CAN WE AMELIORATE THE SAFETY OF INTRADUCTAL RADIOFREQUENCY ABLATION FOR PERSISTENT DYSPLASIA AFTER ENDOSCOPIC AMPULLECTOMY?

Aims After endoscopic ampullectomy, intraductal adenoma may persist. Intraductal radiofrequency ablation (ID-RFA) is a potential alternative to avoid surgery. In a previous trial, acute pancreatitis and biliary stenosis were noted in 15% of cases, respectively. Systematic pancreatic and biliary stenting could potentially prevent these complications. This retrospective study aimed to evaluate the safety profile of ID-RFA when associated with prophylactic stenting.

Methods All patients treated in Mermoz Hospital from December 2015 to October 2019 for intraductal recurrence of adenoma after endoscopic ampullectomy were prospectively included in a database. For biliary ID-RFA, systematic plastic pancreatic stenting before irradiation and systematic biliary stenting with fully-covered self-expandable metal stents (FCSEMS) were performed. For pancreatic ID-RFA, systematic plastic pancreatic stenting was performed.

Results Fifteen patients were included (mean age of 74 years (62-89), 11 males). There were 13 endobiliary adenomas (11 low-grade dysplasia (LGD), 2 high-grade dysplasia (HGD)), 2 intrapancreatic LGD). 23 sessions (21 biliary, 2 pancreatic) were performed with ELRA system (settings: 30-240 seconds;7-10W; maximum heat 80°). Pancreatic and biliary stents were inserted as per protocol. There were no immediate complications but one transient conduction heart block. Four patients developed a late common bile duct stenosis (19%) of which 2 were successfully calibrated by FCSEMS and 2 are currently under ongoing endoscopic treatment. Seven patients (47%) had no recurrence (mean follow-up 12 months (1-24), 86% after one session). One was operated without remaining biliary adenoma, 4 are under ongoing treatment (LGD, mean follow-up 27 months (11-36)), 3 had unrelated severe diseases (one death, 2 pancreatic tail adenocarcinoma).

Conclusions In this trial no major adverse events were noted after ID-RFA of adenomatous remnant post endoscopic ampullectomy. Systematic pancreatic stenting prevented acute pancreatitis (0%) but biliary stenting did not modify the risk of common biliary strictures (19%). No patients developed ductal malignancy during follow-up.