S0908 Outcomes of Endoscopic vs Surgical Approach for Ampullary Adenoma: A Systematic Review and Meta-Analysis

Abstract

INTRODUCTION: Ampullary adenomas (AA) form an uncommon group of gastrointestinal neoplasms that are can be incidentally discovered on a routine upper GI endoscopy. These lesions have traditionally necessitated a pancreatoduodenectomy or a transduodenal surgical ampullectomy (SA), which entail considerable morbidity. In recent years, endoscopic ampullectomy (EA) has surged as an alternative in periampullary neoplasms however, data about rates of successful resection, complication and long-term recurrence rates is sparse. METHODS: We searched Medline and Embase databases up to May 30, 2020, to identify RCTs and observational studies evaluating the efficacy and safety of endoscopic vs surgical approach for patients with AA. The outcomes of interest were complete primary resection, primary success, recurrence, complications, length of stay and mortality. Odds ratios (ORs) and standard mean difference were calculated for categorical and continuous variables, respectively. Meta-analysis was performed using the Random effects model in Revman 5.3. RESULTS: Ten retrospective cohort studies were selected (728 patients). Majority of studies had complete primary resection and primary success data available, which showed a difference that slightly favored surgical treatment (OR 0.15 CI [0.05–0.45], I2 = 46%) and (OR 0.14 CI [0.05–0.40], I2 = 24%) respectively. Recurrence data indicated a statically significant odd’s ratio of having recurrence with endoscopy (OR 3.22 CI [1.65–6.28], I2 = 1%). Median follow-up period was variable ranging from 8 to 38 months for EA group vs 15 to 48 months for SA group. Postoperative complications were less common after EA vs SA (OR 0.35 CI [0.16 to 0.75], I2 = 59%), mainly hemorrhage and pancreatitis in both groups, and wound dehiscence/infection and leak in the SA group. Only five studies included data about length of stay of patients with ranges between 0 and 8.5 days for EA vs 9.5–20 days for SA, however no reported SD thus analysis was not feasible. Only 3 studies (314 patients) compared mortality rates (1 patient in EA vs 3 patients in SA). CONCLUSION: EA is a less invasive technique associated with lower morbidity and improved LOS compared to conventional surgery, however, has a higher chance of recurrence and lower successful papillectomy rates. With the presence of high heterogeneity among studies and the lack of a randomized trials, further studies are required to evaluate long-term outcomes with EA and the need for post endoscopy surveillance to assess for recurrence.Figure 1.: A. Complete primary resection. B. primary success.Figure 2.: C. Recurrence. D. Complications.Figure 3.: Length of stay in endoscopy vs surgery group.