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PTU-009 Giant laterally spreading tumours of the papilla: endoscopic features, resection technique and outcome
  1. A D Hopper,
  2. M J Bourke,
  3. S J Williams,
  4. M P Swan
  1. Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia

Abstract

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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