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Endoscopic resection of duodenal ampulla with a transparent plastic cap
Endoscopic resection of duodenal ampulla with a transparent plastic cap Yosuke Izumi, MD, Kenichi Teramoto, MD, Masahiro Ohshima, MD, Shigehiro Shin, MD, Akihiko Yamamura, MD, and Michio Matsumoto, MD, Tokyo, Japan
From the Department of Surgery and Pathology, NTT Izu Teishin Hospital, Tokyo, Japan
ENDOSCOPIC PAPILLECTOMY WAS PERFORMED for a case of dysplasia of the papilla of Vater. A transparent plastic cap (Olympus, Tokyo, Japan) was attached to the tip of the endoscope. Endoscopic snare papillectomy demands some skills, but this modification made it very easy and safe. This method was originally developed by Inoue et al.1 for endoscopic mucosectomy of the esophagus. We found it suitable for resection of the papilla of Vater. CASE REPORT A 54-year-old woman underwent partial gastrectomy and Billroth I reconstruction for gastric mucosal cancer on February 23, 1995. During follow-up an endoscopic examination was performed because of increasing serum carcinoembryonic antigen (CEA) level and revealed marked redness with an irregular surface and almost normal size of the papilla of Vater. First biopsy was done, and the pathologic diagnosis was “well differentiated adenocarcinoma, suspected.” She was admitted to this hospital for the purpose of further examination and treatment. The physical examination and laboratory data were normal except for high serum CEA level of 8.3 ng/ml (normal, less than 5.0 ng/ml). The computed tomography scan revealed no mass in the pancreas head. Endoscopic retrograde cholangiopancreatogram showed normal pancreatic duct and intact Santorini’s duct. The second endoscopic examination was performed, and slight villous change of the papilla was found. The biopsy specimen showed hyperchromatic dysplastic epithelium. The pathologic diagnosis was again “well differentiated adenocarcinoma, suspected.” Endoscopic papillectomy with a transparent plastic cap was performed on October 31, 1995. The snare was opened inside the cap with the nail as a hook (Fig. 1, A). Accepted for publication March 18, 1997. Reprint requests: Yosuke Izumi, MD, First Department of Surgery, Tokyo Medical and Dental University, 5-45, Yushima 1, Bunkyo-ku, Tokyo 113, Japan. Surgery 1998;123:109-10. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0
11/57/81949
Fig. 1. Procedure of endoscopic papillectomy with a transparent plastic cap. A, A 0.5-mm-long nail (N) is attached along the inside of tip of cap. Snare (S) can be easily looped along the nail. B, Lesion-bearing papilla (P) was suctioned up inside the cap and snared tightly. C, Strangulated papilla was resected by electrical cauterization. D, Specimen was easily retrieved by keeping it firmly inside the cap. The lesion-bearing papilla was suctioned up inside the cap and snared tightly (Fig. 1, B). The strangulated papilla was resected by electrical cauterization (Fig. 1, C). The specimen was easily retrieved by keeping it firmly inside the cap (Fig. 1, D). Neither bleeding nor perSURGERY 109
110 Izumi et al.
Fig. 2. Resected specimen. Arrow points to the aperture of Vater’s papilla. Open arrows point to Oddi’s sphincter. foration occurred. A biliary stent was inserted after resection to prevent obstruction. The postoperative course was uneventful, and no symptoms such as abdominal pain or obstructive jaundice were noted. Only the serum amylase level increased to 1016 IU (normal, 42 to 116 IU) on postoperative day 1 with no clinical symptoms but decreased to 225 IU on postoperative day 3, and soft meal was provided. Postoperative sonogram showed no abnormality of the upper abdomen. She was discharged from hospital on postoperative day 10, confirming the pathologic result. Serum CEA level decreased to 5.8 ng/ml. A whole specimen of papilla, 1.0 × 1.0 cm in size, was resected, including Oddi’s sphincter muscle (Fig. 2). On histologic examination it consisted of high-columnar dysplastic epithelium with moderate cellular atypia and slight architectural atypia caused by chronic inflammation. There was no associated neoplasia. The surgical margins were free of dysplasia. The biliary stent was removed 2 months after papillectomy. There has been no recurrence during 11 months of follow-up.
DISCUSSION In this article we have shown the safety and feasibility of endoscopic resection of Vater’s papilla. Concern has been expressed that the sensitive anatomy of the papilla of Vater may increase the risk for potential complications, including bleeding, perforation, jaundice, and pancreatitis.
Surgery January 1998 However, Binmoeller et al.2 proved the feasibility and safety of snare papillectomy. They encountered five complications (bleeding in two patients and acute pancreatitis in three patients) out of 25 cases, which they could deal with conservatively. Snare excision demands a certain degree of skill from the endoscopist especially in the case of flat lesions. The transparent plastic cap method made the procedure much easier and safer. The principal advantages of this method compared with the conventional snare excision are the following: (1) safety and handiness because the papilla is caught in the cap by endoscopic suction; (2) easy retrieval of the specimen by keeping it firmly inside the cap; (3) possibility to resect flat lesions; (4) possibility to use a forward viewing endoscope, which is easier to handle than oblique viewing endoscope. Moreover, the depth of the resection can be adjusted by changing the size of the cap. In this case pathologists could not exclude malignancy with the repeated biopsy specimens. The resected specimen revealed dysplasia, not adenocarcinoma. It is sometimes hard for the pathologist to make a diagnosis with only a forceps specimen.3 Pancreatoduodenectomy would have been out of proportion to the benign nature. In this case the endoscopic papillectomy was thus beneficial not only as a diagnostic procedure but also as a therapeutic measure. REFERENCES 1. Inoue H, Endo M. A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Surg Endosc 1992;6:264-5. 2. Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993;39:127-31. 3. Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol 1992;87:37-42.
From the Department of Surgery and Pathology, NTT Izu Teishin Hospital, Tokyo, Japan
ENDOSCOPIC PAPILLECTOMY WAS PERFORMED for a case of dysplasia of the papilla of Vater. A transparent plastic cap (Olympus, Tokyo, Japan) was attached to the tip of the endoscope. Endoscopic snare papillectomy demands some skills, but this modification made it very easy and safe. This method was originally developed by Inoue et al.1 for endoscopic mucosectomy of the esophagus. We found it suitable for resection of the papilla of Vater. CASE REPORT A 54-year-old woman underwent partial gastrectomy and Billroth I reconstruction for gastric mucosal cancer on February 23, 1995. During follow-up an endoscopic examination was performed because of increasing serum carcinoembryonic antigen (CEA) level and revealed marked redness with an irregular surface and almost normal size of the papilla of Vater. First biopsy was done, and the pathologic diagnosis was “well differentiated adenocarcinoma, suspected.” She was admitted to this hospital for the purpose of further examination and treatment. The physical examination and laboratory data were normal except for high serum CEA level of 8.3 ng/ml (normal, less than 5.0 ng/ml). The computed tomography scan revealed no mass in the pancreas head. Endoscopic retrograde cholangiopancreatogram showed normal pancreatic duct and intact Santorini’s duct. The second endoscopic examination was performed, and slight villous change of the papilla was found. The biopsy specimen showed hyperchromatic dysplastic epithelium. The pathologic diagnosis was again “well differentiated adenocarcinoma, suspected.” Endoscopic papillectomy with a transparent plastic cap was performed on October 31, 1995. The snare was opened inside the cap with the nail as a hook (Fig. 1, A). Accepted for publication March 18, 1997. Reprint requests: Yosuke Izumi, MD, First Department of Surgery, Tokyo Medical and Dental University, 5-45, Yushima 1, Bunkyo-ku, Tokyo 113, Japan. Surgery 1998;123:109-10. Copyright © 1998 by Mosby, Inc. 0039-6060/98/$5.00 + 0
11/57/81949
Fig. 1. Procedure of endoscopic papillectomy with a transparent plastic cap. A, A 0.5-mm-long nail (N) is attached along the inside of tip of cap. Snare (S) can be easily looped along the nail. B, Lesion-bearing papilla (P) was suctioned up inside the cap and snared tightly. C, Strangulated papilla was resected by electrical cauterization. D, Specimen was easily retrieved by keeping it firmly inside the cap. The lesion-bearing papilla was suctioned up inside the cap and snared tightly (Fig. 1, B). The strangulated papilla was resected by electrical cauterization (Fig. 1, C). The specimen was easily retrieved by keeping it firmly inside the cap (Fig. 1, D). Neither bleeding nor perSURGERY 109
110 Izumi et al.
Fig. 2. Resected specimen. Arrow points to the aperture of Vater’s papilla. Open arrows point to Oddi’s sphincter. foration occurred. A biliary stent was inserted after resection to prevent obstruction. The postoperative course was uneventful, and no symptoms such as abdominal pain or obstructive jaundice were noted. Only the serum amylase level increased to 1016 IU (normal, 42 to 116 IU) on postoperative day 1 with no clinical symptoms but decreased to 225 IU on postoperative day 3, and soft meal was provided. Postoperative sonogram showed no abnormality of the upper abdomen. She was discharged from hospital on postoperative day 10, confirming the pathologic result. Serum CEA level decreased to 5.8 ng/ml. A whole specimen of papilla, 1.0 × 1.0 cm in size, was resected, including Oddi’s sphincter muscle (Fig. 2). On histologic examination it consisted of high-columnar dysplastic epithelium with moderate cellular atypia and slight architectural atypia caused by chronic inflammation. There was no associated neoplasia. The surgical margins were free of dysplasia. The biliary stent was removed 2 months after papillectomy. There has been no recurrence during 11 months of follow-up.
DISCUSSION In this article we have shown the safety and feasibility of endoscopic resection of Vater’s papilla. Concern has been expressed that the sensitive anatomy of the papilla of Vater may increase the risk for potential complications, including bleeding, perforation, jaundice, and pancreatitis.
Surgery January 1998 However, Binmoeller et al.2 proved the feasibility and safety of snare papillectomy. They encountered five complications (bleeding in two patients and acute pancreatitis in three patients) out of 25 cases, which they could deal with conservatively. Snare excision demands a certain degree of skill from the endoscopist especially in the case of flat lesions. The transparent plastic cap method made the procedure much easier and safer. The principal advantages of this method compared with the conventional snare excision are the following: (1) safety and handiness because the papilla is caught in the cap by endoscopic suction; (2) easy retrieval of the specimen by keeping it firmly inside the cap; (3) possibility to resect flat lesions; (4) possibility to use a forward viewing endoscope, which is easier to handle than oblique viewing endoscope. Moreover, the depth of the resection can be adjusted by changing the size of the cap. In this case pathologists could not exclude malignancy with the repeated biopsy specimens. The resected specimen revealed dysplasia, not adenocarcinoma. It is sometimes hard for the pathologist to make a diagnosis with only a forceps specimen.3 Pancreatoduodenectomy would have been out of proportion to the benign nature. In this case the endoscopic papillectomy was thus beneficial not only as a diagnostic procedure but also as a therapeutic measure. REFERENCES 1. Inoue H, Endo M. A new simplified technique of endoscopic esophageal mucosal resection using a cap-fitted panendoscope (EMRC). Surg Endosc 1992;6:264-5. 2. Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993;39:127-31. 3. Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol 1992;87:37-42.