Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis

Marcus Hollenbach, Department of Gastroenterology, Endocrinology, Metabolism and Clinical Infectiology, University Hospital of Giessen and Marburg Campus Marburg, Marburg, Germany marcus.hollenbach@web.de.
Christian Heise, Medical Department I, Martin-Luther-Universitat Halle-Wittenberg, Halle, Germany.
Einas Abou-Ali, Department of Gastroenterology, Digestive Oncology and Endoscopy, Paris Descartes University Paris, Paris, France.
Aiste Gulla, Department of Surgery, George Washington University, School of Medicine and Health Sciences, Washington DC, District of Columbia, USA.
Francesco Auriemma, Gastrointestinal Endoscopy, Humanitas Mater Domini, Castellanza, Italy.
Kevin Soares, Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Galen Leung, Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
Mark A. Schattner, Gastroenterology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
William R. Jarnagin, Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Tiegong Wang, Hepatopancreatobiliary Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA.
Fabrice Caillol, Digestive Endoscopy Department, Institut Paoli Calmettes, Marseille, France.
Marc Giovannini, Digestive Endoscopy Department, Institut Paoli Calmettes, Marseille, France.
Yanis Dahel, Digestive Endoscopy Department, Institut Paoli Calmettes, Marseille, France.
Thilo Hackert, Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany.
Woo Hyun Paik, Division of Gastroenterology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
Alessandro Zerbi, Department of Biochemical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Gennaro Nappo, Department of Biochemical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
Bertrand Napoleon, Endoscopie Digestive, hopital privé Jean Mermoz, Générale de Santé, Lyon, France.
Urban Arnelo, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
Erik Haraldsson, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
Asif Halimi, Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
Alexander Waldthaler, Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden.
Uwe Will, Department of Gastroenterology, Hepatology, Diabetology and General Internal Medicine, SRH Wald-Klinikum Gera GmbH, Gera, Germany.
Rita Saadeh, Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany.
Viliam Masaryk, Department of Gastroenterology, Hepatology, Diabetes and General Internal Medicine, SRH Wald-Klinikum Gera, Gera, Germany.
Sophia E. van der Wiel, Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Marco J. Bruno, Department of Gastroenterology and Hepatology, Erasmus Medical Center, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Enrique Perez-Cuadrado-Robles, Interventional Endoscopy, Department of Gastroenterology, Georges-Pompidou European Hospital, Paris, France.
Pierre Deprez, Department of Gastroenterology, Cliniques universitaires Saint-Luc, Bruxelles, Belgium.
Alain Sauvanet, Departement of Digestive Surgery, Beaujon Hospital APHP, Clichy, France.
Louisa Bolm, Department of Surgery, University Medical Center Schleswig Holstein, Campus Luebeck, Luebeck, Germany.
Tobias Keck, Department of Surgery, University Medical Center Schleswig Holstein, Campus Luebeck, Luebeck, Germany.

Document Type

Journal Article

Publication Date

12-12-2024

Journal

Gut

DOI

10.1136/gutjnl-2022-327996

Keywords

ENDOSCOPIC PROCEDURES; ENDOSCOPIC RETROGRADE PANCREATOGRAPHY; PANCREATIC CANCER; PANCREATIC TUMOURS; PANCREATICODUODENECTOMY

Abstract

OBJECTIVE: Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA. DESIGN: Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10-47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher's exact or χ test, Mann-Whitney-U-test and log-rank test for survival. RESULTS: Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable. CONCLUSIONS: The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.

Department

Surgery

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