A 70-year-old woman with familial adenomatous polyposis (FAP), who had undergone proctocolectomy
for FAP and laparoscopic total gastrectomy with Roux-en-Y reconstruction for multiple
early gastric cancers, underwent double-balloon endoscopy (DBE) for duodenal adenoma
screening. DBE revealed an ampullary tumor, diagnosed as a tubular adenoma by biopsy
([Fig. 1 a]). For resection of the ampullary tumor, we planned an underwater endoscopic papillectomy.
Fig. 1 Endoscopic images showing: a an adenoma of the papilla of Vater; b the ensnared papilla during underwater papillectomy (underwater view); c the appearance following underwater papillectomy (underwater view); d insertion of a pancreatic stent into the main pancreatic duct (MPD) and closure of
the mucosal defect with clips.
Video 1 Underwater endoscopic papillectomy of an adenoma of the papilla of Vater.
We used a short-type double-balloon endoscope (EI-580BT; Fujifilm, Tokyo, Japan),
equipped with an auxiliary waterjet injection cap (Water Please AF-WP1; Forte Grow
Medical Co. Ltd., Tochigi, Japan) to allow irrigation while leaving the operative
channel free. We performed underwater papillectomy using a single-use snare (Captivator
II; Boston Scientific, Tokyo, Japan) without submucosal injection ([Fig. 1 b, c]). A 5-Fr plastic stent (Geenen pancreatic stent; Cook Medical, Tokyo, Japan) was
placed into the main pancreatic duct to prevent post-papillectomy pancreatitis and
the mucosal defect was closed with clips (QuickClip Pro; Olympus, Tokyo, Japan) ([Fig. 1 d]).
The patient did not experience any early adverse events and was discharged on postoperative
day 7. The pathological diagnosis of the resected tumor confirmed it to be a tubular
adenoma and the resection margins were free of dysplasia.
Endoscopic papillectomy (EP) is a less invasive treatment for localized ampullary
tumors; however, the procedure is not standardized, and severe adverse events such
as pancreatitis, perforation, bleeding, and cholangitis may occur after the procedure
[1]
[2]. Underwater endoscopic mucosal resection (EMR) has been reported as a novel approach
for the treatment of small duodenal adenomas (≤ 20 mm) [3], but the efficacy of the procedure and its safety for ampullary tumors are unclear.
In this case, we applied the underwater EMR technique to an endoscopic papillectomy
procedure using DBE. The underwater EMR technique has been similarly reported to be
a safe and novel treatment approach for an ampullary tumor in a patient with altered
gastrointestinal anatomy [4].
Endoscopy_UCTN_Code_TTT_1AR_2AF
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