Date Published: January 23, 2019
Publisher: Public Library of Science
Author(s): Masanori Kobayashi, Shomei Ryozawa, Hirotoshi Iwano, Ryuichiro Araki, Yuki Tanisaka, Akashi Fujita, Tsutomu Kobatake, Lise Lotte Gluud.
Although endoscopic papillectomy is useful for treating papillary tumors, it is associated with a high rate of complications including pancreatitis; therefore, safer treatment options are needed. We examined the utility of wire-guided endoscopic papillectomy by comparing the pancreatic duct stenting and pancreatitis rates before and after wire-guided endoscopic papillectomy was introduced at our institution.
We retrospectively examined the data from 16 consecutive patients who underwent conventional endoscopic papillectomy between November 1995 and July 2005 and the data from 33 patients in whom wire-guided endoscopic papillectomy was first attempted at our institution between August 2005 and April 2017. We compared the pancreatic duct stenting and pancreatitis rates between the two groups.
Of the 33 patients in whom wire-guided endoscopic papillectomy was first attempted, the procedure was completed in 21. Pancreatic duct stenting was possible in 30 of the 33 patients in whom wire-guided endoscopic papillectomy was attempted (91%), and this rate was significantly higher than that before the introduction of wire-guided endoscopic papillectomy (68.8%). The incidence of pancreatitis before the introduction of wire-guided endoscopic papillectomy was 12.5%, but after August 2005, the incidence was reduced by half to 6.1%, which includes those patients in whom wire-guided endoscopic papillectomy could not be completed.
Although wire-guided endoscopic papillectomy cannot be completed in some patients, we believe that this method shows some potential for reducing the total incidence of post-endoscopic papillectomy pancreatitis owing to more successful pancreatic duct stenting.
Tumors of the major duodenal papilla are relatively rare, with most of these tumors being adenoma or carcinoma. For patients with carcinoma, surgical pancreatoduodenectomy is considered an appropriate treatment . In contrast, for patients with localized adenoma of the papilla, no treatment guidelines have been defined . Although many reports on the usefulness of endoscopic papillectomy (EP) for treating localized adenoma of the papilla exist [3–8], EP is associated with many complications. For instance, the American Society for Gastrointestinal Endoscopy Guidelines mention pancreatitis, perforation, bleeding, and cholangitis as acute-phase complications . Of these, acute pancreatitis is the most frequent and potentially lethal complication, although it can be prevented, unlike perforation and bleeding. Thus, treatments for or methods of preventing EP-associated acute pancreatitis are needed.
This study was approved by the Saitama Medical University International Medical Center institutional review board (Approval No. 17-041) and conformed to the principles of the Declaration of Helsinki (as revised in Fortaleza, Brazil, in October 2013). All patients’ data were completely anonymized before we accessed them. As per the directives of the institutional review board, although the requirement for informed consent was waived, we ensured that the information about this study was released to the public on our homepage and guaranteed the subjects of this study an opportunity of refusal to participate in the study.
A total of 49 patients were included in this study. The median age of the patients was 65 years (interquartile range: 59–70 years) and the median tumor diameter was 11 mm (interquartile range: 10–20 mm). Regarding the final histological diagnosis, 33 patients had an adenoma, 14 had carcinoma including carcinoma-in-adenoma, 1 had hyperplasia, and 1 had no evidence of tumor tissue on resection. No significant differences in these factors were noted between the two patient groups (before and after the introduction of WGEP). En bloc resection was completed in 41 patients (83.7%) and adverse events occurred in 17 patients (34.7%) (Table 1).
The present study retrospectively analyzed the utility of WGEP versus conventional EP by comparing the rates of pancreatic duct stenting and pancreatitis before and after the introduction of WGEP at our institution.