Pathogenesis of urticaria in autoimmune gastritis

Abstract

Background: Surgery is considered treatment of choice of papillary adenomas. However, morbidity and mortality is high after Whipple's operation and local resection may be associated with recurrence. Literature on endoscopic treatment is scanty and mostly involved laser coagulation, which precludes histological examination. Aim: To evaluate the results of endoscopic snare resection (papillectomy) of benign papillary tumors. Methods: Papillectomy was performed using a therapeutic duodenoscope and a monofilament snare with cutting current. Sessile lesions were excised by piecemeal resection, small remnants were coagulated. A 7 F pancreatic stent was placed to prevent pancreatitis and removed when follow-up endoscopy showed complete resection. Benign recurrences were re-treated. Patients with invasive carcinoma (CA) and those with intraductal growth not amenable for endoscopy were operated. Results: From 2/85 to 8/99, 57 pts, 40 f, 17 m, median age 73 yrs (31-93) underwent papillectomy. Median size of the adenomas was I cm (0.5-6). Median no. of sessions was I (1-4). 24 pts were treated by snare resection alone, additional coagulation was used in 33. Complications were severe pancreatitis in I and mild pancreatitis in 5 pts, all managed conservatively, and bleeding in 7 pts managed endoscopically during the treatment session. There was no delayed bleeding. Histology was adenoma (45), hyperplastic/inflammatory (10), lymphangioma (I) and invasive CA (I). 40 adenomas had mild! moderate dysplasia, 5 had severe dysplasia. The pt with CA, I pt with severe dysplasia and I pt with intraductal growth underwent subsequent surgery. Over a median follow-up of 24 mos (r:0-159), 12 pts (21%) had a benign recurrence. 3 underwent surgery, Ipt died of apoplexia after 6 mos without further therapy and 8 were managed endoscopically. Among these, complete removal was achieved in 6, 2 inoperable pts with intraductal growth are also managed by stenting. Intraductal growth was present in II pts. Of these, 10 were managed endoscopically (resection: 7, stenting: 3) and I underwent surgery. 3 pts refused endoscopic controls and are well at 42, 98 and 107 rnos, 2 pts were lost to follow-up and 3 died of unrelated disease. All other pts are well without recurrence or malignancy. Overall, 88% were treated by endoscopy only. Conclusions: Endoscopic papillectomy can be performed safely with a low complication rate. The high recurrence rate warrants regular endoscopic controls. In this study, only 12% of the pts ultimately required surgery.