Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis
Authors: Hollenbach Marcus , Heise Christian , Abou-Ali Einas , Gulla Aiste , Auriemma Francesco , Soares Kevin , Leung Galen , Schattner Mark A , Jarnagin William R , Wang Tiegong , Caillol Fabrice , Giovannini Marc , Dahel Yanis , Hackert Thilo , Paik Woo Hyun , Zerbi Alessandro , Nappo Gennaro , Napoleon Bertrand , Arnelo Urban , Haraldsson Erik , Halimi Asif , Waldthaler Alexander , Will Uwe , Saadeh Rita , Masaryk Viliam , van der Wiel Sophia E , Bruno Marco J , Perez-Cuadrado-Robles Enrique , Deprez Pierre , Sauvanet Alain , Bolm Louisa , Keck Tobias , Souche Régis , Fabre Jean-Michel , Musquer Nicolas , Kähler Georg , Seyfried Steffen , Petrone Maria Chiara , Mariani Alberto , Zaccari Piera , Belfiori Giulio , Crippa Stefano , Falconi Massimo , Partelli Stefano , Yilmaz Bengisu , Demir Ihsan Ekin , Ceyhan Güralp O , Satoi Sohei , Regimbeau Jean Marc , Gagniére Johan , Repici Alessandro , Anderloni Andrea , Vollmer Charles , Casciani Fabio , Del Chiaro Marco , Oba Atsushi , Schulick Richard D , Berger Arthur , Maggino Laura , Salvia Roberto , Schemmer Peter , Wichmann Doerte , Inoue Yosuke , Dinis-Ribeiro Mario , Laranjo Ana , Libanio Diogo , Kleemann Tobias , Sandru Vasile , Ilie Madaline , Ahola Reea , Laukkarinen Johanna , Schumacher Brigitte , Albers David , Cúrdia Gonçalves Tiago , Barbier Louise , Salamé Ephrem , Weismüller Tobias J , Heling Dominik , Alves Arnaud , Karam Elias , Regenet Nicolas , Dugic Ana , Muehldorfer Steffen , Truant Stéphanie , Caca Karel , Meier Benjamin , Miutescu Bogdan P , Tantau Marcel , Birnbaum David , Miksch Rainer Christoph , Wedi Edris , Salzmann Katrin , Bruzzi Matthieu , Lupinacci Renato M , David Patrice , De Ponthaud Charles , Schmidt Arthur , Regnér Sara , Gaujoux Sebastien 
Published: December 2024

Objective

Ampullary neoplastic lesions can be resected by endoscopic papillectomy (EP) or transduodenal surgical ampullectomy (TSA) while pancreaticoduodenectomy is reserved for more advanced lesions. We present the largest retrospective comparative study analysing EP and TSA.

Design

Of all patients in the database, lesions with prior interventions, benign histology advanced malignancy (T2 and more), patients with hereditary syndromes and those undergoing pancreatoduodenectomy were excluded. All remaining cases as well as a subgroup of them, after propensity-score matching (nearest-neighbour-method) based on age, gender, anthropometrics, comorbidities, size and histological subtype, were analysed. The median follow-up was 21 months (IQR 10–47) after the primary intervention. Primary outcomes were rates of complete resection (R0) and complications. Groups were compared by Fisher’s exact or χ2test, Mann-Whitney-U-test and log-rank test for survival.

Results

Of 1673 patients in the database, 1422 underwent EP and 251 TSA. Of them, 23.2% were excluded for missing or inconclusive data and 19.8% of patients for prior interventions or hereditary syndromes. Final histology showed in 24.2% of EP and 14.8% of TSA patients a histology other than adenoma or adenocarcinoma while advanced cancers were recorded in 10.9% of EP and 36.6% of TSA patients. Finally, 569 EP and 63 TSA were included in the overall analysis, with a higher rate of more advanced cases and higher R0 resection rates in the TSA groups (90.5% vs 73.1%; p<0.01), with additional ablation in the EP group in 14.4%. Severe adverse event rates were 3.2% (TSA) vs 1.9% (EP). Recurrence after histological R0 resection was 16% (EP) vs 3.2% (TSA; p=0.01), and additional therapy for R1 resection was applied in 67% of the 159 cases. Propensity-score-based matching identified 62 pairs of EP/TSA patients with comparable baseline patient and lesion characteristics. The initial R0-rate was 72.6% (EP) compared with 90.3% (TSA, p=0.02) with recurrences found in 8% (EP) vs 3.2% (TSA; p=0.07); reinterventions were more frequent in the EP group. Overall survival was comparable.

Conclusions

The rate of patients with poor indications due to non-neoplastic disease or advanced cancer is still high for both EP and TSA; multiple retreatments were necessary for EP. Although EP can be considered an appropriate primary therapy for certain ampullary adenomas, case selection for both therapies (especially with regard to the best step-up approach) should be studied further.