10 January 2020
Adenoma in either major and minör papilla is rare outside of familial polyposis syndrome. With a forward viewing endoscope (gastroscope) it is difficult to have a full Picture of majör or minor papilla. However when thre is an adenoma, it is usually detected. In case it is detected what should be done is contentious issue. My advice is to switch to duodenoscope and to have a full evaluation. To biopsy or not-to-biopsy ? I strongly advice against forceps biopsy unless you explain what you find to the patient and get his informed consent for biopsy, because especially major papilla biopsy may result with pancreatitis. The best strategy would be to refer the patient to a center specialized in EUS/ERCP. When such a patient is referred to us, we perform duodoenoscopy to confirm presence of adenoma and we perform en EUS examination to exclude an invasive papillary malignancy. We sometimes perform forceps biopsy after explaining the panceratitis risk to the patient.
I do not advice a previous sphincterotomy.
In case the patient presents with jaundice, the possibility of papillary carcinoma increases. In this case, biopsy is necessary however even if it is negative, carcinoma may not be excluded. deep biopsies after sphincterotomy is more yielding. However biopsy immediately after biopsy may be false negative because of cotery artifacts. Furthermore sphincterotomy may make future endoscopic papillectomy more difficult.
We stage papilla vateri carcinoma as following by EUS:
T1a: Tumour confined to mucosa
T1b:Tumor confined to mucosa and submucosa
T2: Tumor invades muscularis propria but not ducts
T3a: Tumor invades pancreatic duct 5 mm or less.
T3b: Tumour invades pancratic duct more than 5 mm.
T4: Tumor invades superior mesenteric artery, coeliac truncus or hepatic artery
While T!a is amenable for endoscopic resection (ER) T1b-T3 requires Whiplle's procedure.
For some patients with T1b with serious comorbidities, ER is still an option.
We do the nodal staging with EUS as well and in case it is necessary we sample lymph nodes.
NO: no lymph node metastatsis
N1: 3 or less lymph node metastasis
N2: More than three lymph node metastasis.
We do papillectomy, in general, under general anesthesia with the patient in supine position. However it may be performed under deep sedation in prone position as well.
While performing papillectomy