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Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection?

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Abstract

Background

Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions.

Materials and methods

Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen.

Results

In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%).

Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma.

Conclusions

In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.

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Authors and Affiliations

  1. Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden

    Erik Haraldsson, Asif Halimi, Elena Rangelova, Roberto Valente, J. Matthias Löhr & Urban Arnelo

  2. Department of Surgery, Skaraborg Hospital, Skövde, Sweden

    Erik Haraldsson

  3. Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden

    Asif Halimi, Roberto Valente & Urban Arnelo

  4. Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden

    Elena Rangelova

  5. Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden

    J. Matthias Löhr

Authors
  1. Erik Haraldsson
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  2. Asif Halimi
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Correspondence to Erik Haraldsson.

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Disclosures

Dr. Urban Arnelo has been engaged as a consultant for Ambu A/S, Boston Scientific Inc, and Medtronic and receives funding from the Stockholm County Council, the Karolinska Institute (SLL: ALF 20170480), and the Swedish Cancer Society (Cancerfonden, 19 0513 Fk 01 H). Dr. Erik Haraldsson has received funding from the Research Fund at Skaraborg Hospital, Skövde, Sweden (VGSKAS-901291) during the conduct of the study. Drs. Asif Halimi, Elena Rangelova, Roberto Valente, J-Matthias Löhr have no conflicts of interest or financial ties to disclose.

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Haraldsson, E., Halimi, A., Rangelova, E. et al. Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection?. Surg Endosc 36, 2401–2411 (2022). https://doi.org/10.1007/s00464-021-08521-y

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