Papilla Of Vater Research Articles

Ultrasonography in diagnosis of the common bile duct pathology and pathology of the major duodenal papilla, complicated by mechanical jaundice

Mechanical jaundice is a clinical syndrome that develops due to the bile flow impairment along the bile ducts to the duodenum, remains one of the urgent problems of medicine. Of great importance among the causes of mechanical jaundice are diseases of the common bile duct and the major duodenal papilla, the diagnosis of which to this day remains a rather difficult task. The use of MRCP, ERСP, endo-ultrasonography and other highly informative bile tract imaging methods, despite great diagnostic capabilities, is associated with a number of limitations. In this regard, an important place, especially in the primary examination of patients, is occupied by transabdominal ultrasound, the advantages of which are non-invasiveness, portability, accessibility, safety, the possibility of multiple reiteration. A review of the literature presents domestic and foreign data of researchers regarding the possibility of ultrasonography in diagnostics of the common bile duct pathology and the pathology of the major duodenal papilla that are complicated by mechanical jaundice, as well as the greatest difficulties in diagnosing this pathology.

Surgical treatment of distal cholangiocarcinoma

Distal cholangiocarcinoma accounts for about 20% of bile duct cancers, representing the third most common tumor entity among periampullary cancers, along with adenocarcinoma of the pancreas and carcinomas of the papilla of Vater. Precise diagnostics of tumor localization and exact knowledge of tumor-specific growth patterns are crucial for successful surgery. When planning the surgical procedure, the differential diagnosis of central bile duct cancer (Bismuth typeI) or middle bile duct carcinoma must be considered. Although benign periampullary bile duct stenosis occurs in only 5% of cases, the presence of immunoglobulin G4-associated cholangitis (IAC) should be excluded in doubtful cases. Basically, in the presence of adistal cholangiocarcinoma, partial pancreatoduodenectomy is indicated analogous to the procedure for ductal adenocarcinoma of the pancreatic head. The 5‑year survival after resection is 20-25% and therefore comparable to adenocarcinoma of the pancreas. Local resection of middle bile duct carcinoma is no longer recommended due to inadequate surgical radicality. To date, perioperative treatment for downsizing does not play arelevant role for surgical treatment of distal cholangiocarcinoma. In the presence of adistal cholangiocarcinoma primary surgery with the aim of aR0 resection is the standard treatment of choice.

A Case Report-Endoscopic Treatments of 47 Incomplete Pancreatic Divisum (IPD) Cases in our Hospital – Special Emphasis on our New Procedures: Rendezvous Pre-Cut Method and Reverse Balloon Dilation Method

We have treated 47 cases of incomplete pancreatic divisum (IPD) in theses 7 years. They were classified by the modified“Hirooka’s classification”— stenotic fusion type I / II, ansa pancreatica type, branch fusion type I / II / III, and one was unclassified. 36 cases were treated by ESWL and/or endoscopy. In difficult cases, we performed our new endoscopic procedures-rendezvous precut method and reverse balloon dilation method, with good results. The therapeutic success rate of IPD via major papilla was 100% (10/10) and via minor papilla 96% (24/25) without severe complications. After endoscopic treatment, the prognosis was good in 32, fair in 3 and one had an operation. In calcified IPD cases, endoscopic treatments were performed many times by stone and pain relapse, and EPS is still placed in 24 cases.

DOG1 expression is in common human tumours: a tissue microarray study on more than 15,000 tissue samples

DOG1 (Discovered on GIST1) is a voltage-gated calcium-activated chloride and bicarbonate channel that is highly expressed in interstitial cells of Cajal and in gastrointestinal stromal tumours (GIST) derived from Cajal cells. To systematically determine in what tumour entities and normal tissue types DOG1 may be further expressed, a tissue microarray (TMA) containing 15,965 samples from 121 different tumour types and subtypes as well as 608 samples of 76 different normal tissue types was analyzed by immunohistochemistry. DOG1 immunostaining was found in 67 tumour types including GIST (95.7%), oesophageal squamous cell carcinoma (31.9%), pancreatic ductal adenocarcinoma (33.6%), adenocarcinoma of the papilla Vateri (20%), squamous cell carcinoma of the vulva (15.8%) and the oral cavity (15.3%), mucinous ovarian cancer (15.3%), oesophageal adenocarcinoma (12.5%), endometrioid endometrial cancer (12.1%), neuroendocrine carcinoma of the colon (11.1%) and diffuse gastric adenocarcinoma (11%). Low level-DOG1 immunostaining was seen in 17 additional tumour entities. In conclusion, our data identify several tumour entities that can show DOG1 expression levels at similar levels as in GIST. Although DOG1 is tightly linked to a diagnosis of GIST in spindle cell tumours, the differential diagnosis is much broader in DOG1 positive epithelioid neoplasms.

Option of staged treatment of a patient with a gunshot wound to the duodenum.

The article presents a method of treatment of patients with multiple duodenal injuries, which consists in implanting a section of the duodenum with a Vater papilla into the small intestine, which avoids complex and traumatic operations on the biliary tract and related complications. We present a clinical case with a follow-up period of 7 years. No data were obtained for the presence of complications in the long-term period.

Utility of the inside stent as a preoperative biliary drainage method for patients with malignant perihilar biliary stricture.

Appropriate preoperative biliary drainage (PBD) is extremely important in patients with operable malignant perihilar biliary strictures. The aim of this study was to clarify the utility of inside stents in PBD. Eighty-one patients with malignant perihilar biliary stricture who underwent endoscopic nasobiliary drainage (ENBD) as the first PBD method were enrolled. Biliary stenting was performed in 61 patients during the study course (41 patients-inside stent implanted in the bile duct; 20 patients-conventional stent placed across the papilla of Vater). Twenty patients continued ENBD until surgery. Treatment outcomes were compared among the three groups. The re-intervention rate was significantly lower in the inside stent group than in the conventional stent group and ENBD group (9.8% vs 40% and 35%, P=.013 and .030, respectively), and the time to re-intervention was also significantly longer (log-rank: P=.004 and .041, respectively). Of the five patients in the inside stent group who underwent neoadjuvant chemotherapy, only one required re-intervention. There was no significant difference in the incidence of postoperative complications among the three groups. The inside stent may be a useful PBD method for patients with malignant perihilar biliary stricture.

Dilated main pancreatic duct can be a negative predictor of pancreatitis related to biliary SEMS insertion across the papilla

Objectives Post-ERCP pancreatitis (PEP) after self-expandable metallic stent (SEMS) insertion across the papilla of Vater is an important adverse event that affects the patient’s quality of life (QOL). We examined the predictive factors of PEP after SEMS insertion to treat obstructive jaundice due to malignancy. Methods Ninety patients who underwent biliary SEMS insertion for biliary obstruction due to malignancy at Iwata City Hospital between 2010 and 2018 were reviewed. We evaluated the relationship between the incidence of PEP after biliary SEMS insertion and clinical factors. We measured the thickness of the pancreatic parenchyma and diameter of the main pancreatic duct (MPD) at the left side of the corpus vertebrae. Results Mild and severe PEP were diagnosed in 10 (11.1%) and 1 (1.1%) patients, respectively. Only the thickness of the pancreatic parenchyma and diameter of MPD significantly differed between the PEP and non-PEP groups. The incidence of PEP among patients whose thickness of the pancreatic parenchyma at the left side of the corpus vertebrae was less than 9.5 mm (0%) on computed tomography was lower than that in patients whose thickness was 9.5 mm or greater (34.4%). Similarly, a wider (5 mm or more) diameter of MPD (4.3%) reduced the incidence of PEP compared with a narrower diameter (40.0%). Logistic regression analysis revealed that the probability of PEP decreases 3.91 times for every 1-mm increase in MPD diameter (95% CI 1.23–12.4, p = .02). Conclusion Based on our study, a dilated MPD is a negative predictive factor of pancreatitis related to biliary SEMS insertion.

Endoscopic resection of a pediatric pyogenic granuloma of the major papilla.

Endoscopic resection of a pediatric pyogenic granuloma of the major papilla.

Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection?

Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions. Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen. In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma. In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.

A RARE HISTOLOGICAL FINDING AFTER PANCREATICODUODENECTOMY

In this paper, we describe the case of successful surgical treatment of a rare combination of three malignant tumors of the major duodenal papilla in one patient. A 59-year-old woman presented with abdominal pain, fever, nausea, vomiting, weight loss and obstructive jaundice. After routine examination, the patient with suspected cancer of the major duodenal papilla underwent pylorus-sparing pancreatoduodenal resection. Final histology revealed a rare collision of three types of cancer in the major duodenal papilla invading the pancreatic head: moderately-differentiated adenocarcinoma (30 %), moderately differentiated squamous cell carcinoma (20 %) and poorly differentiated small cell neuroendocrine cancer (50 %), surgical resection margins were intact. Immunohistochemical analysis revealed positivity for synaptophysin, chromogranin A and cytokeratin 5/6. The tumor diameter of 2 cm and the absence of signs of locoregional spread allowed the process to be staged as T2N0M0, so the patient did not receive any adjuvant treatment. Follow-up CT performed 6 months later showed two lesions in the liver, and biopsy of one of them was performed. Metastasis of neuroendocrine cancer was histologically and immunohistochemically verified. She started first-line chemotherapy with etoposide + cisplatin.

Argon plasma coagulation of the papilla of Vater for treatment of a Dieulafoy lesion.

A 54-year-old man was admitted to the emergency room for a syncope episode and melena. The laboratory test highlighted a hemoglobin of 6.8 g/dL, and 2 blood transfusions were performed. An upper endoscopy revealed stigmata of recent bleeding in the duodenum, and active bleeding was visualized at the level of the major papilla. Therefore, hemobilia or hemosuccus pancreaticus was suspected. An abdominal computed tomography (CT) scan did not reveal any underlying biliopancreatic disorder.

Tratamiento endoscópico de adenomas de la papila menor: reporte de dos casos.

Existen numerosas publicaciones sobre resección endoscópica de lesiones de la papila mayor, pero solo se han presentado series de casos individuales de resección de lesiones de la papila menor. En el presente artículo describimos el éxito técnico y la seguridad de la resección endoscópica de dos lesiones adenomatosas de la papila menor.

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation

BackgroundExisting proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV.MethodsThe classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study.ResultsThe novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and < 1 transverse fold over the oral protrusion; type IIB, prominent tubular pleated type, with an oral protrusion and > 2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498–0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410–0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586–0.715) and nonexperts (K = 0.646, 95% CI 0.615–0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively).ConclusionsThe novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.

Endoscopic management of superficial nonampullary duodenal tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE recommends that all duodenal adenomas should be considered for endoscopic resection as progression to invasive carcinoma is highly likely.Strong recommendation, low quality evidence. 2: ESGE recommends performance of a colonoscopy, if that has not yet been done, in cases of duodenal adenoma.Strong recommendation, low quality evidence. 3: ESGE recommends the use of the cap-assisted method when the location of the minor and/or major papilla and their relationship to a duodenal adenoma is not clearly established during forward-viewing endoscopy.Strong recommendation, moderate quality evidence. 4: ESGE recommends the routine use of a side-viewing endoscope when a laterally spreading adenoma with extension to the minor and/or major papilla is suspected.Strong recommendation, low quality evidence. 5: ESGE suggests cold snare polypectomy for small (< 6 mm in size) nonmalignant duodenal adenomas.Weak recommendation, low quality evidence. 6: ESGE recommends endoscopic mucosal resection (EMR) as the first-line endoscopic resection technique for nonmalignant large nonampullary duodenal adenomas.Strong recommendation, moderate quality evidence. 7: ESGE recommends that endoscopic submucosal dissection (ESD) for duodenal adenomas is an effective resection technique only in expert hands.Strong recommendation, low quality evidence. 8: ESGE recommends using techniques that minimize adverse events such as immediate or delayed bleeding or perforation. These may include piecemeal resection, defect closure techniques, noncontact hemostasis, and other emerging techniques, and these should be considered on a case-by-case basis.Strong recommendation, low quality evidence. 9: ESGE recommends endoscopic surveillance 3 months after the index treatment. In cases of no recurrence, a further follow-up endoscopy should be done 1 year later. Thereafter, surveillance intervals should be adapted to the lesion site, en bloc resection status, and initial histological result. Strong recommendation, low quality evidence.

Efficacy and safety of endoscopic papillectomy of major duodenal papilla neoplasms

Objective: To discuss the efficacy and safety of endoscopic papillectomy of major duodenal papilla neoplasms. Methods: The clinical-pathological data of 21 patients who were admitted to the Department of Endoscopy, Cancer Hospital, Chinese Academy of Medical Sciences and underwent endoscopic papillectomy of major duodenal papilla neoplasms from January 2014 to January 2020 were retrospectively studied, their postoperative outcomes and complication were also analyzed. Results: Tweenty-one patients were successfully performed endoscopic papillectomy of major duodenal papilla neoplasms. The resected lesions varied between 0.5-2.8 cm. Completed lesion was resected in 19 cases and lesion blocks in 2 cases. The incidence of postoperative complication was 52.4% (11/21), including 8 cases of postoperative bleeding (38.1%). Five patients stopped bleeding after endoscopic hemostasis and 3 patients stopped after interventional embolization. Two patients experienced perforation (9.5%) and recovered after conservative treatment including anti-inflammatory treatment and abdominal drainage. Five patients had pancreatitis (23.8%) and recovered after treatment with pre-somatostatin and anti-inflammatory rectal suppository. Preoperative pathological results of 21 patients suggested that 11 were high-grade intraepithelial neoplasia and 8 were low-grade intraepithelial neoplasia, and 2 were chronic inflammation. Postoperative pathological results suggested that 4 were adenocarcinoma, and the rest 17 were adenoma. The coincidence rate of preoperative biopsy results and postoperative pathology was 38.1%(8/21), and underestimate of the pathological stage occurred in 11 patients (52.4%) during the preoperative biopsy, overestimate occurred in two patients (9.5%). Four cases had a positive incisal margin. All patients had good prognoses and no death event occurred during the follow-up period. Conclusions: Early-stage major duodenal papilla neoplasms should be treated with aggressive resection. Endoscopic papillectomy of duodenal papilla neoplasms is safe, effective, and can be recommended as the preferred procedure for major duodenal papilla neoplasms.

Whipple procedure for ampulla of Vater cancer in a patient with situs inversus (clinical case)

A clinical case of a rare combination of complete transposition of internal organs (situs inversus totalis) with adenocarcinoma of the major duodenal papilla is presented. In addition to situs vicserum inversus, the patient has a special variant of vascular anatomy that is not included in the generally accepted classification of variants of arterial liver anatomy according to Michaels N.A. (1955), namely: separate separation of the left and right hepatic arteries from the ventral trunk. After individual preoperative planning, a patient with a complete reverse position of the abdominal organs and non-standard vascular anatomy was performed Whipple procedure. Non-invasive CT angiography is important in a complex preoperative examination, which allows timely identification and clarification of frequently occurring features of blood supply to the hepatopancreatoduodenal zone in patients with situs inversus totalis. Such surgical interventions should be performed in large multi-specialty medical centers that have extensive experience in performing pancreatoduodenal resections.

Possibilities of CT perfusion in diagnostics of periampullary tumors

Purpose. To study the possibilities of CT perfusion (CTP) in detecting periampullary tumors depending on the anatomical localization, to compare the diagnostic efficiency with the standard CT protocol. Materials and methods. CT scan of the abdominal organs according to the standard protocol and CTP were performed in 229 patients with periampullary tumors. Results. In adenocarcinoma of the pancreas, compared with adenocarcinoma of the major duodenal papilla, BF, BV, MSI (p&lt;0,005) were statistically significantly lower, there were no differences in MTT, TTP, and PS (p&gt;0,005). In distal cholangiocarcinoma, compared with adenocarcinomas of the pancreas and the major duodenal papilla (MDP), the BF, BV and MSI values were statistically significantly higher, the TTP values were lower (p&lt;0,005), there were no differences in the MTT and PS values (p&gt;0,005). Conclusion. CT perfusion is a highly informative method for detecting and determining the anatomical affiliation of periampullary tumors with a sensitivity of 98,7%, a specificity of 98%, and a diagnostic accuracy of 98,4%.

Feasibility Study of Partial Submucosal Injection Technique Combining Underwater EMR for Superficial Duodenal Epithelial Tumors.

Endoscopic mucosal resection (EMR) and Underwater EMR have been reported as effective endoscopic treatment for superficial duodenal tumor (SDET). However, a notable problem of EMR for SDET is technical difficulty for the lesion with non-lifting sign, and it of UEMR is that en bloc resection rate is relatively low. Therefore, we performed partial submucosal injection combining UEMR (PI-UEMR). The aim of this study is to evaluate feasibility and safety of this technique for duodenal tumor. This is a prospective observational study from tertiary care hospital. We performed PI-UEMR in patients with SDET that is 13-20mm in diameter, or less than 13mm with technical difficulty for EMR and UEMR from January 2019 to March 2020. Primary outcome was en bloc resection rate. Secondary outcomes were R0 resection rate, mean total procedure time, intra- and post-procedure complication. Thirty patients were included in this study. Mean age was 62 ± 12years old. Three fourths lesions were located at anal side from major papilla. Median lesion size was 12mm [IQR 10-16mm]. Twenty-four cases were taken endoscopic biopsy in prior hospital and observed biopsy scar. En bloc resection rate was 97%. Ro resection rate was 83%. Mean total procedure time was 17 ± 12min. And there was an only one case of complication, intra-procedure bleeding that was controllable endoscopically. PI-UEMR might be very useful and safe technique of endoscopic resection for SDET including relatively large lesions.

Morphological and functional charakteristics of histogenetically related structures - producers of monoamines - in the local regulatory apparatus of the large duodenal papilla

Purpose of the study. Study of the morphology of open-type fluorescent cells and adrenergic nerve structures of the major duodenal papilla. Material and research methods. The material for the study was the area of the large duodenal papilla of 12 rabbits and 5 dogs. Fluorescent endocrine cells and adrenergic nerve structures were revealed by processing cryostat sections of the material with a gly-oxylic acid solution. Research results. It has been established that the fluorescent cells of the diffuse endocrine (APUD) system contain serotonin and catecholamines, the shade of their luminescence depends on the quantitative ratio of which. Where these two structures are located side by side, the shade of the glow is approximately the same. Discussion. It is assumed that the implementation of a complex response to the primary chemoreceptor information on the composition of the chyme, obtained by the fluorescent cells of the diffuse endocrine system of the major duodenal papilla, occurs through the exchange of biogenic amines between them and the adrenergic nerve structures of the duodenal papilla.

The position of a duodenal diverticulum in the area of the major duodenal papilla and its potential clinical implications.

Although duodenal diverticula are associated with less frequent pathology than the colonic diverticula in the large intestine, their periampullary position may have significant clinical implications. The aim of the study was to identify any possible correlation between the type of localisation of the major duodenal papilla, duodenal diverticula, and some particular clinical issues. In total, 628 patients (408 females and 220 males; aged 21-91 years), who underwent endoscopic retrograde cholangiopancreatography were included in this study. The patients were divided into two groups: a study group comprising 66 (10.5%) patients with periampullary position of diverticula (group A), and a control group comprising 562 (89.5%) patients without diverticula (group B). A duodenal diverticulum was diagnosed in the periampullary position in 66/628 (10.5%) patients: 41 women (aged 52-91 years) and 25 men (aged 54-83 years). Three types of localisation were observed for the major duodenal papilla with regard to the diverticula, with the most common type being next to each other (type III). In patients with diverticula, similar frequencies of gallstone occurrence are observed in men and women. Patients with papilla in the diverticulum who underwent cholecystectomy are more prone to develop lithiasis.