Endoscopic papillectomy: Data of a prospective observational study

AIM:To investigate the clinical value of endoscopic papillectomy indicated by feasibility and safety of the procedure in various diseases of the papilla in a representative number of patients in a setting of daily clinical and endoscopic practice and care by means of a systematic prospective observational study. METHODS:Through a defined time period, all consecutive patients with tumor-like lesions of the papilla, who were considered for papillectomy, were enrolled in this systematic bicenter prospective observational study, and subdivided into 4 groups according to endoscopic and endoscopic ultrasonography (EUS) findings as well as histopathological diagnosis:adenoma; carcinoma/ neuroendocrine tumor (NET)/lymphoma; papilla into which catheter can not be introduced; adenomyomatosis, respectively. Treatment results and outcome were characterized by R0 resection, complication, recurrence rates and tumor-free survival.RESULTS:Over a 7-year period, 58 patients underwent endoscopic papillectomy. Main symptoms prompting to diagnostic measures were unclear abdominal pain in 50% and cholestasis with and without pain in 44%. Overall, 54/58 patients [inclusion rate, 93.1%; sex ratio, males/females = 25/29 (1:1.16); mean age, 65 (range, 22-88) years] were enrolled in the study. Prior to papillectomy, EUS was performed in 79.6% (n = 43/54). Group 1 (adenoma, n = 24/54; 44.4%):91.6% (n = 22/24) with R0 resection; tumor-free survival after a mean of 18.5 mo, 86.4% (n = 19/22); recurrence, 13.6% (n = 3/22); minor complications, 12.5% (n = 3/24). Group 2 (carcinoma/NET/lymphoma, n = 18/54; 33.3%):75.0% (n = 10/18) with R0 resection; tumor-free survival after a mean of 18.5 (range, 1-84) mo, 88.9% (n = 8/9); recurrence, 11.1% (n = 1/9). Group 3 (adenomyomatosis, n = 4/54; 7.4%). Group 4 (primarily no introducible catheter into the papilla, n = 8; 14.8%). The overall complication rate was 18.5% (n = 10/54; 1 subject with 2 complications):Bleeding, n = 3; pancreatitis, n = 7; perforation, n = 1 (intervention-related mortality, 0%). In summary, EUS is a sufficient diagnostic tool to preoperatively clarify diseases of the papilla including suspicious tumor stage in conjunction with postinterventional histopathological investigation of a specimen. Endoscopic papillectomy with curative intention is a feasible and safe approach to treat adenomas of the papilla. In high-risk patients with carcinoma of the papilla with no hints of deep infiltrating tumor growth, endoscopic papillectomy can be considered a reasonable treatment option with low risk and an approximately 80% probability of no recurrence if an R0 resection can be achieved. In patients with jaundice and in case the catheter can not be introduced into the papilla, papillectomy may help to get access to the bile duct. CONCLUSION:Endoscopic papillectomy is a challenging interventional approach but a suitable patientand local finding-adapted diagnostic and therapeutic tool with adequate risk-benefit ratio in experienced hands.

Differential treatment and early outcome in the interventional endoscopic management of pancreatic pseudocysts in 27 patients

AIM： Pancreatic pseudocysts （PPC） as a complication of pancreatitis are approached only in the case of abdominal pain, infection, bleeding, and compression onto the gastrointestinal tract or biliary tree. METHODS： From 02/01/2002 to 05/31/2004, all con- secutive patients with symptomatic PPC who underwent an interventional endoscopic approach were evaluated in this pilot case-series study： Group （Gr.） Ⅰ-Primary percutaneous （external）, ultrasound-guided drainage. Gr. Ⅱ- Primary EUS-guided cystogastrostomy. Gr. Ⅲ-EUS-guided cystogastrostomy including intracystic necrosectomy. RESULTS： （=＂follow up＂： n = 27）： Gr. Ⅰ （n = 9; 33.3%）： No complaints （n = 3）; change of an external into an internal drainage （n = 4）; complications： （a） bleeding （n = 1） followed by 3 d at ICU, discharge after 40 d; （b） septic shock （n = 1） followed by ICU and several laparotomies for programmed lavage and necrosectomy, death after 74 d. Gr. Ⅱ （n = 13; 48.1%）： No complaints （n = 11）; external drainage （n = 2）; complications/problems out of the 13 cases： 2nd separate pseudocyst （n = 1） with external drainage （since no communication with primary internal drainage）; infection of the residual cyst （n = 1） ＋ following external drainage; spontaneous PPC perforation （n = 1） ＋ following closure of the opening of the cystogastrostomy using clips and subsequently ICU for 2 d. Gr. Ⅲ （n = 5; 18.5%）： No complaints in all patients, in average two endoscopic procedures required （range, 2-6）. CONCLUSION： Interventional endoscopic management of pancreatic pseudocysts is a reasonable alternative treatment option with low invasiveness compared to surgery and an acceptable outcome with regard to the complication rate （11.1%） and mortality （3.7%）, as shown by these initial study results.

Endoscopic ultrasonography-guided drainage for patients with symptomatic obstruction and enlargement of the pancreatic duct

AIM: To evaluate the use of translumenal pancreatography with placement of endoscopic ultrasonography(EUS)-guided drainage of the pancreatic duct.METHODS: This study enrolled all consecutive patients between June 2002 and April 2014 who underwent EUSguided pancreatography and subsequent placement of a drain and had symptomatic retention of fluid in the pancreatic duct after one or more previous unsuccessful attempts at endoscopic retrograde cannulation of the pancreatic duct. In all,94 patients underwent 111 interventions with one of three different approaches:(1) EUS-endoscopic retrograde drainage with a rendezvous technique;(2) EUS-guided drainage of the pancreatic duct; and(3) EUS-guided,internal,antegrade drainage of the pancreatic duct.RESULTS: The mean duration of the interventions was 21 min(range,15-69 min). Mean patient age was 54 years(range,28-87 years); the M:F sex ratio was 60:34. The technical success rate was 100%,achieving puncture of the pancreatic duct including pancreatography in 94/94 patients. In patients requiring drainage,initial placement of a drain wassuccessful in 47/83 patients(56.6%). Of these,26 patients underwent transgastric/transbulbar positioning of a stent for retrograde drainage; plastic prostheses were used in 11 and metal stents in 12. A ring drain(antegrade internal drainage) was placed in three of these 26 patients because of anastomotic stenosis after a previous surgical intervention. The remaining 21 patients with successful drain placement had transpapillary drains using the rendezvous technique; the majority(n = 19) received plastic prostheses,and only two received metal stents(covered self-expanding metal stents). The median follow-up time in the 21 patients with transpapillary drainage was 28 mo(range,1-79 mo),while that of the 26 patients with successful transgastric/transduodenal drainage was 9.5 mo(range,1-82 mo). Clinical success,as indicated by reduced or absence of further pain after the EUS-guided intervention was achieved in 68/83 patients(81.9%),including several who improved without drainage,but with manipulation of the access route.CONCLUSION: EUS-guided drainage of the pancreatic duct is a safe,feasible alternative to endoscopic retrograde drainage when the papilla cannot be reached endoscopically or catheterized.

Sealing of the hepatic resection area using fibrin glue reduces significant amount of postoperative drain fluid

AIM: To investigate whether the routine use of fibrin glue applied onto the hepatic resection area can diminish postoperative volume of bloody or biliary fluids drained via intraoperatively placed perihepatic tubes and can thus lower the complication rate.METHODS: Two groups of consecutive patients with a comparable spectrum of recent hepatic resections were compared: (1) 13 patients who underwent application of fibrin glue immediately after resection of liver parenchyma;(2) 12 patients who did not. Volumes of postoperative drainage fluid were determined in 4-h intervals through 24 h indicating the intervention caused bloody and biliary segregation.RESULTS: Through the first 8 h postoperatively, there was a tendency of higher amounts of fluids in patients with no additional application of fibrin glue while through the following intervals, a significant increase of drainage volumes was documented in comparison with the first two 4-h intervals, e.g., after 12 h, 149.6 mL +/-110 mL vs 63.2 mL +/-78 mL. Using fibrin glue, postoperative fluid amounts were significantly lower through the postoperative observation period of 24 h (851 mL +/-715 mL vs 315 mL +/-305 mL).CONCLUSION: For hepatic resections, the use of fibrin glue appears to be advantageous in terms of a significant decrease of surgically associated segregation of blood or bile out of the resection area. This might result in a better outcome.