Clinical Medicine: Gastroenterology   

Uwe Will¹, Peter Gottschalk², Hans Bosseckert² and Frank Meyer³

¹Department of Gastroenterology, Municipal Hospital, Gera, Germany. ²Department of Internal Medicine I, University Hospital, Jena, Germany. ³Department of Surgery, University Hospital, Magdeburg, Germany

Abstract

Endoscopic papillectomy is a promising and challenging endoscopic intervention.  The aim of this study was  i) to classify the differential indication, and  ii) to study the outcome in papillectomy of suspicious tumor lesions of Vater (papilla).  Methods:  Thirty nine patients were enrolled (22 males/17 females; range of age, 21-88 years) who underwent endoscopic papillectomy because of a polypoid tumor at the papilla revealed by previous endoscopic ultrasonography (EUS) over a time period of 5 years.  Follow-up EUS and histologic investigation were performed within 28 days(d).  Results:  I) All tumors were detectable using EUS (range of tumor size, 1-4.5 cm).  II) Indications, histologic diagnoses and their distribution were as follows:  Group(Gr.)1 (n=21):  Adenoma (n=18), uT1 carcinoma(Ca) of high risk patients (n=3) with R0 resection (n=17) vs. R1 (n=4; all reapproached using argon beamer).  On the 28th postinterventional d, all subjects were free of tumor.  Recurrent tumor growth was found in 3 cases after 6, 18 and 26 months (range of endoscopic follow up [n=14], 3-60 months).  Three patients (free of tumor) died from other causes after 3, 8 and 18 months, respectively.  Gr.2 (n=8):  Contradiction between EUS (infiltrating tumor growth) and histologic finding (adenoma or unspecific inflammation); histological findings were:  Adenomyomatosis of the papilla (n=5), infiltrating Ca of the papilla or peripapillary region (n=3).  Gr.3 (n=4):  Neuroendocrine tumors of the major (n=2) or minor papilla (n=2):  2 benign, 1 Ca and 1 carcinoid tumor.  Gr.4 (n=6):  Non-introducible catheter through the minor papilla in case of suspected pancreas divisum (n=2) or through the major papilla (n=1) after previous gastric resection (Billroth II) or because of Ca of the papilla with no successful attempts to drain the bile duct (n=3):.  Catheter insertion was achieved after papillectomy (n=3) or partial tumor resection (n=3).  III) Complications:  8 of 39 patients (20.5 %) developed postinterventional pancreatitis (severe course, n=1); in 7 cases, bleeding occurred, no perforation was seen.  The rate of recurrent tumor growth after R0 resection was 17.6 % (3 of 17 subjects).  In summary, papillectomy is feasible in the case of  i) polypoid tumor of the papilla, ii) infiltrating tumor growth revealed by EUS and negative histologic investigation (optional: plus deep biopsy), and  iii) tumor lesion, through which catheter cannot be placed to get access to the pancreatobiliary system.  In conclusion, endoscopic papillectomy fulfills diagnostic as well as therapeutic requirements and can be recommended as minimally invasive but appropriate method for well-defined indications of papillary tumor lesions.