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• W2123805503 abstract "Tumors arising from the major duodenal papilla account for 5% of GI neoplasms1Scarpa A. Capelli P. Zamboni G. et al.Neoplasia of the ampulla of Vater. Ki-ras and p53 mutations.Am J Pathol. 1993; 142: 1163-1172PubMed Google Scholar but are being identified more frequently with increasing use of upper endoscopic examination and ERCP. Of a wide variety of benign papillary tumors, adenoma is the most common. It is clinically important because of its premalignant potential.1Scarpa A. Capelli P. Zamboni G. et al.Neoplasia of the ampulla of Vater. Ki-ras and p53 mutations.Am J Pathol. 1993; 142: 1163-1172PubMed Google Scholar Although complete resection of papillary adenomas is standard practice,2Sobol S. Cooperman A.M. Villous adenoma of the ampulla of Vater. An unusual cause of biliary colic and obstructive jaundice.Gastroenterology. 1978; 75: 107-109PubMed Scopus (68) Google Scholar, 3Tarazi R.Y. Hermann R.E. Vogt D.P. et al.Results of surgical treatment of periampullary tumors: a thirty-five year experience.Surgery. 1986; 100: 716-723PubMed Google Scholar, 4Shemesh E. Nass S. Czerniak A. Endoscopic sphincterotomy and endoscopic fulguration in the management of adenoma of the papilla of Vater.Surg Gynecol Obstet. 1989; 169: 445-448PubMed Google Scholar opinions differ as to the optimal method of excision.Adenoma of the major duodenal papilla can be excised either surgically or endoscopically. The surgical options include transduodenal local excision (ampullectomy) and radical pancreatoduodenectomy.3Tarazi R.Y. Hermann R.E. Vogt D.P. et al.Results of surgical treatment of periampullary tumors: a thirty-five year experience.Surgery. 1986; 100: 716-723PubMed Google Scholar, 5Rattner D.W. Fernandez-del Castillo C. Brugge W.R. et al.Defining the criteria for local resection of ampullary neoplasms.Arch Surg. 1996; 131: 366-371Crossref PubMed Scopus (134) Google Scholar, 6Beger H.G. Treitschke F. Gansauge F. et al.Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients.Arch Surg. 1999; 134: 526-532Crossref PubMed Scopus (281) Google Scholar, 7Bjork K.J. Davis C.J. Nagorney D.M. et al.Duodenal villous tumors.Arch Surg. 1990; 125: 961-965Crossref PubMed Scopus (71) Google Scholar, 8Posner S. Colletti L. Knol J. et al.Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater.Surgery. 2000; 128: 694-701Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 9Gray G. Browder W. Villous tumors of the ampulla of Vater: local resection versus pancreatoduodenectomy.South Med J. 1989; 82: 917-920Crossref PubMed Scopus (36) Google Scholar Endoscopic treatment methods consist of endoscopic resection and thermal ablation.4Shemesh E. Nass S. Czerniak A. Endoscopic sphincterotomy and endoscopic fulguration in the management of adenoma of the papilla of Vater.Surg Gynecol Obstet. 1989; 169: 445-448PubMed Google Scholar, 10Catalano M.F. Linder J.D. Chak A. et al.Endoscopic management of adenoma of the major duodenal papilla.Gastrointest Endosc. 2004; 59: 225-232Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 11Zadorova Z. Dvofak M. Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater: a clinicopathologic study.Am J Gastroenterol. 1992; 87: 37-42PubMed Google Scholar, 12Cheng C.L. Sherman S. Fogel E.L. et al.Endoscopic snare papillectomy for tumors of the duodenal papillae.Gastrointest Endosc. 2004; 60: 757-764Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar, 13Norton I.D. Geller A. Petersen B.T. et al.Endoscopic surveillance and ablative therapy for periampullary adenomas.Am J Gastroenterol. 2001; 96: 101-106Crossref PubMed Google Scholar Surgical resection has been the mainstay for resection of adenomas of the major duodenal papilla.3Tarazi R.Y. Hermann R.E. Vogt D.P. et al.Results of surgical treatment of periampullary tumors: a thirty-five year experience.Surgery. 1986; 100: 716-723PubMed Google Scholar, 5Rattner D.W. Fernandez-del Castillo C. Brugge W.R. et al.Defining the criteria for local resection of ampullary neoplasms.Arch Surg. 1996; 131: 366-371Crossref PubMed Scopus (134) Google Scholar, 6Beger H.G. Treitschke F. Gansauge F. et al.Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients.Arch Surg. 1999; 134: 526-532Crossref PubMed Scopus (281) Google Scholar, 7Bjork K.J. Davis C.J. Nagorney D.M. et al.Duodenal villous tumors.Arch Surg. 1990; 125: 961-965Crossref PubMed Scopus (71) Google Scholar, 8Posner S. Colletti L. Knol J. et al.Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater.Surgery. 2000; 128: 694-701Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 9Gray G. Browder W. Villous tumors of the ampulla of Vater: local resection versus pancreatoduodenectomy.South Med J. 1989; 82: 917-920Crossref PubMed Scopus (36) Google Scholar Accumulating evidence indicates that endoscopic papillectomy can be used as an alternative first-line therapy.10Catalano M.F. Linder J.D. Chak A. et al.Endoscopic management of adenoma of the major duodenal papilla.Gastrointest Endosc. 2004; 59: 225-232Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar, 12Cheng C.L. Sherman S. Fogel E.L. et al.Endoscopic snare papillectomy for tumors of the duodenal papillae.Gastrointest Endosc. 2004; 60: 757-764Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar Because the ampulla of Vater is strategically located at the confluence of the pancreatic and common bile ducts, endoscopic resection of papillary neoplasms may be technically different from EMR in other parts of the GI tract. The best method of endoscopic ablation and the optimal period for surveillance have not been established.This is a systematic review on the indication, the outcome, and the complication of endoscopic papillectomy for adenomas of the major duodenal papilla, with special focus on the techniques.Literature review methodologyThe MEDLINE database was used to search publications through March 2005 related to endoscopic resection of ampullary neoplasms with the following keywords: ampulla of Vater, major duodenal papilla, endoscopic papillectomy, and endoscopic retrograde cholangiopancreatography. Pertinent articles published in the English language literature were reviewed. All references were manually verified. The references of published articles were searched. Where applicable, the level of evidence was reviewed by using Evidence Based Gastroenterology and Hepatology.14McDonald J. Burroughs A. Feagan B. Evidence based gastroenterology and hepatology. BMJ, London1999Google ScholarDefining extent of endoscopic resectionFor adenomas of the major duodenal papilla, the endoscopically resectable area is limited only to mucosa and submucosa of the duodenal wall, and the resection of this area is termed endoscopic papillectomy (Fig. 1). Tissue around the bile duct and the pancreatic-duct orifices located at the major duodenal papilla almost always are removed along with the tumor.15Fujita N. Noda Y. Kobayashi G. et al.Endoscopic papillectomy: is there room for this procedure in clinical practice?.Dig Endosc. 2003; 15: 253-255Crossref Scopus (10) Google Scholar With endoscopic papillectomy, it is impossible to remove tumor tissues that invade into the common bile duct or the main pancreatic duct. In clinical practice, the terms “endoscopic papillectomy” and “endoscopic ampullectomy” are used interchangeably. Strictly speaking, however, ampullectomy consists of circumferential resection of the ampulla of Vater, with complete reinsertion of the common bile duct and separate reinsertion of the main pancreatic duct into the duodenal wall (Fig. 1). This necessitates surgical duodenotomy and resection of pancreatic-head tissue in the area of the anatomical attachments of the ampulla to the wall of the duodenum.16Beger H.G. Staib L. Schoenberg M.H. Ampullectomy for adenoma of the papilla and ampulla of Vater.Langenbecks Arch Surg. 1998; 383: 190-193Crossref PubMed Scopus (7) Google Scholar “Endoscopic papillectomy,” therefore, is a more appropriate term than “endoscopic ampullectomy” in patients who undergo endoscopic resection for papillary adenoma.IndicationAlthough careful patient selection is a prerequisite to successful endoscopic papillectomy, indications for endoscopic papillectomy are not yet fully established. Criteria for selecting patients who would benefit the most from endoscopic papillectomy vary from one study to another.According to the study by Binmoeller et al,17Binmoeller K.F. Boaventura S. Ramsperger K. et al.Endoscopic snare excision of benign adenomas of the papilla of Vater.Gastrointest Endosc. 1993; 39: 127-131Abstract Full Text PDF PubMed Scopus (290) Google Scholar adenomas of the major duodenal papilla that met the following criteria were selected for endoscopic papillectomy: (1) size less than 4 cm, (2) no evidence for malignancy based on endoscopic appearance (regular margins, no ulceration) and soft consistency, and (3) benign histologic findings on forceps biopsy (minimum of 6 biopsies). In another study,16Beger H.G. Staib L. Schoenberg M.H. Ampullectomy for adenoma of the papilla and ampulla of Vater.Langenbecks Arch Surg. 1998; 383: 190-193Crossref PubMed Scopus (7) Google Scholar only histologically proven adenomas in which en bloc resection was possible were included. For widespread flat adenomas, huge bulky tumors >5 cm in diameter and suspected local infiltration into deeper submucosal layers, surgical resection was attempted. Desilets et al18Desilets D.J. Dy R.M. Ku P.M. et al.Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications.Gastrointest Endosc. 2001; 54: 202-208Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar considered that the following criteria indicated resectability in endoscopic papillectomy: (1) a soft tumor that was not indurated or ulcerated; (2) the ability to elevate tumor by submucosal injection; (3) the absence of extension into pancreatic or biliary ducts; and (4) a size no greater than half the circumference of the duodenum, which is about 4 cm in maximal diameter.Predetermined selection criteria for endoscopic papillectomy in one large multicenter study10Catalano M.F. Linder J.D. Chak A. et al.Endoscopic management of adenoma of the major duodenal papilla.Gastrointest Endosc. 2004; 59: 225-232Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar were that previously untreated, endoscopically accessible lesions of the major duodenal papilla with endoscopically benign features (pale lobulated, well marginated without malignant features, such as firmness to palpation, induration, ulceration, depressed areas) were included. Patients with direct biliary or pancreatic extension of the lesion demonstrated at ERCP and histologically proven carcinoma were referred for surgical resection. Cheng et al12Cheng C.L. Sherman S. Fogel E.L. et al.Endoscopic snare papillectomy for tumors of the duodenal papillae.Gastrointest Endosc. 2004; 60: 757-764Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar used the following criteria to select patients for endoscopic papillectomy: (1) tumor diameter less than 4.5 cm; (2) no endoscopic evidence of malignancy (e.g., absence of ulceration, excessive friability, and spontaneous bleeding); (3) a soft consistency to palpation with any device; and (4) benign histopathologic features in prior forceps biopsy specimens. On the other hand, indications for endoscopic papillectomy proposed by one Japanese group19Maguchi H. Takahashi K. Katanuma A. et al.Indication of endoscopic papillectomy for tumors of the papilla of Vater and its problems.Dig Endosc. 2003; 15 ([review]): S33-S35Crossref Scopus (36) Google Scholar are as follow: (1) exposed-type adenoma or carcinoma in situ, (2) without invasion of duodenal muscularis, and (3) no infiltration into the pancreas or the bile duct. These indications differ from criteria by other investigators that the size of adenoma is not included and carcinoma in situ is included. It should be noted that these criteria are expert opinions and are based on Grade C evidence.Patients with direct biliary or pancreatic extension of the lesion demonstrated at ERCP or at EUS are referred for surgical excision even if the lesion is confined to mucosa in one study.10Catalano M.F. Linder J.D. Chak A. et al.Endoscopic management of adenoma of the major duodenal papilla.Gastrointest Endosc. 2004; 59: 225-232Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar In two other studies,20Kahaleh M. Shami V.M. Brock A. et al.Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia.Am J Gastroenterol. 2004; 99: 2235-2239Crossref PubMed Scopus (66) Google Scholar, 21Bohnacker S. Seitz U. Seewald S. et al.Endoscopic snare resection of benign ampullary tumor: can intraductal growth be treated endoscopically?.Gastrointest Endosc. 2003; 57 ([abstract]): AB101Google Scholar however, adenoma with less than 1 cm of intraductal extension has been successfully resected by endoscopic papillectomy. Simple intraductal extension does not seem to be an absolute contraindication for endoscopic papillectomy, because the tumor can be exposed to the luminal side with sphincterotomy and/or balloon sweeping and, thus, resected completely. Direct infiltration or invasion of the tumor into intraductal mucosa precludes endoscopic papillectomy.Indications for endoscopic papillectomy are the collection of features that can predict complete removal of adenomas, while minimizing procedure-related morbidities. As experience with endoscopic papillectomy accumulates, endoscopic techniques improve, and novel diagnostic modalities appear, indications for endoscopic papillectomy will and must evolve. Actually, indications for endoscopic papillectomy for adenoma of the major duodenal papilla are changing. The most notable change in indication is a gradual increase in the size of the tumor resected. Application of piecemeal resection when appropriate has contributed much to this. For example, tumors up to 7 cm in diameter have been successfully resected piecemeal.11Zadorova Z. Dvofak M. Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater: a clinicopathologic study.Am J Gastroenterol. 1992; 87: 37-42PubMed Google Scholar As increased application of EUS and/or intraductal US (IDUS) has contributed to more accurate staging of early cancer of the ampulla of Vater contained within the Oddi's muscle, there have been attempts to expand indications for endoscopic papillectomy to include early cancer of the ampulla of Vater.22Jung S. Kim M.H. Seo D.W. et al.Endoscopic snare papillectomy of adenocarcinoma of the major duodenal papilla.Gastrointest Endosc. 2001; 54: 622Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar, 23Ito K. Fujita N. Noda Y. et al.Case of early ampullary cancer treated by endoscopic papillectomy.Dig Endosc. 2004; 16: 157-161Crossref Scopus (30) Google ScholarAssessment of tumor extent before resectionAfter histopathologic diagnosis of adenoma by endoscopic biopsy, detailed endoscopic evaluation of adenoma of the major duodenal papilla is done before endoscopic papillectomy. ERCP with side-viewing duodenoscope is required in all patients to obtain both cholangiogram and pancreatogram before resection. It can demonstrate intraductal extension of the tumor.On the other hand, EUS and/or IDUS, if available and at the hands of an expert, can be performed in addition to ERCP and can clearly demonstrate the anatomy of the ampulla of Vater, including proper muscle layer.24Itoh A. Goto H. Naitoh Y. et al.Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater.Gastrointest Endosc. 1997; 45: 251-260Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar, 25Menzel J. Hoepffner N. Sulkowski U. et al.Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT—a prospective, histopathologically controlled study.Gastrointest Endosc. 1999; 49: 349-457Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 26Menzel J. Domschke W. Gastrointestinal miniprobe sonography: the current status.Am J Gastroenterol. 2000; 95: 605-616Crossref PubMed Google Scholar EUS and/or IDUS will provide more detailed and accurate information on the extent of adenoma of the major duodenal papilla. These can provide additional information regarding actual size and echogenicity of the tumor, layered structures of the duodenal wall, and regional lymph node status, thus determining optimal treatment modality and differentiating between carcinoma and adenoma (Fig. 2).27Rösch T. Braig C. Gain T. et al.Staging of pancreatic and ampullary carcinoma by endoscopic ultrasonography. Comparison with conventional sonography, computed tomography, and angiography.Gastroenterology. 1992; 102: 188-199PubMed Google Scholar Unlike EUS, IDUS can be inserted through the working channel of the duodenoscope and into the common bile duct.28Itoh A. Goto H. Naitoh Y. et al.Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater.Gastrointest Endosc. 1997; 45: 251-260Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar IDUS may be more suited for imaging the detailed anatomy of the ampulla of Vater than EUS, because it has a higher US frequency than EUS and images in a plane tangential to the duct.25Menzel J. Hoepffner N. Sulkowski U. et al.Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT—a prospective, histopathologically controlled study.Gastrointest Endosc. 1999; 49: 349-457Abstract Full Text Full Text PDF PubMed Scopus (135) Google Scholar, 26Menzel J. Domschke W. Gastrointestinal miniprobe sonography: the current status.Am J Gastroenterol. 2000; 95: 605-616Crossref PubMed Google Scholar, 28Itoh A. Goto H. Naitoh Y. et al.Intraductal ultrasonography in diagnosing tumor extension of cancer of the papilla of Vater.Gastrointest Endosc. 1997; 45: 251-260Abstract Full Text Full Text PDF PubMed Scopus (191) Google ScholarFigure 2EUS finding of adenoma of the major duodenal papilla. A 13 × 7-mm sized lesion (asterisk) with focal hypoechoic echogenicity is confined to the mucosal layer; the proper muscle layer is intact (arrowheads).View Large Image Figure ViewerDownload (PPT)Techniques of endoscopic snare papillectomySubmucosal injectionWhile some endoscopists advocate the use of submucosal injection of either physiologic saline solution or dilute epinephrine, some do not. Whether physiologic saline solution or dilute epinephrine should be used is also not established. Submucosal injection of either dilute epinephrine or saline solution may be useful for avoiding inappropriate resection because failure to lift the tumor from the proper muscle layer of the duodenum may indicate deeper invasion18Desilets D.J. Dy R.M. Ku P.M. et al.Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications.Gastrointest Endosc. 2001; 54: 202-208Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar and is the strongest predictor of malignancy.20Kahaleh M. Shami V.M. Brock A. et al.Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia.Am J Gastroenterol. 2004; 99: 2235-2239Crossref PubMed Scopus (66) Google Scholar In one study,20Kahaleh M. Shami V.M. Brock A. et al.Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia.Am J Gastroenterol. 2004; 99: 2235-2239Crossref PubMed Scopus (66) Google Scholar failure to adequately lift the lesion was considered reason enough to abandon endoscopic papillectomy and change the purpose of the procedure to obtaining adequate tissue for diagnosis. Moreover, injection of an epinephrine solution may reduce the risk of bleeding. A sclerotherapy needle usually is used, and the number of injections and the total volume of solution injected varies with the size of the lesion.18Desilets D.J. Dy R.M. Ku P.M. et al.Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications.Gastrointest Endosc. 2001; 54: 202-208Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar Methylene blue can be added to the saline solution to improve the endoscopic visualization of the tumor, particularly its margins.29Charton J.P. Deinert K. Schumacher B. et al.Endoscopic resection for neoplastic diseases of the papilla of Vater.J Hepatobiliary Pancreat Surg. 2004; 11 ([review]): 245-251Crossref PubMed Scopus (25) Google ScholarInjecting saline solution into the submucosal layer beneath the lesion to lift the lesion for safe resection is a very common practice in cases of EMR in other parts of the GI tract (Fig. 3A to F; see video clip no. 1 online at www.giejournal.org). In adenomas of the major duodenal papilla, however, some investigators do not recommend submucosal injection. Firstly, not only the surrounding mucosa at the region of the duodenal papilla but also the tumor is lifted by submucosal injection, so capturing the lesion with a snare becomes difficult.30Hirooka Y. Itoh A. Goto H. EUS/IDUS and endoscopic papillectomy.Dig Endosc. 2004; 16 ([review]): S176-S177Crossref Scopus (23) Google Scholar Secondly, submucosal injection may blur the margin of the tumor and does not elevate the bile duct that runs through the duodenal wall.31Aiura K. Imaeda H. Kitajima M. et al.Balloon-catheter-assisted endoscopic snare papillectomy for benign tumors of the major duodenal papilla.Gastrointest Endosc. 2003; 57: 743-747Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Several studies have been conducted without submucosal injection, but there have been no reports of difficulty in complete resection or an increase in complication.11Zadorova Z. Dvofak M. Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater: a clinicopathologic study.Am J Gastroenterol. 1992; 87: 37-42PubMed Google Scholar, 13Norton I.D. Geller A. Petersen B.T. et al.Endoscopic surveillance and ablative therapy for periampullary adenomas.Am J Gastroenterol. 2001; 96: 101-106Crossref PubMed Google Scholar, 17Binmoeller K.F. Boaventura S. Ramsperger K. et al.Endoscopic snare excision of benign adenomas of the papilla of Vater.Gastrointest Endosc. 1993; 39: 127-131Abstract Full Text PDF PubMed Scopus (290) Google Scholar, 23Ito K. Fujita N. Noda Y. et al.Case of early ampullary cancer treated by endoscopic papillectomy.Dig Endosc. 2004; 16: 157-161Crossref Scopus (30) Google Scholar, 32Vogt M. Jakobs R. Benz C. et al.Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up.Dig Liver Dis. 2000; 32: 339-345Abstract Full Text PDF PubMed Google Scholar, 33Fukushima T. Fogel E.L. Devereaux B.M. et al.Use of ERCP and papillectomy in management of ampullary tumors: seven-year review of 75 cases at Indiana University Medical Center.Gastrointest Endosc. 2001; 53 ([abstract]): AB88Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 34Norton I.D. Gostout C.J. Baron T.H. et al.Safety and outcome of endoscopic snare excision of the major duodenal papilla.Gastrointest Endosc. 2002; 56: 239-243Abstract Full Text Full Text PDF PubMed Scopus (213) Google Scholar, 35Ponchon T. Berger F. Chavaillon A. et al.Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater.Cancer. 1989; 64: 161-167Crossref PubMed Scopus (145) Google Scholar, 36Ito K. Fujita N. Noda Y. et al.Modes of spread in early ampullary cancer in terms of establishing proper indications for endoscopic papillectomy.Dig Endosc. 2004; 16: 224-228Crossref Scopus (25) Google ScholarFigure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Figure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Figure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Figure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Figure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Figure 3Endoscopic snare papillectomy. A, Endoscopic view of adenoma arising from the major duodenal papilla. B and C, Submucosal injection with a sclerotherapy needle. D, Snaring the tumor with a standard polypectomy snare. E, Excision with application of electrosurgical current. F, Gross appearance of the resected specimen flattened and pinned to a polystyrene plate (see Appendix, Appendix online at www.giejournal.org).View Large Image Figure ViewerDownload (PPT)Modes of resectionSnaringMost studies do not mention either the size of the snare used or the direction of snaring.11Zadorova Z. Dvofak M. Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater: a clinicopathologic study.Am J Gastroenterol. 1992; 87: 37-42PubMed Google Scholar, 13Norton I.D. Geller A. Petersen B.T. et al.Endoscopic surveillance and ablative therapy for periampullary adenomas.Am J Gastroenterol. 2001; 96: 101-106Crossref PubMed Google Scholar, 17Binmoeller K.F. Boaventura S. Ramsperger K. et al.Endoscopic snare excision of benign adenomas of the papilla of Vater.Gastrointest Endosc. 1993; 39: 127-131Abstract Full Text PDF PubMed Scopus (290) Google Scholar, 18Desilets D.J. Dy R.M. Ku P.M. et al.Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications.Gastrointest Endosc. 2001; 54: 202-208Abstract Full Text Full Text PDF PubMed Scopus (167) Google Scholar, 19Maguchi H. Takahashi K. Katanuma A. et al.Indication of endoscopic papillectomy for tumors of the papilla of Vater and its problems.Dig Endosc. 2003; 15 ([review]): S33-S35Crossref Scopus (36) Google Scholar, 32Vogt M. Jakobs R. Benz C. et al.Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up.Dig Liver Dis. 2000; 32: 339-345Abstract Full Text PDF PubMed Google Scholar, 33Fukushima T. Fogel E.L. Devereaux B.M. et al.Use of ERCP and papillectomy in management of ampullary tumors: seven-year review of 75 cases at Indiana University Medical Center.Gastrointest Endosc. 2001; 53 ([abstract]): AB88Abstract Full Text Full Text PDF Scopus (2) Google Scholar, 35Ponchon T. Berger F. Chavaillon A. et al.Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater.Cancer. 1989; 64: 161-167Crossref PubMed Scopus (145) Google Scholar, 37Yasuda K. Uno K. Tanaka K. et al.Endoscopic resection of tumor of papilla Vater: our experiences.Dig Endosc. 2003; 15: S31-S32Crossref Scopus (1) Google Scholar, 38Martin J.A. Haber G.B. Korta P.P. et al.Endoscopic snare ampullectomy for resection of benign ampullary neoplasms.Gastrointest Endosc. 1997; 45 ([abstract]) (AB139)Google Scholar Endoscopists use polypectomy snares of various diameters, ranging from 11 to 27 mm, depending on the size of the tumor.10Catalano M.F. Linder J.D. Chak A. et al.Endoscopic management of adenoma of the major duodenal papilla.Gastrointest Endosc. 2004; 59: 225-232Abstract Full T" @default.
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• W2123805503 date "2006-02-01" @default.
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• W2123805503 title "Endoscopic papillectomy for adenomas of the major duodenal papilla (with video)" @default.
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