Abstract
Background: Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Since hybrid endoscopic submucosal dissection (ESD) had been established as an alternative option for relatively large and difficult gastrointestinal tumors, we evaluated a novel EP with hybrid ESD (hybrid ESD-EP) for curative safe margin in this proof-of-concept study. Methods: A total of eight cases who underwent hybrid ESD-EP between 2018 and 2020 were identified from our prospectively maintained database. Hybrid ESD-EP involved a (sub)circumferential incision with partial submucosal dissection, and subsequent snare resection of ampullary tumors, which was performed by two endoscopists with expertise in ESD or endoscopic retrograde cholangiopancreatography. Demographic data and clinicopathological outcomes were retrospectively evaluated. Results: En bloc resection was achieved by hybrid ESD-EP in all eight cases, with the median procedure time of 112 (range: 65–170) minutes. The median diameters of the resected specimens and tumors were 18 and 12 mm, respectively. All lateral margins were clear, whereas vertical margin was uncertain in three (38%), resulting in the complete resection rate of 63%. Postoperative bleeding and pancreatitis developed in each one (13%). No tumor recurrence was observed even in those cases with uncertain vertical margin, after a median follow-up of 244 (range, 97–678) days. Conclusions: Hybrid ESD-EP seems to be feasible and promising in ensuring the lateral resection margin. However, further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required.
Highlights
Ampullary adenomas, which occur sporadically or in the setting of familial adenomatous polyposis, have malignant potential, and complete resection should be considered [1]
In this proof-of-concept study, we aimed to describe technical tips of hybrid endoscopic submucosal dissection (ESD)-Endoscopic papillectomy (EP) and to investigate its clinical outcomes in patients with ampullary tumors
Low grade adenoma Low grade adenoma Low grade adenoma Low grade adenoma Low grade adenoma Low grade adenoma Low grade adenoma Low grade adenoma. This preliminary proof-of-concept case series demonstrated the feasibility of novel hybrid ESD-EP, which involved acircumferential incision with partial submucosal dissection and subsequent snare resection, for ampullary adenoma
Summary
Ampullary adenomas, which occur sporadically or in the setting of familial adenomatous polyposis, have malignant potential, and complete resection should be considered [1]. In addition to the risk of adverse events (AEs) such as bleeding and pancreatitis, a curative resection rate with clear tumor margin is limited to 87.1%, and local recurrence can occur in up to 11.8% of patients [4]. Because most of the submucosal dissection can be replaced by snare resection in hybrid ESD, it may decrease the risk of perforation as well as the procedure time. Based on these findings, we conceived novel EP with hybrid ESD (hybrid ESD-EP) for ampullary tumors to maximize the chance of complete resection, especially a lateral margin, without increasing AEs. Endoscopic papillectomy (EP) carries a potential risk of procedure-related adverse events and incomplete resection. Further investigations, especially to secure the vertical margin and to shorten the procedure time, should be required
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