Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications

Background. Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniqu es for decreasing complications and enhancing efficacy. Methods: Forty-one patients were referred for endoscopic management of papi llary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephr ine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent remova l was performed 1 month later. Results: Nine patients (22%) had lesions other than papillary adenoma or ca ncer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were o btained. Three patients with adenomas (7%) did not undergo endoscopic resec tion (because of extremely large lesions and/or comorbid illnesses). Thirte en patients with adenomas (32%) had endoscopic resection; 12 (92%) were les ion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient. Conclusions: Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresectio n sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive tre atment.