Endoscopic Snare Papillectomy Research Articles

Long-term Outcomes of Endoscopic Intraductal Radiofrequency Ablation for Ampullary Adenoma with Intraductal Extension after Endoscopic Snare Papillectomy.

There are limitations in treating ampullary adenomas with intraductal extension using conventional endoscopic modalities. Endoscopic intraductal radiofrequency ablation (ID-RFA) may be useful for treating intraductal (common bile duct [CBD] and/or pancreatic duct [PD]) extensions of ampullary adenomas, but long-term data are lacking. We thus evaluated the long-term outcomes of endoscopic ID-RFA for managing ampullary adenomas with intraductal extension. Prospectively collected endoscopic ID-RFA database at Asan Medical Center was reviewed to identify consecutive patients with ampullary adenoma who underwent ID-RFA for intraductal extension between January 2018 and August 2021. Technical success, short-term and long-term clinical success, and adverse events were evaluated. A total of 29 patients (14 CBD, 1 PD, and 14 CBD and PD) were analyzed. All patients had undergone endoscopic snare papillectomy prior to ID-RFA. A median of one session of ID-RFA (range, 1 to 3) for residual or relapsed intraductal extension of ampullary adenoma were successfully performed (technical success=100%). Both biliary and pancreatic stenting were routinely performed after ID-RFA to prevent ductal stricture. After a median follow-up of 776 days (interquartile range, 470 to 984 days), the short-term and long-term clinical success rates were 93% and 76%, respectively. Seven patients experienced procedural adverse events and three patients developed ductal strictures. Endoscopic ID-RFA showed good long-term outcomes in treating residual or relapsed ampullary adenomas with intraductal extension. Repeated ID-RFA may be considered as an option for managing recurrence. Further studies are needed to standardize the procedure.

S1104 Endoscopic Papillectomy of Ampullary Lesions: Predictors of Recurrence and Adverse Events

Introduction: Endoscopic papillectomy (EP) is an effective endoscopic modality for managing ampullary adenomas, early ampullary carcinoma, and piecemeal resection of large laterally spreading lesions. EP has comparable efficacy and a better safety profile compared to a pancreaticoduodenectomy (Whipple surgery) or transduodenal ampullectomy (TA). However, there is a need to identify risk factors for recurrence and adverse events after EP. Thus, this study aims to evaluate predictors for recurrence and adverse events in patients who underwent EP for ampullary lesions. Methods: This study is a retrospective analysis of all consecutive patients who underwent endoscopic snare papillectomy for an ampullary lesion between January 2006 and December 2021. We assessed multiple patient and procedure-related variables to identify risk factors related to post-EP adverse events and ampullary lesion recurrence using both univariate and multivariate analysis. Results: A total of 51 patients undergoing EP for ampullary lesions were included in the final analysis. There were 11 patients with familial adenomatous polyposis (FAP) while 40 had sporadic lesions (Table). Recurrence was seen in 17 patients (37.0%) among those who followed up after technical success; five FAP (55.5%) and twelve sporadic (32.4%) patients had a recurrence. Adverse events included intraprocedural bleeding in 17 patients (33.3%), delayed bleeding requiring endoscopic evaluation in 7 patients (13.7%), post-ERCP pancreatitis (PEP) in 7 patients (13.7%), papillary stenosis in two patients (3.9%), and perforation in one (2%). Three patients (5.9%) had concomitant delayed bleeding and post-ERCP pancreatitis. Nine patients (19.6%) had intraprocedural bleeding requiring endoscopic clip placement of whom one later presented for delayed bleed. Age, method of resection, lesion size, and intraductal extensions were not associated with recurrence. Complete histologic (R0) resection was the only factor associated with no recurrence following EP (OR=5.4, 95% CI: 1.4-20.8, P-value=0.014). Post-ERCP pancreatitis was associated with delayed bleeding (OR=7.5, 95% CI: 1.2-46.1, P-value=0.03). The median follow-up was 228 (40-795) days for those who followed up (46 patients). Conclusion: In patients who underwent EP for ampullary lesions, R0 resection was associated with reduced risk of recurrence. In addition, delayed bleeding after EP is associated with an increased risk of developing PEP. Table 1. - Baseline characteristics of patients who underwent endoscopic papillectomy Characteristics (n=51) Age, years (median (IQR)) 65 (56-76) Gender (male) 29 (56.8%) Symptoms attributable to the ampullary lesion prior to EPAbdominal pain or dyspepsiaObstructive jaundicePancreatitisNone 8 (15.7%)7 (13.7%)4 (7.8%)32 (62.7%) Histology obtained prior to EP 40 (78.4%) Endoscopic ultrasound prior to EP 37 (72.5%) Lesion size, mm (median (IQR)) 15 (10.8-20) Median duration of the procedure in minutes (median (IQR)) 79 (57.8-101.3) Method of resection En-bloc snare resectionEn-bloc snare resection + APCPiecemeal snare resection Piecemeal snare resection + APC 30 (58.8%)8 (7.8%)6 (11.8%)7 (13.7%) Intraductal extension 8 (15.7%) Duodenal diverticulum 4 (7.8%) Altered post-surgical anatomy 3 (5.9%) Pancreas divisum 3 (5.9%) Biliary sphincterotomy 40 (78.4%) Pancreatic sphincterotomy 11 (21.6%) Submucosal lifting prior to EP 7 (13.7%) Pancreatic stent after EP 46 (90.2%) Biliary stent after EP 45 (88.2%) Final diagnosis Tubular adenomaTubulovillous adenoma Tubular adenoma with high grade dysplasiaAdenocarcinomaNeuroendocrine tumorsOther (non-neoplastic) 25 (49.0%)14 (27.5%)5 (9.8%)2 (3.9%)1 (2.0%)4 (7.8%) Concordant histology before and after EP 32 (62.7%) Complete histological (R0) resection 23 (45.1%) Number of procedures to achieve technical successOneTwoThree 44 (86.3%)5 (9.8%)2 (3.9%) Antiplatelets or anticoagulation therapy prior to EP 14 (27.5%) Overnight admission after EP 24 (47.1%) ED visit within 30 days of index EP 7 (13.7%) Hospital readmission within 30 days of index EP 6 (11.8%) APC: Argon plasma coagulation; ED: Emergency department; EP: Endoscopic papillectomy; IQR: Interquartile range.

Impact of 5-Year Endoscopic Surveillance Intervals with Biopsy following Endoscopic Papillectomy for Ampullary Adenoma.

Background: Endoscopic snare papillectomy (ESP) has been established as a safe and effective treatment for ampullary adenomas. However, little is known about the optimal post-procedure follow-up period and the role of routine endoscopic surveillance biopsy following ESP. We aimed to evaluate patient adherence to a 5-year endoscopic surveillance and routine biopsy protocol after ESP of ampullary adenoma. Methods: We reviewed our prospectively collected database (n = 98), all members of which underwent ESP for ampullary lesions from January 2011 to December 2016, for the evaluation of long-term outcomes. The primary outcome was the rate of patient adherence to 5-year endoscopic surveillance following ESP. The secondary outcomes were the diagnostic yield of routine endoscopic biopsy, recurrence rate, and adverse events after endoscopic surveillance in the 5-year follow-up (3-month, 6-month, and every 1 year). Results: A total of 19 patients (19.4%) experienced recurrence during follow-up, all of these patients experienced recurrence within 3 years of the procedure (median 217 days, range 69–1083). The adherence rate for patients with sporadic ampullary adenoma were 100%, 93.5%, and 33.6% at 1, 3, and 5 years after ESP, respectively. The diagnostic yield of routine endoscopic biopsy without macroscopic abnormality was 0.54%. Pancreatitis occurred in four patients (4%, 3 mild, 1 moderate) after surveillance endoscopic biopsy without macroscopic abnormality. Conclusions: Given the low 5-year adherence rate and diagnostic yield of routine endoscopic biopsy with risk of pancreatitis, optimal surveillance intervals according to risk stratification (low grade vs. high grade adenoma/intramucosal adenocarcinoma) may be required to improve patient adherence, and routine biopsy without macroscopic abnormality may not be recommended.

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

Efficacy of Hypertonic Saline-Epinephrine Local Injection Around the Anal Side before Endoscopic Papillectomy for Ampullary Tumors.

Background/AimsBleeding is a complication of endoscopic snare papillectomy for ampullary tumors. This study aimed to investigate the clinical efficacy of hypertonic saline-epinephrine (HSE) local injection before endoscopic papillectomy for prevention of bleeding. MethodsWe retrospectively reviewed the data of 107 consecutive patients with ampullary tumors who underwent endoscopic papillectomy. The rates of en bloc resection, pathological resection margins, and prevention of immediate or delayed bleeding in the simple snaring resection group (Group A) and the HSE injection group (Group B) were compared. ResultsA total of 44 and 63 patients were enrolled in Groups A and B, respectively. The total complete resection rate was 89.7% (96/107); the clinical complete resection rates in Group A and Group B were 86.3% (38/44) and 92.1% (58/63), respectively (p=0.354). Post-papillectomy bleeding occurred in 22 patients. In Groups A and B, the immediate bleeding rates were 20.5% (9/44) and 4.8% (3/63), respectively (p=0.0255), while the delayed bleeding rates were 7% (3/44) and 11% (7/63), respectively (p=0.52). The rates of positive horizontal and vertical pathological margin in both groups were 27% and 16%, respectively. ConclusionsHSE local injection was effective in preventing immediate bleeding and was useful for safely performing endoscopic papillectomy for ampullary tumors.

Is it necessary to place a pancreatic duct stent to reduce post endoscopic snare papillectomy pancreatitis?

Is it necessary to place a pancreatic duct stent to reduce post endoscopic snare papillectomy pancreatitis?

Endoscopic snare papillectomy for adenoma of the ampulla of vater: Long-term results in 135 consecutive patients

BackgroundThe premalignant nature of ampullary adenomas justifies their radical excision. AimsAim of this study is to evaluate the long-term results of endoscopic snare papillectomy in a consecutive series of patients with ampullary adenomas. MethodsPatients who underwent endoscopic snare papillectomy between October 1999 and October 2017 were identified from an electronic database. Endoscopic snare papillectomy was performed en bloc, when possible; a pancreatic stent or a nasopancreatic drainage were inserted. Endoscopic follow-up was scheduled after 3, 6 and 12 months for the first year, then yearly. ResultsEndoscopic snare papillectomy was performed in 135 patients (70 M, mean age 60.5 years) by en bloc (83%) or piecemeal (17%) resection. Delayed bleeding occurred in 16 patients (11.8%), infected retroperitoneal collections in 6 patients (4.4%), pancreatitis in 4 patients (3%). One patient died (0.7%).Follow-up was available in 103/114 (90.3%) patients. In case of residual (24.3%) and recurrent (23.3%), adenomas endoscopic retreatment was successful in 42/49 cases (85.7%). After a mean follow-up of 40 months, 93.2% (96/103) of the patients were disease free ConclusionEndoscopic snare papillectomy of ampullary adenomas is effective with favorable long-term outcomes. Compliance to the scheduled follow-up is important for the early detection and re-treatment of recurrences.

Endoscopic papillectomy of benign papillary tumors: A single-center experience.

Endoscopic treatment of duodenal papillary tumors is well described. This study aims to provide new evidence for the treatment of benign papillary tumors through comparisons between endoscopic snare papillectomy (ESP) and endoscopic mucosal resection (EMR).Between May 2010 and December 2017, 72 patients were enrolled. Diagnosis and treatment procedures were ESP and EMR. Endoscopic follow-up evaluation was done periodically as a surveillance measurement for recurrence.Seventy-two patients with ampullary tumors were enrolled, of which 66 had adenomas including 9 high-grade intraepithelial neoplasias and 2 carcinomas in adenoma. Complete resections with tumor-free lateral and basal margins were achieved in all patients. Postoperative complications were bleeding (9.5% in EMR vs 10% in ESP) and pancreatitis (2.4% in EMR and 3.3% in ESP), with no occurrence of perforation, cholangitis or papillary stenosis. Adenoma recurrence was found in 7 patients (14.3% in EMR vs 3.3% in ESP) at 1 year.The ESP procedure is safe and effective for benign ampullary adenoma, high-grade intraepithelial neoplasias, and noninvasive cancer without intraductal tumor growth, which has a shorter procedural duration, as well as lower complication, recurrence rates and hospitalization costs.

Combined excision and ablation of ampullary tumors with biliary or pancreatic intraductal extension is effective even in malignant neoplasms.

The feasibility and outcome of endoscopic resection in ampullary tumors with intraductal growth remains unclear. To assess the safety, feasibility and outcomes of these patients treated by thermal ablation. Retrospective observational study. All consecutive patients who underwent an endoscopic snare papillectomy with a 6-month minimum follow-up were included. Ablation was performed with cystotomes and soft/forced coagulation. Successful endoscopic treatment was defined as no adenomatous residual tissue or recurrence observed at follow-up. Of 86 patients presenting with an ampullary tumor, 73 (58 ± 14 years old, 49% men, 34% familial adenomatous polyposis) (median tumor size: 20 mm, range: 8-80) were included. En bloc and curative resection rates were achieved in 46.6% and 83.6%, respectively.Intraductal ingrowth was seen in 18 (24.7%) patients and histologically confirmed in 12 (16.4%). Intraductal ablation achieved a 100% success rate, with a 20-month median follow-up. Most of these patients had malignant forms (n = 8, 66.7%), with a higher adenocarcinoma rate (33.3% versus 3.3%, p = 0.001) compared to extraductal tumors.Overall, there was a 20.5% complication rate with no significant differences between both groups (p = 0.676). Intraductal ablation achieves a high therapeutic success rate in ampullary tumors with ≤20 mm ductal extension, even in malignant forms or biliary and pancreatic involvement. The technique is feasible, cheap and safe and may avoid major surgery.

A prospective multicenter study of submucosal injection to improve endoscopic snare papillectomy for ampullary adenoma

Whether or not submucosal injection of a diluted epinephrine solution should be used to lift ampullary tumors during endoscopic snare papillectomy is unclear. This study aimed to investigate the clinical efficacy of a simple snaring method versus submucosal injection for papillectomy. A prospective multicenter study was performed at 4 tertiary referral centers. Patients with papillary lesions were randomized to undergo either simple snare papillectomy (SSP) or submucosal injection papillectomy (SIP) using 1:10,000 diluted epinephrine. The main outcome measures were complete resection rate and post-papillectomy adverse events. A total of 50 patients with biopsy-proven papillary adenomas were enrolled. Complete resection rates in the SSP and SIP groups were 80.8% (21/26) and 50.0% (12/24), respectively (P= .02). However, tumor persistence at 1 month (15.4% vs 8.3%, P= .62) and recurrence at 12 months (12.0% vs 9.5%, P= .58) did not differ despite initial differences in the prevalence of a positive resection margin. The mean tumor size was 12mm in the SSP group and 9.29mm in the SIP group. Post-papillectomy bleeding developed in 42.3% (11/26) and 45.8% (11/24) of patients, respectively (P= .80). Delayed bleeding (>12 h) occurred in 27.3% (3/11) and 36.4% (4/11) of patients, respectively (P= .50). Post-procedure pancreatitis occurred in 15.4% (4/26) and 25% (6/24) of patients, respectively (P= .49). Pancreatitis severity did not differ between the groups, and there were no procedure-related mortalities. Although the recurrence rate was similar between the SSP and SIP groups, SIP showed no advantage over SSP in terms of achieving complete resection or decreasing the frequency of post-papillectomy adverse events, such as bleeding. SSP may thus be a simpler and primarily recommendable technique. (Clinical trial registration number: NCT02165852.).

Tu1732 The Usefulness of Argon Plasma Coagulation Ablation Subsequent to Endoscopic SNARE Papillectomy for Ampulla Adenoma

Tu1732 The Usefulness of Argon Plasma Coagulation Ablation Subsequent to Endoscopic SNARE Papillectomy for Ampulla Adenoma

Endoscopic Duodenal Snare Papillectomy Induced Complication: Prevention and Management

Tumors of the major duodenal papilla are being recognized more often because of the increased use of diagnostic upper endoscopy and ERCP. The standard of management for ampullary tumor is local surgical excision or pancreaticoduodenectomy, but these procedures are associated with significant mortality, as well as post-operative and long-term morbidity. Endoscopic snare papillectomy was introduced as an alternative to surgery, but post-procedure complications are serious drawback. The most serious complications are perforation, delayed bleeding and pancreatitis. Identification of high risk patients, early recognition of complications, and aggressive management abates frequency and severity. Prevention and management of endoscopic duodenal papillectomy-induced complications will be reviewed in this article.

Ampullary Adenoma Treated by Endoscopic Double-Snare Retracting Papillectomy.

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.

Prophylactic pancreatic stent placement after duodenal endoscopic snare papillectomy; prospective, randomized single center study

Prophylactic pancreatic stent placement after duodenal endoscopic snare papillectomy; prospective, randomized single center study

709 Prophylactic Pancreatic Stent Placement After Duodenal Endoscopic snare Papillectomy; Prospective, Randomized Single Center Study

Endoscopic snare papillectomy (ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. The aim of this study was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement.

Endoscopic snare papillectomy: A single institutional experience of a standardized technique. A retrospective cohort study

Background: Indications for endoscopic snare papillectomy (ESP) remain controversial. Main concerns with ESP are related to the incomplete removal of the lesion, high recurrence rates and inadequate oncological resection. Aim of the study is to report short and long term outcomes after endoscopic papillectomy in a single institutional series with strict inclusion criteria and a standardized technique. Methods: Patients with ampullary tumors who underwent endoscopic papillectomy over a 5 year period were reviewed. Inclusion criteria for endoscopic resection were: tumor diameter less than 3 cm, no endoscopic evidence of malignancy, absence of infiltration of biliary and pancreatic duct at pre-operative ERCP and tumor confined to the submucosa at EUS. An en-block resection was attempted in all cases, followed by a pancreatic stent insertion whenever possible. Results: Twenty-seven patients (10 female, mean age 68 y) have been identified. Ampullectomy was successfully performed in all the cases. En bloc resection was completed in 24 patients (88.8%), while 3 patients had a piecemeal resection. A pancreatic stent was successfully placed in all the patients. Five patients experienced complications, including bleeding (2 cases, 7.4%) and acute pancreatitis (3 cases, 11.1%). There was no procedure-related mortality. Histology revealed a poor prognosis in two patients, which were subsequently treated by duodenopancreatectomy. Over a long-term follow-up (median 18 months), one patient developed local recurrence, which was successfully treated with further endoscopic resection. Overall curative resection rate was 92.6%. Conclusions: Endoscopic ampullectomy allows resection of benign tumors and in situ carcinoma. Strict indications and a proper standardized technique seem to be key factors in order to achieve excellent short and long-term results.

Placement of an intra-arterial stent-graft for a pseudoaneurysm after pancreatic resection

Background: Endoscopic snare papillectomy(ESP) is an efficient treatment for benign tumors of the duodenal major papilla. However, acute pancreatitis is the most common and serious complication following an ESP. Aims: The aim was to compare the rate of post-ESP pancreatitis in patients who did or did not receive prophylactic pancreatic stent placement after ESP. Patients & methods: From March 2010 to February 2014, consecutive patients who were to undergo ESP were randomized to pancreatic stent placement group or to no stent placement group. The overall outcomes after ESP including complications were compared between two groups. Results: The 36 patients who received ESP of major duodenal papillary tumors were enrolled. 20 patients were assigned to the stent group and 16 patients to the no stent group. Post-ESP pancreatitis developed in 9 patients (25%, 9/36), 6 cases occurred in the stent group and 3 cases occured in the no stent group. One case in the stent group was considered moderate grade pancreatitis and the others were considered mild grade pancreatitis. The overall incidence of post-EPS pancreatitis were 30% (6/20) in the stent group and 18.8% (3/16) in the no stent group (p1⁄40.700). The rates of hyperamylasemia were 5% (1/20) in the stent group and 6.3% (1/16) in the no stent group (p1⁄40.700). Conclusion: The development of post-ESP pancreatitis and hyperamylasemia were not significantly different in patients with prophylactic pancreatic stent placement compared to those without it. Our data suggest that the effectiveness of prophylactic pancreatic stent placement after ESP may be doubtful. Therefore, more large scaled prospective, randomized controlled studies are needed.

Sa1446 Is Endoscopic SNARE Papillectomy Curative Treatment for T1 Ampullary Adenocarcinoma?: Comparison With Surgical Resection

Sa1446 Is Endoscopic SNARE Papillectomy Curative Treatment for T1 Ampullary Adenocarcinoma?: Comparison With Surgical Resection

Acute Acalculous Cholecystitis without Cholangitis As a Complication of Endoscopic Snare Papillectomy for Ampullary Adenoma

Endoscopic snare papillectomy (ESP) for ampulla of Vater tumor (AVT) has been performed successfully instead of surgical ampullectomy (SA) because ESP is a less invasive procedure than SA. Hemorrhage, perforation and pancreatitis are relatively common complications of ESP and other rare complications such as cholangitis, liver abscess has been reported. Recently we encountered a case of acute acalculous cholecystitis after ESP for AVT, which was treated successfully with percutaneous cholecystostomy with intravenous antibiotics. We therefore report this case with a brief review of the literature. Keywords: Ampulla of Vater tumor, Endoscopic papillectomy, Acute acalculous cholecystitis Keywords: ë°”í„°íŒ½ëŒ€ë¶€ì¢ ì–‘, ë‚´ì‹œê²½ì  ìœ ë‘ì ˆê°œìˆ , 급성무결석성 담낭염

Acute Acalculous Cholecystitis without Cholangitis As a Complication of Endoscopic Snare Papillectomy for Ampullary Adenoma

Acute Acalculous Cholecystitis without Cholangitis As a Complication of Endoscopic Snare Papillectomy for Ampullary Adenoma