Original article
Clinical endoscopy
Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos)

https://doi.org/10.1016/j.gie.2009.11.021Get rights and content

Background

Successful endoscopic treatment of conventional papillary adenomas is well described. However, many authors recommend surgical resection for larger lesions with extrapapillary extension.

Objective

To describe the classification, technique, and outcome for the endoscopic resection of giant laterally spreading tumors of the papilla (LST-P).

Design

Single-center case series.

Settings

Tertiary referral academic gastroenterology unit.

Patients

Patients referred for endoscopic treatment of LST-P.

Intervention

Pre-resection staging and single-session endoscopic removal of papillary adenomas. For those classified as LST-P (>30 mm, extending beyond the papilla onto the duodenal wall and involving as much as two thirds of the duodenal circumference), a standardized single-session EMR technique was used.

Main Outcome Measurements

Technical success, complications, and adenoma recurrence for single-session removal of LST-P. Outcomes were compared with those of conventional ampullary adenoma resection during the same period.

Results

Twenty-five patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; adenoma size 30-80 mm), combination EMR and papillectomy was performed in a single session. The median admission duration was 1 night (range 0-35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in 1 patient (10%). Complication and recurrence rates in smaller (<30 mm) ampullary adenoma resections were not significantly different.

Limitations

A relatively uncommon entity and thus small sample size.

Conclusions

Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands, the outcomes are comparable to those for conventional ampullary adenomas.

Section snippets

Patient recruitment and lesion identification

Over a 24-month period ending in March 2009, patients referred for endoscopic treatment of papillary adenomas were enrolled prospectively. Giant papillary lesions with significant extrapapillary extension, identified as adenomatous tumors involving the major duodenal papilla, with a size greater than 30 mm, extending beyond the papilla onto the duodenal wall with the extrapapillary component equal to or greater than the size of the papillary lesion (and involving as much as two thirds of the

Results

During the study period, 25 patients with papillary adenomas were referred for consideration of endoscopic papillectomy. Ten patients had LST-P and 15 remaining patients had smaller conventional papillary lesions.

Discussion

The results of our series show that even in a mainly elderly population, the single-session combination of EMR and papillectomy is a viable option for LST-P. With careful tumor staging and meticulous resection technique, all LST-P were successfully removed in a single session. Our initial experience would also indicate that nearly all patients are cured with a single intervention.

For this study, we applied the Paris classification system of large sessile or flat neoplastic lesions of the

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

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