- Email: [email protected]
Endoscopic resection of minor papilla adenomas (with video)
Endoscopic resection of minor papilla adenomas (with video) Jessica M. Trevino, MD, C. Mel Wilcox, MD, MSPH, Shyam Varadarajulu, MD Birmingham, Alabama, USA
Background: Although there are several large series on endoscopic resection of the major duodenal papilla, only commentary on individual cases has been presented on endoscopic minor papilla resection. Objective: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Design: Observational study. Setting: Academic tertiary-referral center. Patients: Consecutive patients referred for endoscopic resection of minor papilla adenomas over a 12-month period. Interventions: All patients underwent an EUS before an ERCP to exclude ductal involvement by the tumor and for evaluation of pancreatic-ductal anatomy. The minor papilla was removed by snare electrocautery in all patients. A pancreatic stent was placed in the dorsal duct in patients with pancreas divisum as a prophylaxis for post-ERCP pancreatitis. Complications were assessed per consensus criteria. Main Outcome Measurements: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Observations: Three patients underwent endoscopic resection of minor papilla adenomas over a 12-month period. The first patient had minor papilla adenoma, the second had coexisting pancreas divisum anatomy, and the third had adenomatous involvement of both the major and minor papillas. Minor papilla resection was technically successful in all 3 patients, with dual major and minor papilla resection in 1 patient who had adenomatous changes at both sites. Although 2 patients experienced no complications, the patient with pancreas divisum developed mild post-ERCP pancreatitis. At a 12-month follow-up, there was no evidence of tumor recurrence in any of the 3 patients. Limitation: Small number of patients. Conclusions: In experienced hands, endoscopic resection of the minor papilla is technically feasible, safe, and is associated with favorable clinical outcomes.
Minor papilla pathology is infrequently described. Case reports described pathology that ranges from adenomas to malignant lesions that involve the main pancreatic duct.1-7 Although endoscopic resection of lesions that arise from the major duodenal papilla has been well described,3,8,9 only commentary on individual cases has been presented on endoscopic minor papilla resection.1,3-7 This lack of data compels further evaluation of managing minor papilla lesions by endoscopy. Herein, we report 3 cases of minor papilla adenomas that were unique in each of their presentations and that were managed successfully by endoscopic resection.
PATIENTS AND METHODS
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2008.03.1070
Three patients underwent endoscopic resection of minor papillary adenomas over a 12-month period. All procedures were performed by using a therapeutic duodenoscope (TJF 160; Olympus America, Center Valley, Pa), with the patient under conscious sedation by using a combination of intravenous midazolam, meperidine, and diazepam. All the patients had undergone a prior gastroscopy (EGD) at outside facilities, and biopsy specimens were taken of the minor papilla that revealed adenomatous changes. Per institutional protocol, all patients underwent an EUS before an ERCP by using a radial echoendoscope (GF UM160; Olympus) to confirm the absence of ductal involvement by the tumor and, in addition, to evaluate pancreatic-ductal anatomy. Before an endoscopic resection, a pancreatogram was obtained via cannulation of the ventral duct in all patients to confirm the
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 383
Abbreviation: APC, argon plasma coagulation.
Endoscopic resection of minor papilla adenomas
absence of pancreas divisum. At an ERCP, every attempt was made to resect the minor papilla adenoma in an en bloc fashion by snare polypectomy by using an ERBE generator (ERBE generator, ICC 200EA; USA Incorporated Surgical Systems, Marietta, Ga), with settings of Auto-cut 200 W and coagulation of 20 W, with the Endocut feature on. Any residual tissue not amenable for a polypectomy was treated with ERBE argon plasma coagulation (APC) 300 (USA Incorporated Surgical Systems), with a straight fire probe at 10 L flow and 45 A. Submucosal injection was not performed to facilitate snare polypectomy in any patient. The retrieved specimens were sent for histopathologic analysis to assess tumor margins and to exclude malignancy. After a snare polypectomy, a single pigtail plastic stent was placed in the dorsal duct in a patient with pancreas divisum as a prophylaxis for postprocedure pancreatitis. When a resection of both the major and minor duodenal papillas was undertaken, in the absence of pancreas divisum, a plastic stent was placed in the ventral pancreatic duct. Patients were admitted for observation if they complained of postprocedure abdominal pain. In patients who underwent pancreatic stenting, an abdomen flat-plate radiograph was performed at 3 weeks to check for spontaneous stent passage, and an EGD with a biopsy was undertaken at 12 months for reassessment of the tumor site. Complications were assessed by a telephone call at 72 hours and at day 30 after the procedure. All patients provided written informed consent for undergoing the procedure, and the study was approved by the institutional review board.
Case 1 A 64-year-old woman, during an EGD performed for complaints of nausea and abdominal pain, was found to have a large polypoid lesion at the minor papilla. A biopsy specimen of the minor papilla revealed an adenoma with high-grade dysplasia. At EUS, the lesion was found to be confined to the mucosal layers and was without any ductal involvement (Video 1, available online at www.giejournal.org). At ERCP, after excluding the presence of pancreas divisum, the lesion was removed en bloc by snare polypectomy (Video 1). The patient was discharged home after the procedure. Histopathology revealed tumor-free margins and the absence of invasive carcinoma. At a follow-up endoscopy, there was no tumor recurrence.
Case 2 A 47-year-old man, during an EGD performed for complaints of heartburn, was found to have a polypoid lesion at the minor papilla. Results of a biopsy specimen revealed high-grade dysplasia in the setting of an adenoma. After the procedure (after an initial biopsy), the patient developed pancreatitis of moderate severity, which necessitated a 6-day hospitalization. After recovery, an EUS at our institution showed the adenoma confined to the mucosal layers, and a coexisting pancreas divisum was diagnosed. 384 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
Trevino et al
At ERCP, after placement of a 5F 2-cm plastic stent in the dorsal duct, a minor papilla sphincterotomy was undertaken to facilitate pancreatic drainage. The adenoma was then resected en bloc by snare polypectomy. The patient developed mild postprocedure pancreatitis and was discharged home 72 hours after the ERCP. Histopathology revealed tumor-free margins and the absence of invasive cancer in the resection specimen. An abdomen flat-plate radiograph at 3 weeks revealed spontaneous stent passage. At 12-month follow-up, the patient was doing well, without any local tumor recurrence.
Case 3 A 52-year-old woman underwent an EGD for complaints of abdominal pain and weight loss, and was found to have polypoid-appearing minor and major papillas (Fig. 1A). Biopsy specimens of the minor and major papillas revealed a tubulovillous adenoma at both sites. After excluding the presence of ductal involvement and pancreas divisum by an EUS (Fig. 1B) and an ERCP, both the major and minor papillas were resected en bloc by snare polypectomy. Residual tissue fragments at the major papilla were ablated by using APC. A 5F 2-cm single pigtail stent was placed in the ventral pancreatic duct as prophylaxis for post-ERCP pancreatitis (Fig. 1C, D). The patient did well immediately after the procedure and was discharged home. Histopathology revealed tumor-free margins and the absence of invasive carcinoma in both the major and minor papilla resection specimens. An abdomen flat-plate radiograph at 3 weeks revealed spontaneous stent passage. At 12-month follow-up, no tumor recurrence was noted at both the major and minor papilla resection sites.
OBSERVATIONS Endoscopic resection of the minor papilla was technically successful in all 3 patients in whom it is was attempted. The first patient had minor papilla adenoma, the second patient had coexisting pancreas divisum anatomy, and the third patient had adenomatous involvement of both the major and minor papillas. Although 2 patients did not encounter any procedural complications, 1 patient with pancreas divisum developed mild postprocedure pancreatitis, despite placement of a prophylactic stent in the dorsal duct. Histopathology of the specimens revealed tumor-free margins in all patients, and, at a follow-up endoscopy (with a biopsy of the resection site), no tumor recurrence was noted at the resection site in all patients.
DISCUSSION Although there are several large series on endoscopic resection of benign tumors of the major duodenal www.giejournal.org
Trevino et al
Endoscopic resection of minor papilla adenomas
Figure 1. A, Endoscopic image of adenomatous involvement of both the major and minor duodenal papillas. B, EUS image of the minor papilla, revealing confinement of the lesion to the mucosal region. C, Endoscopic view of snare polypectomy of the minor papilla. D, Endoscopic view, after resection of both the major and minor papillas followed by prophylactic pancreatic-stent placement in the ventral duct.
papilla,8,9 reports on endoscopic minor papilla resection have been limited to individual case reports (Table 1). In this case series, we described 3 patients with minor papilla adenomas that were treated successfully by endoscopic resection. It is important to resect papillary adenomas en bloc, because nearly 30% of lesions have a missed diagnosis of cancer when only a biopsy is undertaken at endoscopy.10 Historically, the removal of papillary lesions necessitated a surgical perspective, which often resulted in an increased hospital stay and intraoperative and/or postoperative complications, with morbidity that ranged as high as 10% to 70%.10 In the absence of ductal involvement, an endoscopic resection appears to be a safe and effective treatment option in these patients. Previous discussions of major ampulla resections have not consistently used an EUS for preresection evaluation. However, an EUS is a highly accurate and noninvasive modality for staging ampullary neoplasms and for evaluating ductal involvement by the tumor.11 Although ductal involvement is considered a relative contraindication, recent reports suggest
that an ampullectomy followed by endoscopic resection of the intraductal growth may be an effective treatment option in selected patients.12 Pancreatitis is a well-recognized complication after an endoscopic resection of benign tumors of the major duodenal papilla.13 A 10% to 15% risk of pancreatitis was reported after minor papilla interventions that did not include ampullary resections.14 This is particularly relevant in the setting of pancreas divisum, because the postinflammatory edema causes obstruction to the flow of pancreatic juice via the small orifice and thereby predisposes to pancreatitis. Hence, a safe approach is mandatory when endoscopic removal of the minor papilla is attempted. In the absence of a pancreas divisum, it appears that a snare polypectomy of the lesion, without pancreatic stenting, would be sufficient treatment. There is only one prior case report on minor papilla resection being performed in the setting of pancreas divisum.1 In that report, after placement of a stent in the dorsal duct and after performing a minor papilla sphincterotomy, a gangliocytic paraganglioma was successfully
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 385
Endoscopic resection of minor papilla adenomas
Trevino et al
TABLE 1. Prior reports on patients with minor papilla lesion managed by endoscopic resection* Reference 1
Study
Presentation
Pathology
Treatment
Loew et al
Case report
Epigastric pain; minor papilla mass at endoscopy; associated pancreas divisum
Gangliocytic paraganglioma
Successful endoscopic resection; no residual mass at 1-mo follow-up
Nakamura et al4
Case report
Epigastric pain; minor papilla mass at endoscopy
Gangliocytic paraganglioma
Successful endoscopic resection; no recurrence at 1-y follow-up
Sugiyama et al5
Case report
Asymptomatic with minor papilla mass on endoscopy
Papillary adenoma
Successful endoscopic resection with no recurrence at 4-y follow-up
Lucena et al6
Case report
Epigastric pain; minor papilla mass at endoscopy
Heterotropic pancreas
Successful endoscopic resection with no recurrence at 1-y follow-up
Itoi et al7
Case report
Asymptomatic; prominent minor papilla on endoscopy
Carcinoid tumor
Endoscopic resection; no recurrence at 4 y
*No procedural complications were reported in any patient.
resected. All other reports on endoscopic minor papilla resection involved dominant pancreatic-duct drainage via the major papilla.1,3-7 None of these patients underwent dorsal-duct stenting, and pancreatitis was not encountered in any of them. Despite the placement of a pancreatic stent, our patient (case 2) developed mild postprocedure pancreatitis. It is very likely that the severity of the pancreatitis was minimized by the placement of a pancreatic stent; a mere biopsy of the minor papilla had induced a more severe attack of pancreatitis in this patient at a prior endoscopy. In one patient who had dual ampullary resection, we stented the ventral pancreatic duct, which is customary in our practice. To our knowledge, a case of dual ampullary resection has not been previously reported in the literature. Pancreatic stenting should be considered mandatory in this clinical scenario, because the postinflammatory edema is likely to impede the flow of pancreatic juice in both the dominant and nondominant ductal systems, thereby increasing the potential for postprocedure pancreatitis. A major limitation of this case series is that we did not assess for stent-induced ductal changes, and the duration of follow-up was short. In summary, in experienced hands, an endoscopic resection of the minor papilla is technically feasible, safe, and associated with favorable clinical outcomes. DISCLOSURE The authors report that there are no disclosures relevant to this publication.
REFERENCES 1. Loew BJ, Lukens FJ, Navarro F, et al. Successful endoscopic resection of gangliocytic paraganglioma of the minor papilla in a patient with pancreas divisum and pancreatitis (video). Gastrointest Endosc 2007;65:547-50.
386 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
2. House MG, Yeo CJ, Schulick RD. Periampullary pancreatic somatostatinoma. Ann Surg Oncol 2002;9:869-74. 3. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004;60: 757-64. 4. Nakamura T, Ozawa T, Kitagawa M, et al. Endoscopic resection of gangliocytic paraganglioma of the minor duodenal papilla: case report and review. Gastrointest Endosc 2002;55:270-3. 5. Sugiyama M, Kimura W, Muto T, et al. Endoscopic resection of adenoma of the minor papilla. Hepatogastroenterology 1999;46: 189-92. 6. Lucena JF, Alvarez OA, Gross GW. Endoscopic resection of heterotropic pancreas of the minor duodenal papilla: case report and review of the literature. Gastrointest Endosc 1997;46:69-72. 7. Itoi T, Sofuni A, Itokawa F, et al. Endoscopic resection of carcinoid of the minor duodenal papilla. World J Gastroenterol 2007;13: 3763-4. 8. Kozarek RA. Endoscopic resection of ampullary neoplasms. J Gastrointest Surg 2004;8:932-4. 9. Bohnacker S, Soehendra N, Maguchi H, et al. Endoscopic resection of benign tumors of the papilla of Vater. Endoscopy 2006;38:521-5. 10. Katsinelos P, Paroutoglou G, Kountouras J, et al. Safety and long-term follow up of endoscopic snare excision of ampullary adenomas. Surg Endosc 2006;20:608-13. 11. Ito K, Fujita N, Noda Y, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc 2007;66: 740-7. 12. Bohnacker S, Seitz U, Hguyen D, et al. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 2005;62:551-60. 13. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62: 367-70. 14. Klein SD, Affronti JP. Pancreas divisum, an evidence-based review: part I, pathophysiology. Gastrointest Endosc 2004;60:419-25.
Received February 3, 2008. Accepted March 9, 2008. Current affiliations: Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA. Reprint requests: Shyam Varadarajulu, MD, Division of GastroenterologyHepatology, University of Alabama at Birmingham Medical Ctr, 410 LHRB, 1530 3rd Ave S, Birmingham, AL 35294.
www.giejournal.org
Background: Although there are several large series on endoscopic resection of the major duodenal papilla, only commentary on individual cases has been presented on endoscopic minor papilla resection. Objective: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Design: Observational study. Setting: Academic tertiary-referral center. Patients: Consecutive patients referred for endoscopic resection of minor papilla adenomas over a 12-month period. Interventions: All patients underwent an EUS before an ERCP to exclude ductal involvement by the tumor and for evaluation of pancreatic-ductal anatomy. The minor papilla was removed by snare electrocautery in all patients. A pancreatic stent was placed in the dorsal duct in patients with pancreas divisum as a prophylaxis for post-ERCP pancreatitis. Complications were assessed per consensus criteria. Main Outcome Measurements: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Observations: Three patients underwent endoscopic resection of minor papilla adenomas over a 12-month period. The first patient had minor papilla adenoma, the second had coexisting pancreas divisum anatomy, and the third had adenomatous involvement of both the major and minor papillas. Minor papilla resection was technically successful in all 3 patients, with dual major and minor papilla resection in 1 patient who had adenomatous changes at both sites. Although 2 patients experienced no complications, the patient with pancreas divisum developed mild post-ERCP pancreatitis. At a 12-month follow-up, there was no evidence of tumor recurrence in any of the 3 patients. Limitation: Small number of patients. Conclusions: In experienced hands, endoscopic resection of the minor papilla is technically feasible, safe, and is associated with favorable clinical outcomes.
Minor papilla pathology is infrequently described. Case reports described pathology that ranges from adenomas to malignant lesions that involve the main pancreatic duct.1-7 Although endoscopic resection of lesions that arise from the major duodenal papilla has been well described,3,8,9 only commentary on individual cases has been presented on endoscopic minor papilla resection.1,3-7 This lack of data compels further evaluation of managing minor papilla lesions by endoscopy. Herein, we report 3 cases of minor papilla adenomas that were unique in each of their presentations and that were managed successfully by endoscopic resection.
PATIENTS AND METHODS
Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2008.03.1070
Three patients underwent endoscopic resection of minor papillary adenomas over a 12-month period. All procedures were performed by using a therapeutic duodenoscope (TJF 160; Olympus America, Center Valley, Pa), with the patient under conscious sedation by using a combination of intravenous midazolam, meperidine, and diazepam. All the patients had undergone a prior gastroscopy (EGD) at outside facilities, and biopsy specimens were taken of the minor papilla that revealed adenomatous changes. Per institutional protocol, all patients underwent an EUS before an ERCP by using a radial echoendoscope (GF UM160; Olympus) to confirm the absence of ductal involvement by the tumor and, in addition, to evaluate pancreatic-ductal anatomy. Before an endoscopic resection, a pancreatogram was obtained via cannulation of the ventral duct in all patients to confirm the
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 383
Abbreviation: APC, argon plasma coagulation.
Endoscopic resection of minor papilla adenomas
absence of pancreas divisum. At an ERCP, every attempt was made to resect the minor papilla adenoma in an en bloc fashion by snare polypectomy by using an ERBE generator (ERBE generator, ICC 200EA; USA Incorporated Surgical Systems, Marietta, Ga), with settings of Auto-cut 200 W and coagulation of 20 W, with the Endocut feature on. Any residual tissue not amenable for a polypectomy was treated with ERBE argon plasma coagulation (APC) 300 (USA Incorporated Surgical Systems), with a straight fire probe at 10 L flow and 45 A. Submucosal injection was not performed to facilitate snare polypectomy in any patient. The retrieved specimens were sent for histopathologic analysis to assess tumor margins and to exclude malignancy. After a snare polypectomy, a single pigtail plastic stent was placed in the dorsal duct in a patient with pancreas divisum as a prophylaxis for postprocedure pancreatitis. When a resection of both the major and minor duodenal papillas was undertaken, in the absence of pancreas divisum, a plastic stent was placed in the ventral pancreatic duct. Patients were admitted for observation if they complained of postprocedure abdominal pain. In patients who underwent pancreatic stenting, an abdomen flat-plate radiograph was performed at 3 weeks to check for spontaneous stent passage, and an EGD with a biopsy was undertaken at 12 months for reassessment of the tumor site. Complications were assessed by a telephone call at 72 hours and at day 30 after the procedure. All patients provided written informed consent for undergoing the procedure, and the study was approved by the institutional review board.
Case 1 A 64-year-old woman, during an EGD performed for complaints of nausea and abdominal pain, was found to have a large polypoid lesion at the minor papilla. A biopsy specimen of the minor papilla revealed an adenoma with high-grade dysplasia. At EUS, the lesion was found to be confined to the mucosal layers and was without any ductal involvement (Video 1, available online at www.giejournal.org). At ERCP, after excluding the presence of pancreas divisum, the lesion was removed en bloc by snare polypectomy (Video 1). The patient was discharged home after the procedure. Histopathology revealed tumor-free margins and the absence of invasive carcinoma. At a follow-up endoscopy, there was no tumor recurrence.
Case 2 A 47-year-old man, during an EGD performed for complaints of heartburn, was found to have a polypoid lesion at the minor papilla. Results of a biopsy specimen revealed high-grade dysplasia in the setting of an adenoma. After the procedure (after an initial biopsy), the patient developed pancreatitis of moderate severity, which necessitated a 6-day hospitalization. After recovery, an EUS at our institution showed the adenoma confined to the mucosal layers, and a coexisting pancreas divisum was diagnosed. 384 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
Trevino et al
At ERCP, after placement of a 5F 2-cm plastic stent in the dorsal duct, a minor papilla sphincterotomy was undertaken to facilitate pancreatic drainage. The adenoma was then resected en bloc by snare polypectomy. The patient developed mild postprocedure pancreatitis and was discharged home 72 hours after the ERCP. Histopathology revealed tumor-free margins and the absence of invasive cancer in the resection specimen. An abdomen flat-plate radiograph at 3 weeks revealed spontaneous stent passage. At 12-month follow-up, the patient was doing well, without any local tumor recurrence.
Case 3 A 52-year-old woman underwent an EGD for complaints of abdominal pain and weight loss, and was found to have polypoid-appearing minor and major papillas (Fig. 1A). Biopsy specimens of the minor and major papillas revealed a tubulovillous adenoma at both sites. After excluding the presence of ductal involvement and pancreas divisum by an EUS (Fig. 1B) and an ERCP, both the major and minor papillas were resected en bloc by snare polypectomy. Residual tissue fragments at the major papilla were ablated by using APC. A 5F 2-cm single pigtail stent was placed in the ventral pancreatic duct as prophylaxis for post-ERCP pancreatitis (Fig. 1C, D). The patient did well immediately after the procedure and was discharged home. Histopathology revealed tumor-free margins and the absence of invasive carcinoma in both the major and minor papilla resection specimens. An abdomen flat-plate radiograph at 3 weeks revealed spontaneous stent passage. At 12-month follow-up, no tumor recurrence was noted at both the major and minor papilla resection sites.
OBSERVATIONS Endoscopic resection of the minor papilla was technically successful in all 3 patients in whom it is was attempted. The first patient had minor papilla adenoma, the second patient had coexisting pancreas divisum anatomy, and the third patient had adenomatous involvement of both the major and minor papillas. Although 2 patients did not encounter any procedural complications, 1 patient with pancreas divisum developed mild postprocedure pancreatitis, despite placement of a prophylactic stent in the dorsal duct. Histopathology of the specimens revealed tumor-free margins in all patients, and, at a follow-up endoscopy (with a biopsy of the resection site), no tumor recurrence was noted at the resection site in all patients.
DISCUSSION Although there are several large series on endoscopic resection of benign tumors of the major duodenal www.giejournal.org
Trevino et al
Endoscopic resection of minor papilla adenomas
Figure 1. A, Endoscopic image of adenomatous involvement of both the major and minor duodenal papillas. B, EUS image of the minor papilla, revealing confinement of the lesion to the mucosal region. C, Endoscopic view of snare polypectomy of the minor papilla. D, Endoscopic view, after resection of both the major and minor papillas followed by prophylactic pancreatic-stent placement in the ventral duct.
papilla,8,9 reports on endoscopic minor papilla resection have been limited to individual case reports (Table 1). In this case series, we described 3 patients with minor papilla adenomas that were treated successfully by endoscopic resection. It is important to resect papillary adenomas en bloc, because nearly 30% of lesions have a missed diagnosis of cancer when only a biopsy is undertaken at endoscopy.10 Historically, the removal of papillary lesions necessitated a surgical perspective, which often resulted in an increased hospital stay and intraoperative and/or postoperative complications, with morbidity that ranged as high as 10% to 70%.10 In the absence of ductal involvement, an endoscopic resection appears to be a safe and effective treatment option in these patients. Previous discussions of major ampulla resections have not consistently used an EUS for preresection evaluation. However, an EUS is a highly accurate and noninvasive modality for staging ampullary neoplasms and for evaluating ductal involvement by the tumor.11 Although ductal involvement is considered a relative contraindication, recent reports suggest
that an ampullectomy followed by endoscopic resection of the intraductal growth may be an effective treatment option in selected patients.12 Pancreatitis is a well-recognized complication after an endoscopic resection of benign tumors of the major duodenal papilla.13 A 10% to 15% risk of pancreatitis was reported after minor papilla interventions that did not include ampullary resections.14 This is particularly relevant in the setting of pancreas divisum, because the postinflammatory edema causes obstruction to the flow of pancreatic juice via the small orifice and thereby predisposes to pancreatitis. Hence, a safe approach is mandatory when endoscopic removal of the minor papilla is attempted. In the absence of a pancreas divisum, it appears that a snare polypectomy of the lesion, without pancreatic stenting, would be sufficient treatment. There is only one prior case report on minor papilla resection being performed in the setting of pancreas divisum.1 In that report, after placement of a stent in the dorsal duct and after performing a minor papilla sphincterotomy, a gangliocytic paraganglioma was successfully
www.giejournal.org
Volume 68, No. 2 : 2008 GASTROINTESTINAL ENDOSCOPY 385
Endoscopic resection of minor papilla adenomas
Trevino et al
TABLE 1. Prior reports on patients with minor papilla lesion managed by endoscopic resection* Reference 1
Study
Presentation
Pathology
Treatment
Loew et al
Case report
Epigastric pain; minor papilla mass at endoscopy; associated pancreas divisum
Gangliocytic paraganglioma
Successful endoscopic resection; no residual mass at 1-mo follow-up
Nakamura et al4
Case report
Epigastric pain; minor papilla mass at endoscopy
Gangliocytic paraganglioma
Successful endoscopic resection; no recurrence at 1-y follow-up
Sugiyama et al5
Case report
Asymptomatic with minor papilla mass on endoscopy
Papillary adenoma
Successful endoscopic resection with no recurrence at 4-y follow-up
Lucena et al6
Case report
Epigastric pain; minor papilla mass at endoscopy
Heterotropic pancreas
Successful endoscopic resection with no recurrence at 1-y follow-up
Itoi et al7
Case report
Asymptomatic; prominent minor papilla on endoscopy
Carcinoid tumor
Endoscopic resection; no recurrence at 4 y
*No procedural complications were reported in any patient.
resected. All other reports on endoscopic minor papilla resection involved dominant pancreatic-duct drainage via the major papilla.1,3-7 None of these patients underwent dorsal-duct stenting, and pancreatitis was not encountered in any of them. Despite the placement of a pancreatic stent, our patient (case 2) developed mild postprocedure pancreatitis. It is very likely that the severity of the pancreatitis was minimized by the placement of a pancreatic stent; a mere biopsy of the minor papilla had induced a more severe attack of pancreatitis in this patient at a prior endoscopy. In one patient who had dual ampullary resection, we stented the ventral pancreatic duct, which is customary in our practice. To our knowledge, a case of dual ampullary resection has not been previously reported in the literature. Pancreatic stenting should be considered mandatory in this clinical scenario, because the postinflammatory edema is likely to impede the flow of pancreatic juice in both the dominant and nondominant ductal systems, thereby increasing the potential for postprocedure pancreatitis. A major limitation of this case series is that we did not assess for stent-induced ductal changes, and the duration of follow-up was short. In summary, in experienced hands, an endoscopic resection of the minor papilla is technically feasible, safe, and associated with favorable clinical outcomes. DISCLOSURE The authors report that there are no disclosures relevant to this publication.
REFERENCES 1. Loew BJ, Lukens FJ, Navarro F, et al. Successful endoscopic resection of gangliocytic paraganglioma of the minor papilla in a patient with pancreas divisum and pancreatitis (video). Gastrointest Endosc 2007;65:547-50.
386 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 2 : 2008
2. House MG, Yeo CJ, Schulick RD. Periampullary pancreatic somatostatinoma. Ann Surg Oncol 2002;9:869-74. 3. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004;60: 757-64. 4. Nakamura T, Ozawa T, Kitagawa M, et al. Endoscopic resection of gangliocytic paraganglioma of the minor duodenal papilla: case report and review. Gastrointest Endosc 2002;55:270-3. 5. Sugiyama M, Kimura W, Muto T, et al. Endoscopic resection of adenoma of the minor papilla. Hepatogastroenterology 1999;46: 189-92. 6. Lucena JF, Alvarez OA, Gross GW. Endoscopic resection of heterotropic pancreas of the minor duodenal papilla: case report and review of the literature. Gastrointest Endosc 1997;46:69-72. 7. Itoi T, Sofuni A, Itokawa F, et al. Endoscopic resection of carcinoid of the minor duodenal papilla. World J Gastroenterol 2007;13: 3763-4. 8. Kozarek RA. Endoscopic resection of ampullary neoplasms. J Gastrointest Surg 2004;8:932-4. 9. Bohnacker S, Soehendra N, Maguchi H, et al. Endoscopic resection of benign tumors of the papilla of Vater. Endoscopy 2006;38:521-5. 10. Katsinelos P, Paroutoglou G, Kountouras J, et al. Safety and long-term follow up of endoscopic snare excision of ampullary adenomas. Surg Endosc 2006;20:608-13. 11. Ito K, Fujita N, Noda Y, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc 2007;66: 740-7. 12. Bohnacker S, Seitz U, Hguyen D, et al. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 2005;62:551-60. 13. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62: 367-70. 14. Klein SD, Affronti JP. Pancreas divisum, an evidence-based review: part I, pathophysiology. Gastrointest Endosc 2004;60:419-25.
Received February 3, 2008. Accepted March 9, 2008. Current affiliations: Division of Gastroenterology-Hepatology, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA. Reprint requests: Shyam Varadarajulu, MD, Division of GastroenterologyHepatology, University of Alabama at Birmingham Medical Ctr, 410 LHRB, 1530 3rd Ave S, Birmingham, AL 35294.
www.giejournal.org