Detection of tumors of the ampulla of Vater, including ampullary adenoma, has been improved by routine screening endoscopic procedures and imaging modalities. Endoscopic resection by endoscopic papillectomy is rapidly replacing classic surgical resection and is a less invasive procedure. Endoscopic resection can have a role not only in the final histopathologic diagnosis but also as a definite therapeutic option. However, the indications for endoscopic resection are not fully established, and endoscopic procedures are not standardized. Significant complications, including severe pancreatitis, intractable bleeding and duodenal perforation, are rare but can occur, especially in less experienced hands. Severe pancreatitis is the most feared complication, but it can be prevented by pancreatic duct stent insertion in most cases. However, in some cases, pancreatic stenting can be challenging after resection. Incomplete resections are sometimes performed to avoid complications. Endoscopic surveillance is also important for identifying and managing remnant adenomatous tissue or recurrent lesions. Further technical development is needed to expand the indications for this procedure, minimize complications and ensure a high success rate.
Adenoma/pathology/*surgery ; Ampulla of Vater/pathology/*surgery ; Carcinoma/pathology/*surgery ; Common Bile Duct Neoplasms/pathology/*surgery ; Endoscopy, Digestive System ; Humans

Ampulla of Vater/pathology* ; Carcinoma/pathology* ; Common Bile Duct Neoplasms/surgery* ; Humans

Here, a case of a patient with incidental finding of a carcinoid tumor of the ampulla of Vater, who was treated with endoscopic snare papillectomy, is reported. A 62-year-old male was admitted to our hospital due to a carcinoid tumor of the ampulla of Vater, which was found during follow-up endoscopy after an endoscopic mucosal resection of early gastric cancer. No lymphadenopathy or visceral metastasis was found on an abdominal CT scan, In-111 octerotide scan and EUS. The ampulla was then en bloc removed by endoscopic snare papillectomy. The resected specimen revealed a 0.7 X 0.5 X 0.1 cm sized carcinoid tumor. All margins of resection were negative for tumor. After six months of follow-up, there was no evidence of recurrence and metastasis, either endoscopically or radiologically. To our knowledge, this case is the first report of an ampullary carcinoid tumor treated by endoscopic snare papillectomy in Korea.
Ampulla of Vater/pathology/*surgery ; Bile Duct Neoplasms/diagnosis/*surgery ; Carcinoid Tumor/diagnosis/*surgery ; *Duodenoscopy ; Electrosurgery/*methods ; Humans ; Male ; Middle Aged

Ampulla of Vater ; Common Bile Duct ; transplantation ; Duodenum ; surgery ; Gastrointestinal Stromal Tumors ; pathology ; surgery ; Humans ; Male ; Middle Aged

Adenosquamous carcinoma of the papilla of Vater is a rare tumor and only a few cases have been reported so far. Here, we report a case of adenosquamous carcinoma in a 76-year-old male who presented with jaundice and right upper quadrant abdominal pain. Ultrasonography and enhanced abdominal CT scans showed dilated common bile duct (CBD) and intrahepatic bile duct (IHD) with a suspicious obstructing mass in distal CBD. On endoscopy, obstructing and ulcerated mass was noted on the papilla of Vater. Histopathological inspection of the biopsied specimens from mass showed adenosquamous cell carcinoma of the papilla of Vater. Since the patient refused operation, we inserted a self-expandable metallic stent in distal CBD. This is the first case report on adenosquamous carcinoma of the papilla of Vater in Korea.
Aged ; Ampulla of Vater/*pathology ; Carcinoma, Adenosquamous/*diagnosis/pathology/surgery ; Cell Differentiation ; Humans ; Immunohistochemistry ; Male ; Tomography, X-Ray Computed

Gangliocytic paragangliomas (GPs) are rare tumors of the duodenum, presenting as single sessile or pedunculated polypoid masses. Clinical manifestations of duodenal GPs can vary from an incidental finding at endoscopy to frequent upper gastrointestinal bleeding caused by mucosal ulceration and abdominal pain. GPs are considered benign, but the disease can recur and spread to regional lymph nodes. A 41-year-old female presented with abdominal pain. Upper gastrointestinal endoscopy revealed a subepithelial tumor of the ampulla of Vater in the second portion of the duodenum. The tumor was resected using the endoscopic mucosal resection technique. The tumor was diagnosed as benign GP of the duodenum using histological and immunohistochemical staining procedures.
Adult ; Ampulla of Vater/chemistry/*pathology/surgery ; Biopsy ; Duodenal Neoplasms/chemistry/*pathology/surgery ; Duodenoscopy ; Female ; Humans ; Immunohistochemistry ; Paraganglioma/chemistry/*pathology/surgery ; Treatment Outcome ; Tumor Markers, Biological/analysis

BACKGROUNDCarcinomas of the ampulla of Vater (CAV) is a relatively rare malignant gastrointestinal tumor, and its postoperative prognostic factors have been well studied. However, as its first symptom, the impact of jaundice on the prognosis of CAV is not so clear. This study aims to explore the role of jaundice as a prognostic factor in patients undergoing radical treatment for CAV.

METHODSThe clinical data of 195 patients with CAV who were treated in the Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, from January 1989 to January 2013 were retrospectively analyzed. Among them, 170 patients with pathologically confirmed CAV entered the statistical analysis. Jaundice was defined as a total bilirubin serum concentration of ≥ 3 mg/dl. Result Of these 170 patients, 99 (58.20%) had jaundice at presentation. Jaundice showed significant correlations with tumor differentiation (P = 0.002), lymph node metastasis (P = 0.016), pancreatic invasion (P = 0.000), elevated preoperative CA199 (P = 0.000), depth of invasion (P = 0.000), and tumor stage (P = 0.000). There were more patients with pancreatic invasion in the jaundice group than in the non-jaundice group. Also, lymph node metastasis was more common in the jaundice group (n = 26) than in the non-jaundice group (n = 8). The non-jaundice group had significant better overall 5-year disease-free survival (72.6%) than the jaundice group (41.2%, P = 0.013). Jaundice was not significantly correlated with the postoperative bleeding (P = 0.050).

CONCLUSIONSJaundice in patients with CAV often predicts more advanced stages and poorer prognoses. Pancreatic invasion and lymph node metastasis are more common in CAV patients with jaundice. Jaundice is not a risk factor for postoperative bleeding and preoperative biliary drainage cannot reduce the incidence of postoperative complications.

Adult ; Aged ; Ampulla of Vater ; pathology ; physiopathology ; surgery ; Common Bile Duct Neoplasms ; pathology ; physiopathology ; surgery ; Disease-Free Survival ; Female ; Humans ; Jaundice ; physiopathology ; Lymphatic Metastasis ; Male ; Middle Aged ; Pancreaticoduodenectomy

Gangliocytic paraganglioma (GP) is a rare, benign tumor which is usually found in the duodenum. We here report four recent cases of GP, with successful endoscopic resection in three cases, including a lesion on the ampulla of Vater. In all cases, each lesion had a stalk that facilitated removal using an endoscopic approach. Endoscopic mucosal resection is a feasible and safe treatment if the location, depth, and lymph node status are all favorable and is also helpful for definite diagnosis of unknown duodenal mass. To avoid morbidity resulting from open surgical resection, careful inspection for the peduncle of the GP will help determine the feasibility of endoscopic resection.
Aged ; Ampulla of Vater/pathology ; Chromogranin A/metabolism ; Colonoscopy ; Duodenal Neoplasms/pathology/*surgery ; Endoscopy, Gastrointestinal ; Female ; Humans ; Immunohistochemistry ; Intestinal Mucosa/pathology/surgery ; Male ; Middle Aged ; Neuroendocrine Tumors/pathology/surgery ; Paraganglioma/pathology/*surgery ; S100 Proteins/metabolism ; Synaptophysin/metabolism ; Tomography, X-Ray Computed

Though surgical resection has been the traditional treatment for tumors of the ampulla of Vater, endoscopic maneuvers such as snare resection, laser photodestruction and electrofulguration have recently been introduced to avoid operation-related morbidity and mortality. From 1994 to 1996, 6 patients with ampullary tumor were managed by endoscopic snare resection and regularly followed. Endoscopic snare resection of the ampullary tumor was technically feasible in all patients and each procedure was performed in a single session. Histologic diagnoses of the resected specimens were adenoma in 4 patients and adenoma with coexistent adenocarcinoma in 2 patients. Resection margins were negative in all patients except 1 with coexistent adenocarcinoma and a radical pancreaticoduodenectomy was performed in that case. For the other patient with adenocarcinoma foci, no further treatment was persued since he was 72-year-old and refused operation. Acute pancreatitis developed in 2 patients after endoscopic therapy, but was resolved with conservative management. There was no procedure-related death. Surveillance duodenoscopy performed at 1 and 6 months after endoscopic resection revealed no evidence of recurrent tumor in 4 patients with adenoma. Among them, 3 patients are alive without evidence of recurrence at 16-37 months after resection, but 1 patient was lost after 9 months of follow-up. The patient with adenocarcinoma in whom a pancreaticoduodenectomy was performed, has been alive without recurrence for 12 months. Oral 5-fluorouracil was administered for the other patient with adenocarcinoma foci. Though he experienced local recurrence at 13 months after the procedure, he has been alive for 28 months after resection. In conclusion, endoscopic snare resection may be applied as a viable alternative to surgery in selected patients with small ampullary tumors.
Aged ; Common Bile Duct Neoplasms/surgery* ; Common Bile Duct Neoplasms/pathology ; Endoscopy ; Female ; Follow-Up Studies ; Human ; Male ; Middle Age ; Pancreaticoduodenectomy ; Vater's Ampulla*

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.
Adenoma/pathology/*surgery ; Adult ; Aged ; Aged, 80 and over ; Ampulla of Vater/pathology/*surgery ; Biopsy ; Common Bile Duct Neoplasms/pathology/*surgery ; Dissection/*methods ; Duodenoscopy/*methods ; Feasibility Studies ; Female ; Humans ; Male ; Middle Aged ; Neoplasm Recurrence, Local ; Treatment Outcome