Clinical outcomes of ampullary neoplasms in resected margin positive or uncertain cases after endoscopic papillectomy

BACKGROUND Endoscopic papillectomy(EP) for benign ampullary neoplasms could be a lessinvasive alternative to pancreatoduodenectomy(PD). There are some problems and limitations with EP. The post-EP resection margins of ampullary tumors are often positive or uncertain because of the burning effect of EP. The clinical outcomes of resected margin positive or uncertain cases after EP remain unknown.AIM To investigate the clinical outcomes of resected margin positive or uncertain cases after EP.METHODS Between January 2007 and October 2018, all patients with ampullary tumors who underwent EP at Kobe University Hospital were included in this study. The indications for EP were as follows: adenoma, as determined by preoperative endoscopic biopsy, without bile/pancreatic duct extension, according to endoscopic ultrasound or intraductal ultrasound. The clinical outcomes of resected margin positive or uncertain cases after EP were retrospectively investigated.RESULTS Of the 45 patients, 29 were male, and 16 were female. The mean age of the patients was 65 years old. Forty-one patients(89.5%) underwent en bloc resection,and 4 patients(10.5%) underwent piecemeal resection. After EP, 33 tumors were histopathologically diagnosed as adenoma, and 12 were diagnosed as adenocarcinoma. The resected margins were positive or uncertain in 24 patients(53.3%). Of these cases, 15 and 9 were diagnosed as adenoma and adenocarcinoma, respectively. Follow-up observation was selected for all adenomas and 5 adenocarcinomas. In the remaining 4 adenocarcinoma cases,additional PD was performed. Additional PD was performed in 4 cases, and residual carcinoma was found after the additional PD in 1 of these cases. In the follow-up period, local tumor recurrence was detected in 3 cases. Two of these cases involved primary EP-diagnosed adenoma. The recurrent tumors were also adenomas detected by biopsy. The remaining case involved primary EPdiagnosed adenocarcinoma. The recurrent tumor was also an adenocarcinoma.All of the recurrent tumors were successfully treated with argon plasma coagulation(APC). There was no local or lymph node recurrence after the APC.The post-APC follow-up periods lasted for 57.1 to 133.8 mo. No ampullary tumor-related deaths occurred in all patients.CONCLUSION Resected margin positive or uncertain cases after EP could be managed by endoscopic treatment including APC, even in cases of adenocarcinoma. EP could become an effective less-invasive first-line treatment for early stage ampullary tumors.

Liver cirrhosis in Japan:Future global trends in the era of progressive antiviral therapy

In Japan,viral hepatitis is the main cause of chronic liver diseases,including liver cirrhosis.Due to the availability of highly effective antiviral drugs in combination with antihepatitis measures,Japan has become one of the most successful countries in the world with regard to hepatitis virus elimination.In Japan,there are many elderly patients who have been infected with hepatitis C virus for a long time,and antihepatitis measures have been in place since the 2000s.Thus,the medical situation in Japan is expected to reflect the future situation in other countries where hepatitis countermeasures have been recently initiated and the infected population is aging.Our nationwide survey clarified the changes in the etiologies of liver cirrhosis in Japan.Although viral hepatitis remains a major cause of liver cirrhosis in Japan,nonviral cirrhosis is suggested to increasingly contribute to the etiologies of liver cirrhosis,as opposed to viral hepatitis‐related liver cirrhosis.The changing etiology of liver cirrhosis in Japan may help to predict future global trends in chronic liver diseases.