Endoscopic papillectomy is indicated for the treatment of duodenal papillary adenoma
[1]
[2]. However, en bloc resection using a snare may be challenging in cases with lateral
extension of tumor. For lesions that are difficult to remove en bloc with papillectomy
alone,
resection of two parts of the lesion with staggered timing is effective, without requiring
submucosal dissection [3]. A man in his fifties was referred to our hospital following a medical examination.
Duodenoscopy revealed a flat lesion arising from the papilla and extending toward
the anus
([Fig. 1]). A diagnosis of ampullary adenoma was made. The use of a snare was considered to
increase the risk of residual peripheral lesions. Consequently, a strategy was devised
to remove
the lesion in two parts: the anal side and the ampullary side. First, we excised the
anal side
of the lesion using cap-assisted endoscopic mucosal resection [4]. Then, we inserted an endoscope (GIF-Q260J; Olympus, Tokyo, Japan) with a disposable
hood (D-206-05; Olympus) ([Video 1]). Following administration of physiological saline under the lesion, a 25-mm snare
was
set in the claw of the hood, and the anal side of the lesion was suctioned, grasped
with the
snare, and excised using the ENDO CUT Q mode (VAIO2; Erbe, Tübingen, Germany). Prior
to
resection, several trial suctions were performed to test the grip accuracy. After
8 weeks, the
ulcer had scarred, and endoscopic papillectomy was performed for the residual tumor
([Fig. 2]). Using a TJF-Q290V endoscope (Olympus, Tokyo, Japan) in the ENDO CUT Q mode, the
residual tumor was excised by applying a snare from the oral side to the anal side.
The
treatment was completed by placing plastic stents in the bile and pancreatic ducts
and applying
clip sutures. The histopathological diagnosis was well-differentiated adenocarcinoma
localized
to the mucosa. Reconstruction of the lesion removed using cap-assisted endoscopic
mucosal
resection and endoscopic papillectomy revealed no residual tumor ([Fig. 3]). No adverse events of the procedures were observed. At 1 year, endoscopy revealed
no
tumor recurrence.
Fig. 1
a, b Duodenoscopy showing the ampullary side (a) and anal side (b) of lesion with lateral extension
(blue arrow). The orifice is indicated by the white arrow.
The ampullary lesion was resected in two parts. First, the anal side of the lesion
was excised using cap-assisted endoscopic mucosal resection (EMR-C). After 8 weeks,
endoscopic papillectomy (EP) was performed to remove the residual tumor.Video 1
Fig. 2
a Residual lesions observed using a side scope. b Margin of the anal side of the residual lesion (white arrow) and previously placed
clip.
Fig. 3
a, b Loupe images of specimens resected during (a) cap-assisted endoscopic mucosal resection (22 × 16 mm) and (b) endoscopic papillectomy (14 × 11 mm). The red dashed lines indicate
the margin of the lesion.
Endoscopy_UCTN_Code_TTT_1AR_2AD
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