Original Articles
Safety and outcome of endoscopic snare excision of the major duodenal papilla☆

https://doi.org/10.1016/S0016-5107(02)70184-3Get rights and content

Abstract

Background: The optimal management of adenoma of the major duodenal papilla is not established. Options include surgical excision, endoscopic ablative techniques, snare excision, and observation with periodic biopsies. The aims of this retrospective study were to determine the safety and outcome of snare excision of the papilla. Methods: Twenty-eight snare excisions of the papilla were performed in 26 patients. Sixteen had familial adenomatous polyposis. In 22 procedures, a minisnare was used, and in 6 cases a prototype snare was designed for excision of the papilla. Pancreatic stents were placed as a prophylactic measure at the discretion of the endoscopist (n = 10). Results: Histopathologically, resected tissue included 25 adenomas, 1 inflammatory polyp, 1 invasive malignancy, and 1 normal papilla. Immediate complications were minor bleeding (n = 2), mild pancreatitis (n = 4) and a duodenal perforation (n = 1). The presence (n = 10) or absence (n = 18) of a pancreatic stent did not correlate with subsequent pancreatitis (2 in each group, p = NS). Follow-up was available for 21 patients (median, 9 months; range, 2-32 months). Pancreatic duct stenosis at the papillectomy site resulted in pancreatitis in 2 patients (17%) at, respectively, 4 months and 24 months. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in 2 (10%). Conclusions: Snare excision of the major duodenal papilla was well tolerated. Most complications were mild except for a small duodenal perforation. Stenosis of the pancreatic duct orifice with pancreatitis may be a late complication. (Gastrointest Endosc 2002;56:239-43.)

Section snippets

Patients and methods

Data were obtained from endoscopic procedure reports and patient records for procedures performed between September 1997 and November 1999. Follow-up data were obtained from patient records. Patients were defined as having “sporadic” adenomas if there was no family history suggestive of FAP. All of these patients underwent colonoscopy to further exclude attenuated FAP. Snare excision was performed for lesions confined to the papilla. All procedures were preceded by retrograde

Results

Twenty-eight snare excision procedures were performed in 26 patients (12 women, 14 men; median age 42 years; range, 21 to 84 years; Table 1) (Fig. 2).

. Demographics and presentation of the sporadic and FAP periampullary patient groups

Empty CellSporadic n = 11FAP n = 15p Value
Age (median and range)60 (36-84)41 (19-69)—
Gender (% male)73470.38
Symptoms
 None3/1111/150.054
 Epigastric pain5/112/15—
 Cholestasis3/111/15—
 Pancreatitis01/15—

. A, Endoscopic view of adenoma arising at major duodenal papilla. B, Deployment

Discussion

This retrospective study demonstrates the safety and efficacy of snare excision for management of adenoma of the major duodenal papilla.

Most patients with adenomas involving the papilla have FAP, a syndrome that afflicts approximately 1 in 8000 people in the United States.7 The duodenum, and particularly the peripapillary region, is the most common upper GI site of malignancy in patients after colectomy with FAP, occurring in up to 4.5% to 8.5%.8, 9 The risk of adenocarcinoma of the major

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☆

Reprint requests: Christopher J Gostout, MD, Department of Gastroenterology, Mayo Clinic and Foundation,, 200 1st St., SW, Rochester, MN, 55902.

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Copyright © 2002 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.