HOW TO ACHIEVE "GOOD" ENDOSCOPIC PAPILLECTOMY

Abstract

The most critical point in endoscopic papillectomy is the assessment of its indication. Adenoma of the duodenal papilla without extension into the bile or pancreatic duct is an accepted indication. Cancer in adenoma without invasion of the muscularis propria of the duodenum, pancreas, or extension along the bile or pancreatic duct is also a possible candidate for this treatment. On some occasions, endoscopic papillectomy may be indicated as a total biopsy.
The procedure is similar to that in polypectomy of the digestive tract. Following insertion of a duodenoscope into the descending portion of the duodenum, a tumor at the papilla of Vater is caught in a snare loop which is delivered via the cannel of the scope, as deep as possible. To achieve this, the tip of the snare should first be put on the top of the oral protrusion as a fulcrum. Then, the entire tumor is trapped in the snare, and the snare is tightened so that it can grasp the bile duct and the pancreatic duct terminals adjacent to the base of the tumor. We apply the 'cut' current for electrocautery to avoid infiltration of the energy to the pancreatic parenchyma. After resection of the tumor, a stent is placed in the pancreatic duct, which will prevent obstruction of the outlet of pancreatic juice that leads to acute pancreatitis.
Detailed histological examination is mandatory for the evaluation of the quality of the resection. It is ideal to obtain cut margins, including the bile duct and pancreatic duct terminals, be free of neoplastic cells. Sometimes it is not possible to confirm such free margins due to burn of the tissue. In such occasions, follow-up in a short term is required and when a remnant tumor is recognized, surgical resection or ablation should be added based on the depth of invasion of tumor. Further accumulation of the data on follow-up is necessary to justify this procedure as a treatment of choice for the tumors mentioned here.