Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney Australia.
Westmead Clinical School, University of Sydney, Sydney, Australia.
Endoscopy. 2018 Oct;50(10):972-983. doi: 10.1055/a-0587-5228. Epub 2018 May 16.
Endoscopic resection of ampullary adenomas is a safe and effective alternative to surgical resection. A subgroup of patients have large laterally spreading lesions of the papilla Vateri (LSL-P), which are frequently managed surgically. Data on endoscopic resection of LSL-P are limited and long-term outcomes are unknown. The aim of this study was to compare the outcomes of endoscopic resection of LSL-P with those of standard ampullary adenomas.
A retrospective analysis of a prospectively collected and maintained database was conducted. LSL-P was defined as extension of the lesion ≥ 10 mm from the edge of the ampullary mound. Piecemeal endoscopic mucosal resection of the laterally spreading component was followed by resection of the ampulla. Patient, lesion, and procedural data, as well as results of endoscopic follow-up, were collected.
125 lesions were resected. Complete endoscopic resection was achieved in 97.6 % at the index procedure (median lesion size 20 mm, interquartile range [IQR] 13 - 30 mm). Compared with ampullary adenomas, LSL-Ps were significantly larger (median 35 mm vs. 15 mm), contained a higher rate of advanced pathology (38.6 % vs. 18.5 %), and had higher rates of intraprocedural bleeding (50 % vs. 24.7 %) and delayed bleeding (25.0 % vs. 12.3 %). Both groups had similar rates of histologically proven recurrence at first surveillance (16.4 % vs. 17.9 %). Median follow-up for the entire cohort was 18.5 months. For patients with at least two surveillance endoscopies (n = 68; median follow-up 29 months, IQR 18 - 48 months), 95.6 % were clear of disease and considered cured.
LSL-P can be resected endoscopically with comparable outcomes to standard ampullectomy, albeit with a higher risk of bleeding. Endoscopic treatment should be considered as an alternative to surgical resection, even for large LSL-P.
内镜下切除壶腹腺瘤是一种安全有效的手术切除替代方法。一组患者有较大的壶腹 Vateri 侧向扩展病变（LSL-P），这些病变通常需要手术治疗。关于 LSL-P 的内镜下切除的数据有限，长期结果尚不清楚。本研究的目的是比较内镜下切除 LSL-P 与标准壶腹腺瘤的结果。
对前瞻性收集和维护的数据库进行回顾性分析。LSL-P 的定义为病变从壶腹丘边缘延伸≥10mm。侧向扩展部分的分片内镜黏膜切除术，然后切除壶腹。收集患者、病变和程序数据，以及内镜随访结果。
共切除 125 个病变。索引手术时，97.6%的病变达到完全内镜下切除（中位病变大小 20mm，四分位间距[IQR]13-30mm）。与壶腹腺瘤相比，LSL-P 明显更大（中位 35mm 比 15mm），高级别病理比例更高（38.6%比 18.5%），术中出血率更高（50%比 24.7%），延迟出血率更高（25.0%比 12.3%）。两组在第一次监测时的组织学证实复发率相似（16.4%比 17.9%）。整个队列的中位随访时间为 18.5 个月。对于至少有两次监测内镜的患者（n=68；中位随访 29 个月，IQR 18-48 个月），95.6%的患者无疾病且被认为已治愈。
LSL-P 可以通过内镜切除，与标准的壶腹切除术结果相当，尽管出血风险较高。即使对于较大的 LSL-P，内镜治疗也应被视为手术切除的替代方法。
