Endoscopic papillectomy for tumors of the major duodenal papilla. Endoscopic papillectomy of ampullary adenomas is a promising alternative to surgical resection. The contents of this video include endoscopic methods, indication, prior evaluation, technical issues, and complications of endoscopic papillectomy. In the identification of ampullary adenoma, endoscopic morphology has been shown to be very reliable. Microscopic criteria suggesting benign ampullary adenoma include no ulceration, no spontaneous bleeding, and no excessive friability. Adenoma of the major duodenal papilla is clinically important because this lesion is premalignant and should be resected completely. This papillary lesion showed even granular appearance. This lesion turned out to be ampullary tubular adenoma on biopsy. Ampullary adenomas can be excised either surgically or endoscopically. The surgical options include transduodenal local excision and radical pancreato-duodenectomy. In the past, surgical resection was considered as the standard treatment of ampullary adenoma. Recently, much evidence has accumulated to suggest that endoscopic papillectomy can be used as a first-line therapy for ampullary adenoma. Its advantage is clearly the less invasive approach, omitting the need for general anesthesia and laparotomy. Endoscopic treatment methods consist of snare resection and thermal ablation. In this case, cauliflower-like sessile lobulated mass is seen. This endoscopic morphology is the typical finding of villus adenoma. By excising through the middle or the deeper part of the submucosa, endoscopic snare resection allows curative removal of affected mucosa with minimal morbidity and mortality. Endoscopists use polypectomy snares of various diameters, depending on the size of the tumor. The tumor together with the papilla was grasped and excised. The snare can be applied either from cephaloid to caudal side or vice versa on individual basis. Regarding the mode of the current, many endoscopists use blended current. Some investigators advocate the use of pure cutting current to avoid edema caused by coagulation mode. Thermal ablation seems to be very effective in the treatment of small remnants not amenable to snare resection. The lesion not amenable to snare resection can be fibrillated by using argon plasma coagulation. Thermal ablation is also useful for hemostasis. In this case, bleeding was seen after papillectomy. Thermal ablation was done for bleeding control. Conventional indications for endoscopic papillectomy can be summarized by collecting common criteria used in previous reports as follows. Tumor size less than 4 to 4.5 cm. No evidence for malignancy based on endoscopic morphology. Benign histology on forceps biopsy specimens. Absence of intraductal involvement. However, those criteria are currently seen as flexible. With time and experience, indications for endoscopic papillectomy have expanded to include larger tumor size, tumors with intraductal extension, and early ampullary cancer. This picture shows a large lateral spreading adenoma. After methylene blue injection, lateral margin of the tumor was clearly seen. For endoscopic treatment of larger tumors, piecemeal resection and thermal ablation can be used. Whether N-block or piecemeal resection is the best method for successful endoscopic papillectomy remains controversial. N-block resection is the fundamental method to the treatment of neoplastic lesions. However, not all the tumors of the major duodenal papilla are amenable to N-block resection. In this case, the tumor was grasped by snare and excised. After snare papillectomy, a remnant tumor still remained. If a remnant lesion is suspected immediately after the excision of the tumor, additional removal with snare resection is attempted in the same session, if technically feasible. This case shows piecemeal resection of remnant tumor. In most centers, a combination of N-block and piecemeal resection is used. For lesions greater than 2 centimeters in diameter, piecemeal resection is frequently used. In this case, remnant tumor is suspected after repeated snare resection. Thermal ablation using argon plasma coagulation is done at the remnant tumor around papillectomy site. When thermal ablation is used primarily for treatment of ampullary adenomas, specimens for histopathologic evaluation cannot be obtained. Thermal ablation, therefore, is mainly used. The presence of introductal growth has been considered as a contraindication for endoscopic papillectomy. In this case, the arrow indicates introductory extension of ampullary adenoma. On entudenoscopy, severe bulging of the ampulla is seen, but the overlying mucosa is intact. So Hendra Group suggested that if the introductal growth is less than 1 centimeter in length and becomes accessible after maximum sphincterotomy, an endoscopic resection can be attempted. In this case, after wide biliary sphincterotomy and balloon sweeping, the tumor is exposed to luminal side and fully accessible to endoscopic resection. This case turned out to be an exposed adenoma, and endoscopic papillectomy could be done. We performed pancreatic stent placement in this patient. However, biliary stent placement is not done because the bile duct orifice was clearly visible, and the biliary drainage is good. The retrieved speechman is flattened and pinned down at the periphery to a plate of polystyrene in order to aid orientation and to make identification of lateral and horizontal margins easier. In this case, a large bulging papilla with normal overlying mucosa is seen on the endoscopy. This lesion turned out to be an intramural tumor of nonexposed type. Forced biopsy was done after small incision of papillary orifice. Pathologic speechman showed volatile adenoma with high-grade dysplasia. Pre-cut incision using needle knife was noted. The snare was placed with the tip dislocated. After resection, residual tumor is suspected after pancreatic ducts stand back. After piecemeal resection, pancreatic stenting is done. A suspected remnant lesion is removed by a biopsy forceps. Thermoblasion using argon plasma coagulation is done for fugalation of possible lesions. In addition to pancreatic stenting, biliary stent placement is done. Following biliary stenting, thermal ablation is done for fugulation of possible residual tumor. Because the resected specimen revealed adenocarcinoma of well-differentiated type, the patient underwent radical pancreatic adenectomy. However, the surgically resected specimen showed no residual tumor, no lymph node metastasis, and no lymphovascular invasion. Recently, our group published an article in GI endoscopy suggesting endoscopic papillectomy should be considered as an alternative to surgery in focal T1 cancer in ampullary adenoma. In this retrospective case series, patients who had high-grade intraepithelial neoplasia or focal T1 ampullary cancer resected by endoscopic papillectomy had no lymphovascular invasion or lymph node metastasis, and there were no occurrences of cancer or death. ERCP is required in all patients to obtain both cholangiogram and pancreatogram. In this case, no tumor invasion was noted into both pancreatic duct and bile duct. ERCP can demonstrate intraductal extension of the tumor. In this case, the arrow indicates intraductal extension of ampullary tumor. EOS is used in an attempt to evaluate and visualize depth of invasion as well as intraductal extension of the tumor. In this case, a 19 by 60 millimeter-sized lesion with focal hypoechoic echogenicity is confined to the mucosal layer. The proper muscle layer is intact. EOS can clearly demonstrate the layered structures of the duodenal wall, including proper muscle layer. In this section, we will provide an overview of technical issues about endoscopic papillectomy. There is extensive discussion about pancreatic duct stent placement. First, while some endoscopists advocate routine placement of pancreatic stent, others advocate selective placement. Second, regarding duration of stent placement, some investigators prefer several days, but others prefer about one month. Third, there is no established consensus regarding the need for additional biliary stenting. Another technical issue is the requirement of submucosal injection. Some authors recommend submucosal injection prior to resections. Others do not. In a recent prospective randomized control trial, prophylactic pancreatic stent placement reduced post-papillectomy pancreatitis. Others advocate pancreatic stent placement only if delayed drainage of the pancreatic duct is noted after endoscopic papillectomy. In this case, delayed pancreatic drainage is noted, so pancreatic duct stent placement is done. Regarding duration of stent placement, some investigators prefer several days, but others prefer one month. If the main purpose of pancreatic stent placement is the prevention of post-papillectomy pancreatitis, while minimizing stent-induced ductal change, endoscopists prefer to place a stent of a small caliber for the shortest duration possible. Some investigators intended that the stents remain in place until the second session of endoscopic examination. The remaining pancreatic stent may protect the pancreatic duct orifice during subsequent endoscopic excision and thermal ablation. In this case, endoscopic sphincterotomy for biliary stenting is done, in addition to pancreatic stenting. Compared to pancreatic duct stenting, less attention has been given to biliary stenting. Theoretically, cholangitis can occur after endoscopic papillectomy by the same pathogenetic mechanism as post-papillectomy pancreatitis or pancreatic stricture. Both biliary sphincterotomy and stent placement could be considered if the bile duct orifice is not clearly visible and there is difficulty in cannulation after resection of the tumor. In this case, bile duct orifice is not clearly visible, so bile duct cannulation and sphincterotomy for stent placement are considered. Following bile duct cannulation, endoscopic sphincterotomy is done. In addition to pancreatic stenting, biliary stent placement is done. While some endoscopists advocate the use of submucosa injection of dilute epinephrine, others do not. A scleral needle is usually used, and the number of injections and the total volume of the solution injected varies with the size of the lesion. Some endoscopists consider the submucosa injection as a diagnostic tool to evaluate lesion resectability. Non-lifting may indicate deeper invasion and may be a predictor of accompanying malignancy. In this case, a lifting sign was positive after submucosa injections. The tumor was grasped and ensnared. They also consider submucosa injection as a safety cushion. Submucosa fluid injection may reduce the risk of perforation because it serves to protect the muscular dyspropria from injury by lifting the mucosa to be resected, and you reduce thermal injury. This papillary lesion shows symmetrical enlargement with even, granular, overlying mucosa. Using sclerotherapy needle, submucosa injection works. The tumor was grasped and excised. Some investigators discourage cell mucosal injection prior to endoscopic papillectomy. First of all, both tumor and surrounding mucosa are lifted by cell mucosal injection, thus making snaring of the lesion difficult. Secondly, some mucosal injection may blur the margin of the tumor. Complications of endoscopic papillectomy can be classified into early and late complications. The two most common early complications are bleeding and post-papillectomy pancreatitis. Late complications include stenosis of bile duct or pancreatic duct orifice. In conclusion, endoscopic papillectomy is a relatively safe and effective therapy for ampullary adenomas. Indications for endoscopic papillectomy are expected to expand, and it may be established as a first-line therapy. We hope this video has been helpful in illustrating the important features of endoscopic papillectomy. Thank you.

endoscopic papillectomy

tumors

major duodenal papilla

ampullary adenomas

technical issues