This retrospective single-center trial [1] included 51 patients treated by endoscopic papillectomy (EP): 11 familial adenomatous
polyposis (FAP), 35 sporadic adenoma/adenocarcinoma lesions (SAL), and five non-adenomatous
lesions. The authors aimed to evaluate predictors for recurrence and adverse events
(AEs). In addition, they compared baseline characteristics and outcomes between patients
with FAP vs SAL. The conclusions of this trial must be compared with results of large
trials and guidelines recently published.
As observed in other trials, 10% of the resected specimens were finally neither adenoma
nor adenocarcinoma. This is consistent with the difficulty for the pathologist in
differentiating adenoma with low-grade dysplasia (LGD) and regenerative tissue. To
overcome this issue, the European Society of Gastrointestinal Endoscopy [2] recommends histological confirmation by endoscopic biopsies in case of LGD adenoma
before initiating any treatment (strong recommendation, low quality of evidence).
The comparison between patients with FAP syndrome and those with sporadic lesions
must be interpretated with caution, given the small number of patients in this trial
(11 FAP). In a recent multicenter European trial [3] including a large cohort of patients, propensity-score matching identified 101 patients
with FAP and 101 with SAL. Some results were comparable to this series. Patients in
the FAP group were mainly asymptomatic (79.2% vs. 46.5%, P < 0.001), AEs were not statistically different between the two groups, with pancreatitis
and bleeding being the most common, and the recurrence rate was higher in the FAP
group (3-year disease-free survival was 76.8% vs 84.8%) but occurred later (median
of 25 vs. 2 months in SAL patients). On the other hand, the initial R0 resection rate
differed between the two groups (63.4% in the FAP group vs 83.2% in the SAL group)
and was higher than in this trial (45% in the two groups) [3]. The low R0 resection rate in this study does not support the conclusion of Suryawanshi
et al to consider it as a predictive factor of the absence of recurrence.
Some points must also be highlighted in management of ampullary adenoma in FAP syndrome.
An ampullary adenoma smaller than 1 cm with only LGD on biopsy can be resected or
followed. The prognosis for the upper digestive tract depends on ampulla lesions but
also on gastric and duodenal lesions. The decision to undertake endoscopic treatment
must take into consideration the other duodenal (Spigelman classification) or gastric
lesions. Upper digestive tract follow-up must be continued even in case of absence
of ampullary adenoma recurrence after 5 years. Due to the rarity and specificity of
FAP and other rare adenomatous polyposis syndromes, patients should be managed at
specialized centers.
The AE rate was comparable to other trials (delayed bleeding and acute pancreatitis
13.7% each). The authors found a correlation between delayed bleeding and pancreatitis,
which needs to be confirmed in a large trial. Actually, it is not consistent with
a large trial that included 307 patients [4]. In that trial, delayed bleeding represented the most common AE and occurred in
44 patients (14.3%). Multivariate analysis identified oral anticoagulant agents (odds
ratio [OR] 4.37, range 2.86–5.95) and procedural bleeding (OR 2.22; range 1.10–4.40)
as independently related to delayed bleeding. In patients without procedural bleeding,
oral anticoagulant agents (OR 5.63, range 2.25–9.83) and ampullary tumor size (OR
1.07, range 1.01–1.13) were independently related to delayed bleeding. Interestingly,
delayed bleeding occurred after a median of 1 day and in 88% of cases within the first
48 hours after EP [4]. A 48-hour hospital stay is consequently systematically planned in many centers
to manage the majority of AEs during hospitalization.
In their conclusion [1], Suryawanshi et al considered EP as safe and effective in removing ampullary lesions.
This must be toned down. EP remains a difficult procedure with a higher rate of AEs
and a lower rate of R0 resection compared with endoscopic resection of other digestive
tumors. Moreover, surgery remains an alternative. In a recent and large matched cohort
analysis comparing transduodenal surgical ampullectomy and EP [5], EP was found non-inferior to the surgical counterpart regarding overall survival,
but recurrences and retreatments appeared to be more frequent. Regardless of the chosen
treatment, these patients should be managed by experts in specialized centers.
Bibliographical Record
Bertrand Napoleon. Endoscopic papillectomy of major papilla lesions: Single tertiary
care center experience. Endosc Int Open 2025; 13: a26840042.
DOI: 10.1055/a-2684-0042
