECTIVE To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions. DESIGN A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database. SETTING Tertiary referral center. PATIENTS One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007. INTERVENTIONS Endoscopic management of ampullary lesions. MAIN OUTCOME MEASUREMENTS The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients. RESULTS One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts. CONCLUSIONS Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.
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Affiliation(s)
- Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, USA
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Kim JH, Kim JH, Han JH, Yoo BM, Kim MW, Kim WH. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol 2009; 16:2547-54. [PMID: 19568817 DOI: 10.1245/s10434-009-0509-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2009] [Revised: 04/16/2009] [Accepted: 04/16/2009] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study was designed to provide safe management guidelines for ampullary adenoma by analysis of clinicopathological features. BACKGROUND The treatment of ampullary cancer has been established; however, the indications for treatment of ampullary adenoma remain controversial. METHODS Between July 1997 and July 2008, a total of 33 patients were diagnosed with ampullary adenoma prior to procedures: 20 endoscopic papillectomies (ESP), 5 transduodenal resections (TDR), and 8 pancreatoduodenectomies (PD). RESULTS The false-negative rate of biopsy for cancer was 27.5% (8/29). Coexistence of cancer in patients with pre-high-grade dysplasia (HGD) was 50.0% (5/10), whereas it was 15.7% in pre-low-grade dysplasia (LGD). In addition, the rate of recurrence was 80% (8/10) in patients with pre-HGD. The size of tumor by final pathology was 1.27 +/- 0.89 cm in LGD, 1.81 +/- 0.99 cm in HGD, and 1.98 +/- 1.08 cm in cancer group. There was a significant correlation between size of tumor and final pathology (P = 0.036). According to receiver operating characteristic (ROC) curve, criterion to predict HGD/cancer was tumor size larger than 1.5 cm; sensitivity and specificity were 55.6% and 80.0%, respectively, and likelihood ratio was 2.778. However, size of tumor was not associated with preprocedural pathology. CONCLUSIONS Ampullary adenoma with preprocedural HGD was highly associated with coexistence of cancer and recurrence. Moreover, most of large tumors were treated by surgical procedures and proved to be cancer. Therefore, we suggest that ampullary adenoma with preprocedural HGD or more than 1.5 cm should not be managed with endoscopic papillectomy due to high associated rates of recurrence.
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Affiliation(s)
- Ji Hun Kim
- Departments of Surgery, School of Medicine, Ajou University, Suwon, Korea
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Woo SM, Ryu JK, Lee SH, Lee WJ, Hwang JH, Yoo JW, Park JK, Kang GH, Kim YT, Yoon YB. Feasibility of endoscopic papillectomy in early stage ampulla of Vater cancer. J Gastroenterol Hepatol 2009; 24:120-4. [PMID: 19032444 DOI: 10.1111/j.1440-1746.2008.05578.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Although endoscopic papillectomy has been attempted in early stage ampullary cancer (pTis, T1), its curative role and indications remain uncertain. The present study was designed to assess the factors that predict malignancy and lymph node metastasis and to suggest potential indications for endoscopic papillectomy by analyzing clinicopathological data. METHODS We performed a retrospective analysis of clinical and histopathological data of 216 patients with ampullary cancer between 1991 and 2006. RESULTS No tumor in pTis stage had metastasized to lymph nodes and only 9% of tumors in pT1 had metastasized. Tumor size (P = 0.018), depth of invasion (P = 0.021) and venous invasion (P = 0.014) were found to be significantly related to lymph node metastasis. Cases with early stage ampullary cancer of less than 2 cm with a well-differentiated histology and no angiolymphatic invasion (n = 13) showed no lymph node metastasis and no recurrence during a median follow up of 35.9 months. CONCLUSION Endoscopic papillectomy can be adopted as a viable alternative to surgery in patients with early stage ampullary cancer of less than 2 cm in size and with a well-differentiated histology. When a resected specimen has a well-differentiated histology, and there is no resection margin involvement and no angiolymphatic invasion, our findings indicate that subsequent radical surgery is unnecessary.
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Affiliation(s)
- Sang Myung Woo
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Kim JK, Hwang HK, Park JS, Cho SI, Yoon DS, Chi HS. Left hemihepatectomy and caudate lobectomy and complete extrahepatic bile duct resection using transduodenal approach for hilar cholangiocarcinoma arsing from biliary papillomatosis. J Surg Oncol 2008; 98:139-42. [PMID: 18521837 DOI: 10.1002/jso.21089] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Biliary papillomatosis (BP) is a rare disease characterized by multiple papillary lesions of variable distribution and extent in the intra and extrahepatic bile duct. Hepatopancreatoduodenectomy (HPD) can be indicated for the resection of diffuse intra and extrahepatic BP that extended to the distal bile duct and ampullary region. The mortality rate for HPD has recently decreased but HPD still has a high morbidity rate. In this study, we present a safe procedure for concomitant intrahepatic and extrahepatic BP. PATIENTS AND METHODS Preoperative studies showed showed multiple, variable-sized, and nodular papillary masses with mucin in the left intrahepatic ducts, confluence of the right and left hepatic ducts, common hepatic duct, and whole CBD, but peripheral to the right intrahepatic bile ducts were grossly well preserved. We underwent Lt. hepatectomy and the common bile duct and ampulla of Vater were completely resected with transduodenal approach and the pancreatic duct was repositioned to the duodenal mucosa. CONCLUSIONS Major hepatic resection and transduodenal approach for complete bile duct resection and pancreatic duct repositioning could be an acceptable therapeutic option for concomitant intrahepatic and extrahepatic biliary papillomatosis without the evidence of pancreatic duct involvement in the patients with severe comorbidity.
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Affiliation(s)
- Jae Keun Kim
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
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Barauskas G, Gulbinas A, Pranys D, Dambrauskas Z, Pundzius J. Tumor-related factors and patient's age influence survival after resection for ampullary adenocarcinoma. JOURNAL OF HEPATO-BILIARY-PANCREATIC SURGERY 2008; 15:423-428. [PMID: 18670845 DOI: 10.1007/s00534-007-1313-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Accepted: 10/01/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND/PURPOSE The majority of surgeons agree that ampullary adenocarcinoma should be removed by partial pancreatoduodenectomy. Favoring extended resection, based on the uncertainty of the preoperative diagnosis and the higher probability of clear resection margins, we aimed to disclose the results of this surgical procedure in terms of postoperative morbidity and mortality, and to identify prognosticators of long-term survival. METHODS We documented, prospectively, 25 consecutive patients with adenocarcinoma of the papilla of Vater in whom pylorus-preserving pancreatoduodenectomy was performed. Clinical data, pathology reports, International Union Against Cancer (UICC) tumor stage, postoperative morbidity, mortality, and long-term follow-up results were evaluated. The Kaplan-Meier method and log-rank test were applied for univariate analysis. The Cox proportional hazard model was used for multivariate analysis. RESULTS Postoperative mortality was 4%, overall morbidity was 32%, and pancreas-associated morbidity was 8%. Mean survival time was 53.8 months. Tumor size, N status, UICC stage, lymphatic invasion, blood vessel infiltration, R0 resection, and age of patient at the cutoff of 70 years were independent predictors of survival on univariate analysis. Multivariate analysis, however, disclosed no independent predictors of prognosis. CONCLUSIONS Pancreatoduodenectomy for ampullary carcinoma is reasonable in terms of postoperative morbidity and mortality. Tumor-related factors, R0 resection, and advanced age appeared as the main predictors of survival.
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Affiliation(s)
- Giedrius Barauskas
- Department of Surgery, Kaunas University of Medicine Hospital, LT 50009, Kaunas, Lithuania
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Abstract
Primary small bowel neoplasms (PSBN) are uncommon, accounting for less than 15 per cent of all gastrointestinal tumors. Benign duodenal neoplasms (BDN) are rare, comprising only 10 to 20 per cent of all PSBN. The treatment is generally surgical resection ranging from local excision to pancreaticoduodenectomy depending on size, location, and number of lesions. Patients undergoing surgical treatment for BDN at Vanderbilt University Medical Center from July 1984 to April 2006, were identified and reviewed retrospectively. Medical records were examined for demographics, operative details, results, and complications. Twenty-six patients were identified of which 56 per cent were male and the mean age was 56 ± 14 years. Lesions were found throughout the duodenum, but the majority (62%) were ampullary. Nearly 75 per cent were adenomas, including over half with dysplasia. Operative interventions and complication rates were: duodenal resection with primary anastomosis (n = 3, 0%), local excision (n = 6, 50%), ampullary resection (n = 10, 30%), and pancreaticoduodenectomy (n = 7, 86%). There were no reoperations or mortalities. Mean followup was 14 months. BDN are an increasingly common problem in an era of frequent use of upper endoscopy. The surgical management of these lesions must be tailored to their size, number, location, and malignant potential. A wide variety of surgical procedures can be performed with acceptable morbidity.
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Affiliation(s)
- Clinton D. Kemp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert T. Russell
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kenneth W. Sharp
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Adler DG, Qureshi W, Davila R, Gan SI, Lichtenstein D, Rajan E, Shen B, Zuckerman MJ, Fanelli RD, Van Guilder T, Baron TH. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2006; 64:849-54. [PMID: 17140885 DOI: 10.1016/j.gie.2006.08.044] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Demetriades H, Zacharakis E, Kirou I, Pramateftakis MG, Sapidis N, Kanellos I, Betsis D. Local excision as a treatment for tumors of ampulla of Vater. World J Surg Oncol 2006; 4:14. [PMID: 16524478 PMCID: PMC1421403 DOI: 10.1186/1477-7819-4-14] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2005] [Accepted: 03/08/2006] [Indexed: 12/12/2022] Open
Abstract
Background Although local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience. Methods From 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6–180) months. Results The combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence. Conclusion In our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(<2 cm), pT1, well differentiated ampullary tumours without nodal involvement.
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Affiliation(s)
- Haralampos Demetriades
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Emmanouil Zacharakis
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Ioanna Kirou
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Manousos-Georgios Pramateftakis
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Nikolaos Sapidis
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Ioannis Kanellos
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
| | - Dimitrios Betsis
- 4Surgical Department. Aristotle University of Thessaloniki, 'G. Papanikolaou' General Hospital, Exohi, Thessaloniki 57010, Greece
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Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006; 63:292-301. [PMID: 16427938 DOI: 10.1016/j.gie.2005.07.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2005] [Accepted: 07/11/2005] [Indexed: 12/24/2022]
Affiliation(s)
- Jimin Han
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Kim RD, Kundhal PS, McGilvray ID, Cattral MS, Taylor B, Langer B, Grant DR, Zogopoulos G, Shah SA, Greig PD, Gallinger S. Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma. J Am Coll Surg 2005; 202:112-9. [PMID: 16377504 DOI: 10.1016/j.jamcollsurg.2005.08.002] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2005] [Revised: 08/01/2005] [Accepted: 08/01/2005] [Indexed: 01/05/2023]
Abstract
BACKGROUND Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma. STUDY DESIGN We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival. RESULTS Forty-three patients (24 men) aged 63.7 +/- 11.4 years (standard deviation) were followed for a mean of 23.9 months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival. CONCLUSIONS Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question.
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Affiliation(s)
- Robin D Kim
- Department of Surgery, Toronto General Hospital, University Health Network, Ontario, Canada
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Abstract
Most ampullary adenomas (80%) are common benign ampullary tumors; however, they can range from mild dysplasia to high-grade dysplasia to invasive carcinoma. They are considered premalignant lesions found in the setting of familial polyposis syndromes or found sporadically, usually manifested by vague abdominal pain, liver enzyme elevation, jaundice, recurrent pancreatitis, or with uncommon symptoms such as gastrointestinal bleeding or duodenal obstruction. Endoscopic retrograde cholangiopancreatography with biopsy is a minimally invasive technique used to visualize these tumors directly and to evaluate their histologic characteristics. Definitive treatment primarily depends on these histologic results. Local resection has a high rate of recurrence (5% to 30%) and requires postoperative endoscopic surveillance, which is the reason it is not considered as a first choice in the management of ampullary tumors. The operative mortality is 10% or less for pancreaticoduodenectomy, a procedure of choice at most experienced centers for frank carcinoma, foci papillary adenocarcinoma in pre-excisional biopsies, or high-grade dysplasia ampullary adenomas. Endoscopic interventions for presumed benign ampullary adenomas have resolved symptoms of obstruction, but long-term follow up is necessary to detect early malignant transformation. In summary, the choice of treatment depends on level of surgical skill available, patient tolerance of long-term endoscopic surveillance versus radical surgery, and the presence or absence of coexisting familial adenomatous polyposis.
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Affiliation(s)
- Tin C Tran
- Department of Surgery, University of Louisville School of Medicine, and the Norton Healthcare Center for Advanced Surgical Technologies, Louisville, KY 40292, USA
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