ENDOSCOPIC PAPILLECTOMY FOR NEOPLASTIC LESIONS OF THE AMPULLA OF VATER: A SYSTEMATIC REVIEW WITH POOLED-ANALYSIS

Aims:

Endoscopic papillectomy (EP) is currently accepted as a viable alternative therapy to surgery in both sporadic and familiar ampullary lesions (AL). Many series have reported relatively low morbidity and acceptable outcomes compared to surgery, but most of them were retrospective studies with limited samples. Considering the lack of conclusive evidences, we performed a pooled analysis of the available literature to assess the safety and efficacy of EP for AL.

Methods:

Electronic databases (Medline, Scopus, EMBASE) were searched up to September2018. The search was restricted to English language full articles. Studies including patients with AL lesions endoscopically resected were eligible. The adverse event rates (primary outcome), complete resection, en-bloc resection, needs-for-further-treaments and curative resection (complete resection without recurrence) rates were pooled by means of a random- or fixed-effect model according to the degree of heterogeneity to obtain a proportion with a 95% confidence interval (CI).

Results:

Twentynine studies were eligible for inclusion providing data on 1751 patients (mean ages ranging from 42 to 68 years). Nine studies were performed in United States, 1 in Australia, 10 in Asia, and the others in Europe; six studies were prospective. The means of the lesion size ranged from 8.7 mm to20.3 mm. Biliary and pancreatic stenting were performed in33.3%(20.2 – 49.5%) and75.2%(63.6 – 84.0%) respectively.

The overall adverse events rate was25.4%(CI:21.5 – 29.7%) with rates of procedural-related bleedings and perforations of 10.7%(8.1 – 14 – 1%) and 3.2%(2.3 – 4.3%) respectively. Pancreatitis occurred after the12.3%(CI 10.7 – 14.1%) of the procedures and cholangitis rate was2.9%(CI:2.0 – 4.4%). Complete resection rate was 91.3%(CI:86.7 – 94.4%) with a rate of en-bloc resection of 81.7%(CI:73.6 – 87.7). Multiple endoscopic treatments were needed in the11.9%(CI:7.2 – 17 – 2) of cases, and 74.1%(CI:66.4 – 80.6) of the procedures were "curative" in a mean endoscopic surveillance period ranging from 9.6 to84.5months).

Conclusions:

Endoscopic papillectomy (EP) is a relatively safe technique compared to surgery for resecting ampullary lesions (AL). Even if efficacy outcomes, are heterogeneously reported by the different studies, EP still seems to be a reliable alternative therapy to surgery in term of curative resection rates.