Curative en bloc resection of a laterally spreading mixed-nodular papillary tumor with endoscopic submucosal dissection: a case report

A 56-year-old man was referred to our hospital with epigastric pain for 3 months. A white light image revealed a laterally spreading mixed-nodular tumor at the duodenal major papilla ([Fig. 1]), diagnosed as a tubular adenoma by biopsy. Narrow-band imaging with magnifying endoscopy demonstrated distinct demarcation, irregular micro-vessel plus surface pattern, and positive white opaque substance (WOS). After signed informed consent, we performed endoscopic submucosal dissection (ESD) using dental floss traction with a supine position ([Video 1]) and captured a resection specimen of 30 × 35 mm ([Fig. 2]).

Fig. 1 The side-viewing endoscopy showed a laterally spreading mixed-nodular papillary tumor.

Video 1 Successful curative en bloc resection of a laterally spreading mixed-nodular papillary tumor with endoscopic submucosal dissection.

Fig. 2 The resection specimen fixed on the foam board after formalin fixation.

The openings of the common bile duct and pancreatic duct were distinctly seen in the procedure ([Fig. 3]). There was a resection plane without muscular injury ([Fig. 4]). After the closure of the mucosal defect with clips, a gastric feed tube and a pancreatic plastic stent were implemented successfully ([Fig. 5]). The patient was discharged 5 days later without complications. The pathological result was a tubular adenoma with high intraepithelial neoplasia and the resection margins were free of dysplasia. At follow-up endoscopy after 4 months, there were no signs of recurrence.

Fig. 3 The view revealed the opening of common bile duct during the endoscopic submucosal dissection procedure (arrow).

Fig. 4 The resection plane without muscular injury after complete endoscopic submucosal dissection.

Fig. 5 The mucosal defect was sutured with SureClips after a gastric feed tube and a pancreatic plastic stent were implemented.

Endoscopic papillectomy is a less invasive treatment for localized papillary tumors, which may occur with incomplete resection, bleeding, perforation, and pancreatitis after the procedure [1]. The European Society of Gastrointestinal Endoscopy recommends en bloc resection of ampullary adenomas up to 20–30 mm in diameter to achieve R0 resection for optimizing the complete resection rate, providing optimal histopathology, and reducing the recurrence rate after endoscopic papillectomy [2]. To avoid piecemeal resection, we finally decided to conduct ESD using a cap-assisted method with forward-viewing endoscopy. To our knowledge, this is the first report that achieves curative en bloc resection of a papillary tumor of more than 30 mm in size with this method. Therefore ESD performed by skilled and experienced endoscopists may be a safe alternative to treat the giant laterally spreading tumor involving the papilla.

Endoscopy_UCTN_Code_CPL_1AH_2AZ

Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kang SH, Kim KH, Kim TN. et al. Therapeutic outcomes of endoscopic papillectomy for ampullary neoplasms: retrospective analysis of a multicenter study. BMC Gastroenterol 2017; 17: 69
• 2 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

Publication History

Article published online:
09 March 2023