Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis
Authors: Marcus Hollenbach, Christian Heise, Einas Abou-Ali, Aiste Gulla, Francesco Auriemma, Kevin Soares, Galen Leung, Mark A Schattner, William R Jarnagin, Tiegong Wang, Fabrice Caillol, Marc Giovannini, Yanis Dahel, Thilo Hackert, Woo Hyun Paik, Alessandro Zerbi, Gennaro Nappo, Bertrand Napoleon, Urban Arnelo, Erik Haraldsson, Asif Halimi, Alexander Waldthaler, Uwe Will, Rita Saadeh, Viliam Masaryk, Sophia E van der Wiel, Marco J Bruno, Enrique Perez-Cuadrado-Robles, Pierre Deprez, Alain Sauvanet, Louisa Bolm, Tobias Keck, Régis Souche, Jean-Michel Fabre, Nicolas Musquer, Georg Kähler, Steffen Seyfried, Maria Chiara Petrone, Alberto Mariani, Piera Zaccari, Giulio Belfiori, Stefano Crippa, Massimo Falconi, Stefano Partelli, Bengisu Yilmaz, Ihsan Ekin Demir, Güralp O Ceyhan, Sohei Satoi, Jean Marc Regimbeau, Johan Gagniére, Alessandro Repici, Andrea Anderloni, Charles Vollmer, Fabio Casciani, Marco Del Chiaro, Atsushi Oba, Richard D Schulick, Arthur Berger, Laura Maggino, Roberto Salvia, Peter Schemmer, Doerte Wichmann, Yosuke Inoue, Mario Dinis-Ribeiro, Ana Laranjo, Diogo Libanio, Tobias Kleemann, Vasile Sandru, Madaline Ilie, Reea Ahola, Johanna Laukkarinen, Brigitte Schumacher, David Albers, Tiago Cúrdia Gonçalves, Louise Barbier, Ephrem Salamé, Tobias J Weismüller, Dominik Heling, Arnaud Alves, Elias Karam, Nicolas Regenet, Ana Dugic, Steffen Muehldorfer, Stéphanie Truant, Karel Caca, Benjamin Meier, Bogdan P Miutescu, Marcel Tantau, David Birnbaum, Rainer Christoph Miksch, Edris Wedi, Katrin Salzmann, Matthieu Bruzzi, Renato M Lupinacci, Patrice David, Charles De Ponthaud, Arthur Schmidt, Sara Regnér, Sebastien Gaujoux
Journal: Gut (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 χ 2 test, 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&lt;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.