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Endoscopic Papillectomy

  • Laura BernardoniEmail author
  • Stefano Francesco Crinò
  • Armando Gabbrielli
Chapter
  • 155 Downloads

Abstract

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 (till 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings (ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound (EUS) can be useful for establish local T staging in ampullary neoplasms. EP 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.  EP is considered a “high-risk” procedure due to complications. Adverse events of EP can be classified as early (pancreatitis, bleeding, perforation, and cholangitis) and late (papillary stenosis) ones. The appropriate use of stenting after EP 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.

Keywords

Endoscopic papillectomy Papillary neoplasms Major duodenal papilla Endoscopic retrograde cholangiopancreatography Ampullary adenoma Endoscopic resection 

Supplementary material

Video 20.1

Patient with FAP (familial adenomatous polyposis) with ampulloma and anamnestic biliary sphincterotomy in the past for choledocholithiasis. The lesion is assessed with NBI. The snare is positioned at the apex of the papilla and opens in a caudal sense; a gentle movement of the snare with the elevator can assess the mobility of tumor and the absence of deep invasion of the duodenal wall. The adenoma is cut with HERBE; small peripheral residues remain; they will be removed with forceps and treated with APC at endoscopic follow-up at 3 months (MP4 255016 kb)

Video 20.2

A young patient with FAP with a large ampulloma of papilla major. The neoplasm is grasped with a snare and en bloc resected with HERBE. After having recovered the adenoma, the main pancreatic duct is immediately sought (5 o’clock) with a guide wire. Pancreatic plastic stent is placed on the guide wire. In a second time, the biliary orifice (11 o’clock) is looked for and plastic biliary stent is positioned (MP4 689059 kb)

Video 20.3

In this patient venous bleeding occurred 24 h after ampullectomy. Hemostasis with adrenaline and by positioning a clip was not sufficient to achieve complete hemostasis. Hemospray was used to stop bleeding. The presence of the plastic pancreatic stent allowed to work safely (MP4 89226 kb)

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Laura Bernardoni
    • 1
    Email author
  • Stefano Francesco Crinò
    • 1
  • Armando Gabbrielli
    • 1
  1. 1.Gastroenterology and Digestive Endoscopy UnitThe Pancreas Institute, G.B. Rossi University HospitalVeronaItaly

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