Three Cases of Ampullary Neuroendocrine Tumor Treated by Endoscopic Papillectomy: A Case Report and Literature Review.

We herein report three cases of patients with an ampullary neuroendocrine tumor (NET), who underwent endoscopic papillectomy (EP). No tumor recurrence or metastasis was detected in the patients for more than two years after EP. Generally, surgical resection is recommended for ampullary NETs by the European Neuroendocrine Tumor Society. However, as EP is less invasive than surgical resection, there are some reports of low-grade small ampullary NETs curatively treated by EP with long-term follow-up. We consider that EP may be a curative treatment for small and low-grade ampullary NETs without regional or distant metastasis.

Síndrome de Cushing producido por un carcinoma neuroendocrino de la ampolla de Vater productor de hormona adrenocorticotropa ectópica / Cushing's syndrome caused by a neuroendocrine carcinoma of the ampulla of Vater with ectopic adrenocorticotropic hormone secretion

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Jaundice as a prognostic factor in patients undergoing radical treatment for carcinomas of the ampulla of Vater.

BACKGROUND: Carcinomas 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. METHODS: The 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). CONCLUSIONS: Jaundice 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.

Clinical usefulness of double-guidewire technique for difficult biliary cannulation in endoscopic retrograde cholangiopancreatography.

BACKGROUND AND AIM: Although biliary cannulation with pancreatic guidewire placement (P-GW) is useful for difficult cases in endoscopic retrograde cholangiopancreatography (ERCP), the clinical significance of wire-guided cannulation with P-GW (double-guidewire technique: DGT) has not been clarified. The aim of the present study was to evaluate the usefulness of DGT for difficult biliary cannulation after unsuccessful biliary cannulation using a cannula/sphincterotome under guidance of injected contrast with P-GW (single-guidewire technique: SGT). METHODS: One-hundred and forty-six patients with difficult biliary cannulation who underwent SGT were included in this retrospective study. DGT was carried out if SGT was unsuccessful. Pancreatic duct (PD) stenting was attempted to prevent post-ERCP pancreatitis (PEP) in all patients. The success rate of cannulation and the risk factors for PEP were investigated. RESULTS: Biliary cannulation with SGT was achieved in 70%. DGT was carried out in 25 patients with unsuccessful SGT, biliary cannulation being successful in 72%. Of the 13 patients who underwent precut sphincterotomy, biliary cannulation was achieved in 46%. The incidence of PEP in patients who had undergone SGT, DGT, and precut sphincterotomy was 8% (12: mild, 8; moderate, 3; severe, 1), 4% (mild, 1), and 0%, respectively. PD stenting was successfully carried out in 86%. Multivariate analysis revealed unsuccessful PD stenting to be the only risk factor for PEP (OR 8.3, 95% CI 2.3-30). CONCLUSIONS: DGT may replace SGT or become the salvage procedure in cases of unsuccessful SGT as a result of its high success rate with an acceptable incidence of PEP. Failed pancreatic duct stenting in these techniques was frequently associated with PEP.

Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater.

AIM: To determine the efficacy of a cap-assisted endoscopy (CAE) to completely visualize the ampulla of Vater (AV) in patients failed by conventional endoscopy. METHODS: A prospective study was conducted on 120 patients > 20 years of ages who visited the Health Promotion Center of Chungbuk National University Hospital for conscious sedation esophagogastroduodenoscopy (EGD) as a screening test from July to October, 2011. First, forward-viewing endoscopy was performed with reasonable effort using a push and pull method. We considered complete visualization of the AV when we could observe the entire AV including the orifice clearly, and reported the observation as complete or incomplete (partial or not found at all). Second, in cases of complete failure of the observation, an additional AV examination was conducted by attaching a short cap (D-201-10704, Olympus Medical Systems, Tokyo, Japan) to the tip of a forward-viewing endoscope. Third, if the second method failed, we replaced the short cap with a long cap (MH-593, Olympus Medical Systems) and performed a re-examination of the AV. RESULTS: Conventional endoscopy achieved complete visualization of the AV in 97 of the 120 patients (80.8%) but was not achieved in 23 patients (19.2%). Age (mean ± SD) and gender [male (%)] were not significantly different between the complete observation and the incomplete observation groups. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma. CONCLUSION: CAE is safe to use as a salvage method to achieve complete visualization of the AV when a regular EGD examination fails.

Duodenal switch operation for juxtapapillary duodenal diverticula.

BACKGROUND/AIMS: Since the first case of juxtapapillary diverticlum reported by Lemmel, several reports have demonstrated an association between periampullary diverticulum and gallstone disease. Thus, we compared the efficiency of the duodenal switch operation and choledchojejunostomy for patients who underwent surgery for cholangitis with juxtapapillary duodenal diverticula. METHODOLOGY: We retrospectively studied 17 patients who had cholangitis associated with juxtapapillary duodenal diverticula. These patients were divided into 2 groups on the basis of the operative procedure: the duodenal switch operation group (DS group) and the choledochojejunostomy group (CJ group). RESULTS: The mean operative time and blood loss were significantly lesser in the DS group than in the CJ group (p<0.0001 and p<0.0005, respectively); however, the duration of nasogastric suction requirement and time after which oral ingestion of solid diet could be safely resumed after surgery were significantly longer in the DS group than in the CJ group (p<0.0001 and p<0.0001, respectively). Gallstone formation after the surgery did not occur in both groups. CONCLUSIONS: Duodenal switch operation is useful and less invasive for cholangitis associated with juxtapapillary duodenal diverticula and for preventing cholangitis for a long period after the operation; however, gastric stasis still remains a problem with this procedure.

[Papilla Vateri restenoses after papillosphincterotomy].

Biliary tract was investigated in 105 patients after endoscopic papillosphincterotomy for choledocholithiasis and papillostenosis. The follow-up revealed papillary restenosis in 8,6%, which occurred during first 2 years after the procedure. Short cut of the duodenal papilla and intramural part of the common bile duct and anamnestic papillostenosis and septic cholangitis proved to be the main reasons of the papillary restenosis.

[Improvement of endoscopic treatment of the acute cholecystitis].

Treatment results of 763 patients with acute cholecystitis were analyzed. Destructive forms of the disease was diagnosed by the ultrasound examination in all cases. Choledocholithiasis was diagnosed in 35 (4.6%), choledocholithiasis with papilla Vatery stricture was in 9 (1.2%) patients and isolated papilla Vatery stricture was registered in 5 (0.7%) patients. All patients were attempted to treat laparoscopically with the use of original "Device for antegrade papillotomy" and "Method of antegrade bipolar papillosphincterotomy". Authors state, that a final decision about the possibility of endoscopic treatment of the acute cholecystitis can be made after detection of anatomical structures of the Calo triangle. By complicated forms of the disease a one-stage laparoscopic treatment should be preferred. Endoscopic papillosphincterotomy should be performed only by the enblocked concrement of the papilla Vatery.

Juxtapapillary duodenal diverticula and pancreatobiliary disease.

Juxtapapillary duodenal diverticula (JPD) are observed in around 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). They are acquired extraluminal outpouchings of the duodenal wall through 'locus minoris resistance' and their incidence increases with age. They have been studied mainly with regard to their association with pancreatobiliary disease. Choledocholithiasis is considered to be strongly associated with JPD, but the role of JPD in the development of cholecystolithiasis and pancreatitis is still disputable. Since JPD are located in the vicinity of the papilla of Vater, they not only cause mechanical compression of the bile duct but also induce dysfunction of the sphincter of Oddi. They are considered to lead to bile stasis and to allow reflux from the duodenum into the bile duct, which results in an ascending infection of beta-glucuronidase-producing bacteria. The ERCP procedure can be hampered by JPD, although recent papers have reported no difference in the successful cannulation rate or complications between patients with JPD and those without JPD. Disorders caused by JPD are amenable to appropriate therapy, e.g. endoscopic sphincterotomy and surgical intervention.

Retrograde jejunoduodenal intussusception: a rare cause of acute pancreatitis after surgery for duodenal atresia.

Duodenojejunostomy is a surgical treatment option in the repair of duodenal atresia. This case describes the heretofore unreported phenomenon of retrograde jejunoduodenal intussusception causing acute pancreatitis in a patient who underwent duodenojejunostomy in infancy.

Functional and morphological changes in pancreatic remnant after pancreaticoduodenectomy.

OBJECTIVES: Pancreatic exocrine insufficiency has been reported to be more common in pancreaticogastrostomy (PG) than in pancreaticojejunostomy (PJ) after pancreaticoduodenectomy (PD). This study aimed to evaluate the long-term outcome after PD between these 2 groups. METHODS: We evaluated the long-term functional status of 42 surviving patients diagnosed with periampullary lesions who underwent PJ or PG after PD and followed up for more than 1 year. Among these, 23 patients underwent PJ and 19 patients underwent PG. To compare the 2 groups, we analyzed the (1) pancreatic exocrine insufficiency by questioning the presence or absence of steatorrhea, (2) pancreatic endocrine function by measuring glycohemoglobin A1c, fasting blood glucose, and history of new-onset diabetes, (3) nutritional status by measuring serum total protein, albumin, cholesterol, and triglyceride, (4) gastric emptying time, (5) panendoscopic findings, (6) changes of pancreatic duct diameter by computed tomography, and (7) relaparotomy rate. RESULTS: The mean follow-up time for PG and PJ were 37 +/- 23 and 103 +/- 52 months, respectively (P < 0.05). A total of 52.4% patients developed pancreatic exocrine insufficiency, and 11.9% had new-onset diabetes. There was no significant difference between PJ and PG groups. A significantly improved postoperative nutritional state regarding serum total protein and albumin were noticed in both groups. There was no significant difference in terms of gastric emptying time, positive panendoscopic findings, and changes in pancreatic duct diameter. The pancreatic remnant-related relaparotomy rate was higher in the PJ group as compared with the PG group (17.4% vs 0%; P = 0.056). CONCLUSIONS: There is no significant difference in pancreatic exocrine or endocrine insufficiency, gastric emptying time, and positive panendoscopic findings between PJ and PG. Pancreaticojejunostomy was associated with a higher pancreatic remnant-related relaparotomy rate; however, because of a shorter follow-up in the PG group, a continuous long-term follow-up is still needed.

Recuperación funcional del esfínter de Oddi tras dilatación con balón de la papila de Vater. Estudio experimental en conejos / Functional recovery of Oddi’s sphincter after balloon dilatation of the papilla of Vater. An experimental study in rabbits

Introducción. La dilatación con balón de la papila de Vater es utilizada para el tratamiento de la ocupación litiásica de la vía biliar con resultados e índice de complicaciones buenos. Los datos publicados apuntan a que tras esta técnica la fisiología del esfínter de Oddi podría verse poco alterada tendiendo a una función normal. Este hecho aportaría una ventaja en relación con otras técnicas utilizadas en las que el mecanismo esfinteriano queda destruido y su función, abolida. El objetivo del estudio es valorar el estado funcional del esfínter tras realizar la técnica de dilatación con balón de la papila de Vater. Material y métodos. Se usaron 24 conejos de raza neozelandés albino que fueron sometidos, tras laparotomía y duodenotomía, a una dilatación con balón de la papila de Vater. Se realizó un estudio manométrico biliar y del esfínter de Oddi previo a la dilatación, inmediatamente después de ésta y a los 21 días. Se analizaron como variables los valores de presión de la vía biliar y el esfínter, así como los valores de las variables de actividad fásica del esfínter (frecuencia, duración y amplitud de las ondas de presión). Resultados. La dilatación con balón de la papila produjo de forma inmediata una relajación importante del esfínter. La comparación de los valores de presión intrabiliar y del esfínter de Oddi basales con los encontrados a los 21 días posdilatación no ha mostrado diferencias significativas. Tampoco se han encontrado diferencias al comparar las variables de actividad fásica del esfínter (frecuencia, duración y amplitud de ondas) entre una y otra fase del experimento. Conclusiones. Los resultados de nuestro trabajo sugieren la recuperación total de la función del esfínter tras ser sometido a una dilatación con balón después de un período de 21 días (AU)

Introduction. Balloon dilatation of the papilla of Vater is used to treat biliary lithiasis. The results and complications rate of this technique are excellent. Published data indicate that this procedure does not significantly alter the physiology of the sphincter of Oddi and that normal function is maintained. Papillary balloon dilatation would therefore provide an advantage over other techniques in which sphincteric function is abolished. The objective of this study was to evaluate the functional status of the sphincter of Oddi after balloon dilatation of the papilla of Vater. Material and methods. Twenty-four New Zealand albino rabbits were used. All animals underwent laparotomy and duodenotomy with balloon dilatation of the papilla of Vater. Manometric study of the biliary tract and of the sphincter of Oddi was also performed before, shortly after, and 21 days after dilatation. Biliary and sphincter of Oddi pressures and phasic activity of the sphincter (frequency, amplitude and duration of waves) were used as measuring variables for each of the stages of the experiment. Results. Papillary balloon dilatation immediately provoked substantial sphincter relaxation. Comparison of the values of basal biliary and sphincter of Oddi pressures with those found 21 days after dilatation showed no statistically significant differences. No significant differences were found when the variables related to phasic activity of the sphincter (frequency, amplitude and duration) were compared between the distinct phases of the experiment. Conclusions. The results of the present study suggest complete recovery of sphincter function 21 days after balloon dilatation (AU)

Carcinoid of ampulla of Vater.

Carcinoid tumors of ampulla are rare clinical entities. They form 0.35% of all the gastrointestinal carcinoids. So far, only 109 cases have been reported in the literature, mostly as individual case reports. Since the metastatic potential and the tumor size have no correlation, unlike in duodenal carcinoids, pancreatoduodenectomy is considered the treatment of choice. Here we present a case of carcinoid of ampulla presenting to our department.

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs

OBJETIVO: Avaliar, em cães, a função da papila duodenal maior submetidas à dilatação por balão hidrostático sob o ponto de vista das alterações radiográficas e manométricas. MÉTODOS: Vinte cães foram submetidos a laparotomia, duodenotomia, dilatação da papila maior - GA(n=10) - com balão de 8mm insuflado com pressão de 0,5atm, durante 2 minutos ou ao procedimento simulado - GB(n=10). A manometria computadorizada e a colangiografia foram efetuadas antes e imediatamente após o procedimento inicial, uma e quatro semanas após a dilatação ou a simulação. Foram calculadas à partir das imagens radiográficas: a média, desvio-padrão, mediana, variação absoluta e porcentual das medidas do diâmetro da papila. Foram medidas: a pressão basal na região da papila, a amplitude das contrações e a pressão do colédoco em todos tempos de observação(t0, t7 e t28). RESULTADOS: Não houve diferença nas medidas do diâmetro da papila em t0 (GA=5,14 e DP=1,1) (GB=4,64 e DP=0,9), assim como nas variações absolutas (0,14mm) ou relativas (-2,7%). Nos animais do GA a medida da pressão basal da papila, mostrou-se menor no t28 (11,1) que nos tempos t0 (18,6) e T7 (16,2). As médias das amplitudes de contração foram significantemente inferiores nos tempos pós-operatórios (pós-t0, t7 e t28) em relação ao tempo inicial (pré-t0), nos animais dos grupos A e B. Os valores médios da pressão no colédoco também foram inferiores em t28 (7,5) que nos tempos t0 (17,8) e t7 (12,6) nos animais do GA.CONCLUSÃO: A função da papila duodenal está comprometida parcialmente com a dilatação, pois provocou diminuição da pressão basal e comprometimento da capacidade do esfíncter em suas contrações cíclicas até aos 28 dias de observação.

Manometric and radiographic evaluation of transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the functions of biliary sphincter subjected to dilation hydrostatic balloon by the point of view of the radiographic and manometric alterations. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). The computerized manometry and the cholangiography were done before and immediately after the initial procedure, one and four weeks after the dilation or the sham. It was calculated from the radiographic images: the mean, standard deviation, absolute and percentual variation of the diameter measures of the papilla. It was measured: the basal pressure in the papilla region, the contraction amplitudes and the choledoc pressure in all observation times (t0, t7 and t28). RESULTS: There was not differences in the diameter measures of the papilla in t0 (GA=5,14 +/- 1,1) (GB=4,64 +/-0,9), as well as in the absolute (0,14 mm) or relative (-2,7%) variations. In the animals of GA the papilla basal pressure measure was found to be smaller in t28 (11,1) than in t0 (18,6) and t7 (16,2). The contraction amplitudes measures were significantly smaller in the postoperatory times (post-t0, t7 and t28) when comparing to the initial time (pre-t0), in the animals of groups A and B. The average pressure values in the choledoc were also smaller in t28 (7,5) than in t0 (17,8) and t7 (12,6) in the animals of GA. CONCLUSION: the function of the major duodenal papilla is partially committed with the dilation, therefore it provoked the basal pressure decrease and compromising of the capacity of sphincter in its cyclical contractions up to the 28 days of observation.

Distended glands or overreplacement of ampullary mucosa at the papilla of Vater.

BACKGROUND/PURPOSE: The role of the ampullary mucosa, especially its distended glands at the papilla of Vater, has not been fully explored. METHODS: Twenty-nine pancreatoduodenectomized specimens from pancreatobiliary diseases and 44 autopsied cases, as controls, were studied histopathologically and immunohistochemically. RESULTS: In 12 out of the 29 pancreatoduodenectomized cases the ampullary mucosa was in contact with the duodenal mucosa just at the outlet of the ampulla. In the remaining 17 cases, the ampullary mucosa overgrew beyond the ostium, replacing a portion of the surrounding duodenal mucosa, termed "distended glands," which measured an average of 1532 microm in length. The muscularis mucosae of the duodenum and the Oddi's sphincter muscle merged in an "end-to-end, sharp-angled" manner at the ostium in the former, whereas this occurred in an "end-to-side, less sharp, rather right-angled" manner in the latter. Immunohistochemically, the distended glands in some cases showed negative/weakly positive staining for anti-carbohydrate antigen (CA) 19-9 and a high proliferation index evaluated using Ki67. In the autopsied materials, distended glands were found in 24 out of the 44 cases. CONCLUSIONS: Distended glands of the ampullary mucosa were frequently found and only grew on the Oddi's sphincter muscle extension. They may represent not only malignant change but also an adaptive phenomenon for bile and pancreatic juice flow.

MRI of slow flow in artificial duct in swine.

Our aim was to evaluate whether it is possible to visualize slow flow within a small catheter placed inside a living animal. We used a flow-sensitive, single-shot turbo spin-echo (SS-TSE) MRI sequence, developed in house, based on diffusion-weighted (DW) techniques. Four anesthetized pigs were used as models. A plastic catheter was surgically placed within the common bile duct (CBD). To mimic flow, the catheter was filled with Ringer's acetate and connected to a pump. b factors (s/m(2)) of 0, 6, and 12, with flow velocities raging from 0 to 1.32 cm/s, were used. A total of 375 images were obtained and examined. After correction for bowel movement artifacts, all images displayed the catheter on zero flow. With a flow of 0.66 cm/s or higher, no images displayed the catheter with a b factor of 6 or 12. On the slower flow velocities, it was variable whether the catheter was visible or not, but at b=6 and flow 0.17 cm/s all catheters were viewable. This method made it possible to perform a semiquantitative evaluation of flow velocities in vivo, dividing flow into three groups.

Tumores da Papila (Ampola) de Vater / Ampulla of Vater Neoplasms

Os autores fazem uma revisão bibliográfica sobre os tumores da Papila de Vater, sua classificação, apresentação clínica, diagnóstico e estadiamento, assim como as alternativas de procedimentos cirúrgicos

[Analysis of causes of mechanical jaundice and treatment methods in a group of 103 hospitalized patients]. / Analiza przyczyn zóltaczki mechanicznej oraz metod leczenia w grupie 103 kolejno hospitalizowanych chorych.

103 consecutive hospitalized patients at the age from 23 to 87 years with mechanical jaundice are presented in this study. In 58 patients, a cause of the jaundice was ductal calculosis, in four, a damage to bile duct after cholecystectomy. In 43 patients (74%), a calculus was removed through endoscopy, in 2 patients (4%) through Kehr's drain, 13 patients required an operation, in 41 patients, jaundice resulted from a neoplasm including 22 patients with a tumor of the head of pancreas, in 9 neoplasm of gall bladder, in 4 tumor of liver invagination, in 4 tumor of distal part of bile duct, in 2 neoplasm of Vater's papilla. 8 patients out of 28 with neoplastic tumor of pancreatoduodenal field had proximal pancreatoduodenectomy performed (29%). 1 patient out of 4 with a tumor of liver invagination had a tumor removed together with II and III segment of liver with the following right side hepatoenterostomy. No perioperational deaths were noted. In two patients after pancreatoduodenectomy (25%), a fistula in pancreatoenterostomy occurred. Due to the advanced stage of the neoplastic disease, resections in tumors of pancreatoduodenal fields and of liver invagination were only possible respectively in 29 and 25%. In most case of ductal calculosis or residual ductal calculosis, a removal of calculi was possible through endoscopy.