A0416 - Endoscopic Papillectomy of Ampullary Lesions: Predictors of Recurrence and Adverse Events

Sunday, October 23, 2022

5:00 PM – 7:00 PM ET

Location: Crown Ballroom

Presenting Author(s)

Gaurav Suryawanshi, MD

University of Minnesota Medical Center
Minneapolis, MN

Gaurav Suryawanshi, MD¹, Mohamed Abdallah, MD¹, Nicholas McDonald, MD², David Jonason, MD¹, Guru Trikudanathan, MD¹, Stuart K. Amateau, MD, PhD¹, Shawn Mallery, MD¹, Martin L. Freeman, MD¹, Nabeel Azeem, MD¹
¹University of Minnesota Medical Center, Minneapolis, MN; ²University of Minnesota, Minneapolis, MN

Introduction: Endoscopic papillectomy (EP) is an effective endoscopic modality for managing ampullary adenomas, early ampullary carcinoma, and piecemeal resection of large laterally spreading lesions. EP has comparable efficacy and a better safety profile compared to a pancreaticoduodenectomy (Whipple surgery) or transduodenal ampullectomy (TA). However, there is a need to identify risk factors for recurrence and adverse events after EP. Thus, this study aims to evaluate predictors for recurrence and adverse events in patients who underwent EP for ampullary lesions.

Methods: This study is a retrospective analysis of all consecutive patients who underwent endoscopic snare papillectomy for an ampullary lesion between January 2006 and December 2021. We assessed multiple patient and procedure-related variables to identify risk factors related to post-EP adverse events and ampullary lesion recurrence using both univariate and multivariate analysis.

Results: A total of 51 patients undergoing EP for ampullary lesions were included in the final analysis. There were 11 patients with familial adenomatous polyposis (FAP) while 40 had sporadic lesions (Table 1). Recurrence was seen in 17 patients (37.0%) among those who followed up after technical success; five FAP (55.5%) and twelve sporadic (32.4%) patients had a recurrence. Adverse events included intraprocedural bleeding in 17 patients (33.3%), delayed bleeding requiring endoscopic evaluation in 7 patients (13.7%), post-ERCP pancreatitis (PEP) in 7 patients (13.7%), papillary stenosis in two patients (3.9%), and perforation in one (2%). Three patients (5.9%) had concomitant delayed bleeding and post-ERCP pancreatitis. Nine patients (19.6%) had intraprocedural bleeding requiring endoscopic clip placement of whom one later presented for delayed bleed.

Age, method of resection, lesion size, and intraductal extensions were not associated with recurrence. Complete histologic (R0) resection was the only factor associated with no recurrence following EP (OR=5.4, 95% CI: 1.4-20.8, P-value=0.014). Post-ERCP pancreatitis was associated with delayed bleeding (OR=7.5, 95% CI: 1.2-46.1, P-value=0.03). The median follow-up was 228 (40-795) days for those who followed up (46 patients).

Discussion: In patients who underwent EP for ampullary lesions, R0 resection was associated with reduced risk of recurrence. In addition, delayed bleeding after EP is associated with an increased risk of developing PEP.

Characteristics	(n=51)
Age, years (median (IQR))	65 (56-76)
Gender (male)	29 (56.8%)
Symptoms attributable to the ampullary lesion prior to EP Abdominal pain or dyspepsia Obstructive jaundice Pancreatitis None	8 (15.7%) 7 (13.7%) 4 (7.8%) 32 (62.7%)
Histology obtained prior to EP	40 (78.4%)
Endoscopic ultrasound prior to EP	37 (72.5%)
Lesion size, mm (median (IQR))	15 (10.8-20)
Median duration of the procedure in minutes (median (IQR))	79 (57.8-101.3)
Method of resection En-bloc snare resection En-bloc snare resection + APC Piecemeal snare resection Piecemeal snare resection + APC	30 (58.8%) 8 (7.8%) 6 (11.8%) 7 (13.7%)
Intraductal extension	8 (15.7%)
Duodenal diverticulum	4 (7.8%)
Altered post-surgical anatomy	3 (5.9%)
Pancreas divisum	3 (5.9%)
Biliary sphincterotomy	40 (78.4%)
Pancreatic sphincterotomy	11 (21.6%)
Submucosal lifting prior to EP	7 (13.7%)
Pancreatic stent after EP	46 (90.2%)
Biliary stent after EP	45 (88.2%)
Final diagnosis Tubular adenoma Tubulovillous adenoma Tubular adenoma with high grade dysplasia Adenocarcinoma Neuroendocrine tumors Other (non-neoplastic)	25 (49.0%) 14 (27.5%) 5 (9.8%) 2 (3.9%) 1 (2.0%) 4 (7.8%)
Concordant histology before and after EP	32 (62.7%)
Complete histological (R0) resection	23 (45.1%)
Number of procedures to achieve technical success One Two Three	44 (86.3%) 5 (9.8%) 2 (3.9%)
Antiplatelets or anticoagulation therapy prior to EP	14 (27.5%)
Overnight admission after EP	24 (47.1%)
ED visit within 30 days of index EP	7 (13.7%)
Hospital readmission within 30 days of index EP	6 (11.8%)

Table: Table 1: Baseline characteristics of patients who underwent endoscopic papillectomy. APC: Argon plasma coagulation; ED: Emergency department; EP: Endoscopic papillectomy; IQR: Interquartile range.

Disclosures:

Gaurav Suryawanshi indicated no relevant financial relationships.

Mohamed Abdallah indicated no relevant financial relationships.

Nicholas McDonald indicated no relevant financial relationships.

David Jonason indicated no relevant financial relationships.

Guru Trikudanathan: Boston Scientific Corporation – Consultant.

Stuart Amateau: Boston Scientific Corporation – Consultant. Merit Medical – Consultant. Olympus Medical – Advisor or Review Panel Member. Olympus Medical – Consultant. Steris – Consultant.

Shawn Mallery indicated no relevant financial relationships.

Martin Freeman: Boston Scientific Corporation – Consultant.

Nabeel Azeem: Boston Scientific – Consultant.

Gaurav Suryawanshi, MD¹, Mohamed Abdallah, MD¹, Nicholas McDonald, MD², David Jonason, MD¹, Guru Trikudanathan, MD¹, Stuart K. Amateau, MD, PhD¹, Shawn Mallery, MD¹, Martin L. Freeman, MD¹, Nabeel Azeem, MD¹. A0416 - Endoscopic Papillectomy of Ampullary Lesions: Predictors of Recurrence and Adverse Events, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.