Pancreaticoduodenectomy for duodenal papilla carcinoma: A single-centre 9-year retrospective study of 112 patients with long-term follow-up

AIM To retrospectively evaluate the factors that influence long-term outcomes of duodenal papilla carcinoma (DPC) after standard pancreaticoduodenectomy (SPD). METHODS This is a single-centre, retrospective study including 112 DPC patients who had a SPD between 2006 and 2015. Associations between serum levels of CA19-9 and CEA and various clinical characteristics of 112 patients with DPC were evaluated by the. 2 test and Fisher's exact test. The patients were followed-up every 3 mo in the first two years and at least every 6 mo afterwards, with a median follow-up of 60 mo (ranging from 4 mo to 168 mo). Survival analysis was conducted using the Kaplan-Meier survival and Cox proportional hazards model analysis. The difference in survival curves was evaluated with a log-rank test. RESULTS In 112 patients undergoing SPD, serum levels of CA19-9 was associated with serum levels of CEA and drainage mode (the P values were 0.000 and 0.033, respectively); While serum levels of CEA was associated with serum levels of CA19-9 and differentiation of the tumour (the P values were 0.000 and 0.033, respectively). The serum levels of CA19-9 and CEA were closely correlated (chi(2) = 13.277, r = 0.344, P = 0.000). The overall 5-year survival was 50.00% for 112 patients undergoing SPD. The Kaplan-Meier survival analysis showed that increased serum levels of CA19-9, CEA, and total bilirubin were correlated with a poor prognosis, as well as a senior grade of infiltration depth, lymph node metastases, and TNM stage(the P values were 0.033, 0.018, 0.015, 0.000, 0.000 and 0.000, respectively). Only the senior grade of infiltration depth and TNM stage retained their significance when adjustments were made for other known prognostic factors in Cox multivariate analysis (RR = 2.211, P = 0.022 and RR = 2.109, P = 0.047). CONCLUSION For patients with DPC, the serum levels of CA19-9 and CEA were closely correlated, and play an important role in poor survival. Increased serum levels of total bilirubin and lymph node metastases were also correlated with a poor prognosis. The senior grade of infiltration depth and TNM stage can serve as independent prognosis indexes in the evaluation of patients with DPC after SPD.

Endoscopic resection of carcinoid of the minor duodenalpapilla

We encountered a 65-year-old man with a carcinoid tumor of the minor duodenal papilla. Since he had liver cirrhosis and completely refused surgery, we performed an endoscopic snare papillectomy. The papillectomy was performed successfully without procedure-related complication. The specimens revealed a carcinoid tumor showing that the margin of the tumor was positive. One week later, upper GI endoscopy was performed and the biopsy specimens obtained from base of ulcer showed no neoplastic cells. We performed a duodenoscopy and CT 3, 6 and 18 mo later, and there was no macroscopic or microscopic evidence of tumor recurrence after more than 4 years.

Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy:A pilot study

BACKGROUND Endoscopic papillectomy(EP)is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients.With the expansion of indications,concerns regarding EP include not only technical difficulties,but also the risk of complications,especially delayed duodenal perforation.Delayed perforation after EP is a rare but fatal complication.Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP.Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.AIM To evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.METHODS This is a single-center,retrospective study.Five patients with exposure or injury of the muscularis propria after EP were included.A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent,modified by an endoscopic nasobiliary drainage tube,were placed in the common bile duct and pancreatic duct,respectively,and the bile and pancreatic juice were drained to the proximal jejunum.RESULTS EP and overlength stents placement were technically feasible in all five patients(63±12 years),with an average operative time of 63.0±5.6 min.Of the five lesions(median size 20 mm,range 15-35 mm),four achieved en bloc excision and curative resection.The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia(HGD),one tubulovillous adenoma with low-grade dysplasia,one hamartomatous polyp with HGD,one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma,HGD and field cancerization invading the muscularis mucosae and submucosa.There were no stent-related complications,but one papillectomy-related complication(mild acute pancreatitis)occurred without any episodes of bleeding,perforation,cholangitis or late-onset duct stenosis.CONCLUSION For patients with exposure or injury of the muscularis propria after EP,the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.

Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size (up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a ‘‘high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis (FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.

Prospective single-center feasible study of innovative autorelease bile duct supporter to delay adverse events after endoscopic papillectomy

BACKGROUND Conventional endoscopic papillectomy(EP)is safe and effective for the treatment of small papilla adenoma to even large laterally spreading tumors of duodenum lesions.As reported by some existing studies,temporarily placing a prophylactic stent in the pancreatic and bile duct can lower the risk of this perioperative complication.AIM To evaluate the usefulness,convenience,safety,and short-term results of a novel autorelease bile duct supporter after EP procedure,especially the effectiveness in preventing EP.METHODS A single-center comparison study was conducted to verify the feasibility of the novel method.After EP,a metallic endoclip and human fibrin sealant kit were applied for protection.The autorelease bile duct supporter fell into the duct segment and the intestinal segment.Specifically,the intestinal segment was extended by nearly 5 cm as a bent coil.The bile was isolated from the pancreatic juice using an autorelease bile duct supporter,which protected the wound surface.The autorelease bile duct supporter fell off naturally and arrived in colon nearly 10 d after the operation.RESULTS En bloc endoscopic resection was performed in 6/8 patients(75%),and piecemeal resection was performed in 2/8 of patients(25%).None of the above patients were positive for neoplastic lymph nodes or distant metastasis.No cases of mortality,hemorrhage,delayed perforation,pancreatitis,cholangitis or duct stenosis with the conventional medical treatment were reported.The autorelease bile duct supporter in 7 of 8 patients fell off naturally and arrived in colon 10 d after the operation.One autorelease bile duct supporter was successfully removed using forceps or snare under endoscopy.No recurrence was identified during the 8-mo(ranging from 6-9 mo)follow-up period.CONCLUSION In brief,it was found that the autorelease bile duct supporter could decrease the frequency of procedure-associated complications without second endoscopic retraction.Secure closure of the resection wound with clips and fibrin glue were indicated to be promising and important for the use of autorelease bile duct supporters.Well-designed larger-scale comparative studies are required to confirm the findings of this study.

Long-term follow-up of endoscopic papillectomy and the value of preventive pancreatic stent placement(with videos)

Background:Early-stage ampullary adenomas have only been reported in a small case series on endoscopic management.Hence,this study aimed to evaluate the long-term outcomes of early ampullary adenoma with endoscopic management and identify the risk factors for acute pancreatitis after endoscopic papillectomy(EP).Methods:In this study,115 patients who underwent EP at Changhai Hospital(Shanghai,China)between January 2012 and December 2018 were retrospectively analysed.Endoscopy was performed at 1,3,6,and 12months after EP.Data were statistically analysed using the t-test or the Mann–Whitney U test.Results:A total of 107 patients were included in this study and the follow-up period was 75643 months.The average age of the 107 patients was 54.6 years and the average tumor size was 17mm.The average age of the patients(53.7610.7 years vs 55.2610.5 years,P=0.482),minimum tumor size(13 vs 19mm,P=0.063),and complete resection rate(84.78%vs 85.25%,P=0.947)did not differ significantly between the stent placement and non-stent placement groups.Post-EP acute pancreatitis rates in the non-stent placement and stent placement groups were 11.48%and 4.35%,respectively.The risk of post-EP acute pancreatitis was significantly associated with the preoperative carcinoembryonic antigen level in univariate analysis,but not in multivariate analysis.The risk of post-EP acute pancreatitis was not significantly associated with the placement of the pancreatic stent in either univariate or multivariate analysis.Moreover,delayed proximal pancreatic duct stenosis was not noted in either group during long-term follow-up.Conclusions:EP is a satisfactory option for treating adenomas of the ampulla of the duodenum.