Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications.
BACKGROUND
Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniques for decreasing complications and enhancing efficacy.


METHODS
Forty-one patients were referred for endoscopic management of papillary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephrine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent removal was performed 1 month later.


RESULTS
Nine patients (22%) had lesions other than papillary adenoma or cancer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were obtained. Three patients with adenomas (7%) did not undergo endoscopic resection (because of extremely large lesions and/or comorbid illnesses). Thirteen patients with adenomas (32%) had endoscopic resection; 12 (92%) were lesion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient.


CONCLUSIONS
Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresection sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive treatment.
Desilets
D J
DJ
Division of Gastroenterology, Department of Medicine, Maine Medical Center, Portland, Maine, USA.
Dy
R M
RM
Ku
P M
PM
Hanson
B L
BL
Elton
E
E
Mattia
A
A
Howell
D A
DA
D000236:Adenoma / Q000473:pathology* / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014670:Ampulla of Vater; D003138:Common Bile Duct Neoplasms / Q000473:pathology* / Q000601:surgery*; D016145:Endoscopy, Digestive System / Q000379:methods*; D004837:Epinephrine / Q000494:pharmacology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts; D011183:Postoperative Complications / Q000517:prevention & control; D016717:Sphincterotomy, Endoscopic / Q000379:methods*; D015607:Stents; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000494:pharmacology
D014662:Vasoconstrictor Agents; D004837:Epinephrine