Introduction Successful endoscopic papillectomy of conventional ampullary adenomas is well described. However, many authors recommend surgical ampullectomy for larger lesions with extra-papillary extension. Our objective was to describe the classification, technique and outcome for the endoscopic resection of giant laterally spreading tumours of the papilla (LST-P).
Methods Over a 24-month period to May 2009, patients referred for endoscopic treatment of ampullary adenomas were enrolled prospectively. LST-P lesions were identified as adenomatous tumours arising from the major duodenal papilla, >30 mm, extending beyond the papilla onto the duodenal wall, and involving up to 2/3 of the duodenal circumference. LST-P lesions were classified as per the Paris classification. All patients underwent pre-resection staging. Resection technique: The key aspect was en-bloc excision of the papilla. LST-P lesions with predominant vertical extra papillary extension (Paris 0-Is+IIa) were treated by initial maximal papillectomy. Following papillectomy, EMR of residual adenomatous tissue was performed. LST-P lesions with predominant lateral spreading morphology (Paris 0-IIa+Is) underwent EMR and submucosal injection at one edge to isolate the papilla, this allowed subsequent en-bloc papillectomy. In all these predominant lateral spreading adenomas injection directly placed into the papillary region before adjacent adenoma was removed was avoided as this could cause a sunken papillary region. Argon plasma coagulation was avoided. The aim was to remove all neoplastic tissue with snare resection. For ampullary adenomas <30 mm complete en-bloc resection was performed without submucosal injection. A 5Fr pancreatic stent was attempted after papillectomy in all cases. Follow-up was performed at 3, 6 and 12-month intervals.
Results 25 patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; size 30–80 mm) combination EMR and papillectomy was performed in a single session. Median admission duration was 1.0 night (range 0–35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in one patient (10%). 15 patients were noted to have conventional ampullary adenomas <30 mm (mean age 65). Comparing the bleeding and recurrence rates between the smaller and larger resection groups showed no significant statistical difference between bleeding (30% vs 7.7%: p=0.28) or recurrence (10% vs 23%: p=0.6).
Conclusion Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands the outcomes are comparable to those for conventional ampullary adenomas.
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