Preemptive purse-string suturing technique-assisted endoscopic papillectomy of ampullary adenoma

Endoscopic papillectomy has been recommended by the European Society of Gastrointestinal Endoscopy for the treatment of ampullary adenomas without intraductal extension [1]; however, it is a challenging procedure that is associated with serious adverse events [2], such as bleeding, which occurs in 11 %–30 % of cases [3]. Techniques used to manage bleeding and perforation include clip closure, but there is no agreement on a standard method [4]. Inspired by the endoscopic purse-string suturing (EPSS) method used for the closure of large gastrointestinal defects or perforations [5], we present a preliminary case of EPSS to facilitate the efficacy and safety of endoscopic papillectomy ([Video 1]).

Video 1 The purse-string suturing technique during endoscopic papillectomy of ampullary adenoma.

A 68-year-old man with ampullary tumor ([Fig. 1 a]) and absence of intraductal extension was referred for endoscopic treatment at our institution. The purse-string structure was created with an endoloop and several clips anchored to the normal mucosa 1.5 cm from the tumor boundary ([Fig. 1 b]). After the tumor was firmly and completely encircled by the snare, it was resected en bloc leaving a large mucosal defect ([Fig. 1 c]). We immediately extracted the specimen and placed a 7 Fr biliary stent. During subsequent cannulation and insertion of a 5 Fr plastic stent into the pancreatic duct, the defect started to bleed. Therefore, we slowly tightened the endoloop until the entire defect was closed and the bleeding stopped instantly ([Fig. 1 d]). The resected specimen was confirmed as having adequate margins of normal mucosa ([Fig. 1 e]).

Fig. 1 Endoscopic view of the endoscopic purse-string suturing method during endoscopic papillectomy. a Ampullar lesion in white-light mode. b The endoloop was anchored to the normal mucosa with clips surrounding the tumor. c After the tumor was completely encircled by the snare, en bloc endoscopic papillectomy was carried out. d After the plastic stents were inserted into the common bile duct and main pancreatic duct, the mucosal defect was closed by slowly tightening the endoloop to control the bleeding. e The resected specimen was flattened and fixed onto a foam board, and confirmed to include adequate margins of normal mucosa.

At follow-up 2 weeks later, we removed the purse-string structure and the plastic stents, and confirmed healing by the presence of a neat scar around the major papilla.

EPSS-aided endoscopic papillectomy not only guarantees en bloc resection of the tumor but also prevents severe complications. With the prepared purse-string structure guarding the operative field, the tumor can be thoroughly resected with adequate negative margins. In addition, with the purse-string structure being tightened after endoscopic papillectomy, the risk of bleeding and perforation can be greatly reduced.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Vanbiervliet G, Strijker M, Arvanitakis M. et al. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 429-448
• 2 Yamamoto K, Itoi T, Nagata N. et al. Optimal mode and power output of electrosurgical units for endoscopic papillectomy based on animal experiments and a preliminary clinical study (with videos). Gastrointest Endosc 2022; 95: 760-776
• 3 Hwang JS, So H, Oh D. et al. Long-term outcomes of endoscopic papillectomy for early-stage cancer in duodenal ampullary adenoma: comparison to surgical treatment. J Gastroenterol Hepatol 2021; 36: 2315-2323
• 4 Fritzsche JA, Fockens P, Barthet M. et al. Expert consensus on endoscopic papillectomy using a Delphi process. Gastrointest Endosc 2021; 94: 760-773
• 5 Inoue H, Tanabe M, Shimamura Y. et al. A novel endoscopic purse-string suture technique, “loop 9”, for gastrointestinal defect closure: a pilot study. Endoscopy 2022; 54: 158-162

Publication History

Article published online:
28 October 2022