Clinical outcomes of endoscopic papillectomy of ampullary adenoma: A multi-center study

Table 1 Baseline characteristics of patients

Characteristics	n (%)/mean ± SD (n = 106)
Age, yr	61.4 ± 12.8
≤ 65	57.5)
> 65	45 (42.5)
Sex
Male	62 (58.5)
Female	44 (41.5)
Body mass index (kg/m2)	23.3 ± 2.2
≤ 25	90 (84.9)
> 25	16 (15.1)
Clinical presentation
Asymptomatic	73 (68.9)
Jaundice	16 (15.1)
Abdominal discomfort	13 (12.3)
Other	4 (3.8)
Familial adenomatous polyposis	3 (2.8)
Initial pathology
Chronic inflammation	2 (1.9)
Atypical proliferative epithelium	3 (2.8)
Low-grade dysplasia	91 (85.8)
High-grade dysplasia	10 (9.4)
Mean follow-up, mo	36.2 ± 18.3

Table 2 Techniques and outcomes of endoscopic papillectomy

	n (%)/mean ± SD (n = 106)
EUS	37 (34.9)
ERCP
Cholangiogram	70 (66.0)
Pancreatogram	87 (82.1)
Submucosal lifting	4 (3.8)
Type of resection
En-bloc	90 (84.9)
Piecemeal	16 (15.1)
Thermal ablation after resection	24 (22.6)
Complete endoscopic resection	105 (99.1)
Stent implantation
Bile duct	25 (23.6)
Pancreatic duct	78 (73.6)
Resection specimen size, mm	13.6 ± 5.5
≤ 15	77 (72.6)
> 15	29 (27.4)
Final pathology
Chronic inflammation	3 (2.8)
Adenoma
Low grade	81 (76.4)
High grade	18 (17.0)
Adenocarcinoma	4 (3.8)
Accuracy of endoscopic biopsy
Underestimate	18 (17.0)
Overestimate	4 (3.8)
Resection margin
Negative	84 (79.2)
Positive/Uncertain	22 (20.8)
Positive	19 (17.9)
Uncertain	3 (2.8)
Curative resection	81 (76.4)
Early recurrence	11 (10.4)
Late recurrence	13 (12.3)
Re-recurrence	6 (5.7)
Endoscopic success	99 (93.4)
Mean hospital stay, d	5.7 ± 3.0
Mean adenoma-free period, mo	29.6 ± 21.3

EUS: Endoscopic ultrasound; ERCP: Endoscopic retrograde cholangiography.

Table 3 Risk factors of early recurrence

	Simple logistic regression (Univariate analysis)		Multiple logistic regression (Multivariate analysis)
	OR (95%CI)	P value	OR (95%CI)	P value
Age, > 65 yr	4.18 (1.042-16.774)	0.044	3.441 (0.807-14.672)	0.095
Sex, Male	1.8 (0.513-6.319)	0.359
Body mass index > 25 kg/m2	1.286 (0.251-6.587)	0.763
Symptomatic	3.022 (0.851-10.738)	0.087
EUS	3.792 (1.031-13.946)	0.045	1.622 (0.290-9.073)	0.582
Cholangiogram	1.125 (0.307-4.128)	0.859
Pancreatogram	2.338(0.281-19.450)	0.432
Submucosal lifting	3.067 (0.291-32.329)	0.351
Piecemeal resection	1.286 (0.251-6.587)	0.763
Thermal ablation	0.313 (0.038-2.578)	0.280
BDS	1.244 (0.304-5.096)	0.761
PDS	0.901 (0.221-3.675)	0.885
Size, > 15 mm	3.757 (1.048-13.461)	0.042	1.811 (0.344-9.521)	0.483
Initial pathology
Benign	Ref
LGD	0.683 (0.074-6.272)	0.736
HGD	2.333 (0.167-32.584)	0.529
Positive/uncertain resection margin	5.925 (1.610-21.801)	0.007	4.023 (1.088-16.387)	0.048
Complication	2.937 (0.815-10.582)	0.100

OR: Odds ratio; EUS: Endoscopic ultrasound; BDS: Bile duct stent insertion; PDS: Pancreatic duct stent insertion; LGD: Low grade dysplasia; HGD: High grade dysplasia.

Table 4 Risk factors of late recurrence

	Simple logistic regression (Univariate analysis)		Multiple logistic regression (Multivariate analysis)
	OR (95%CI)	P value	OR (95%CI)	P value
Age, > 65 yr	0.564 (0.162-1.961)	0.368
Sex, Male	0.865 (0.263-2.847)	0.812
Body mass index > 25 kg/m2	2.095 (0.645-6.810)	0.219
Symptomatic	4.659 (1.292-16.797)	0.019	4.213 (0.091-16.728)	0.061
EUS	0.521 (0.134-2.023)	0.346
Cholangiogram	1.250 (0.377-4.140)	0.715
Pancreatogram	2.880 (0.351-23.609)	0.324
Submucosal lifting	2.500 (0.240-26.004)	0.443
Piecemeal resection	7.114 (1.993-25.398)	0.003	6.610 (1.760-24.820)	0.005
Thermal ablation	2.434 (0.715-8.293)	0.155
BDS	1.524 (0.426-5.449)	0.517
PDS	4.657 (0.576-37.636)	0.149
Size, > 15 mm	0.444 (0.092-2.140)	0.312
Positive/uncertain resection margin	0.286 (0.035-2.326)	0.242
Complication	0.913 (0.231-3.606)	0.897

OR: Odds ratio; EUS: Endoscopic ultrasound; BDS: Bile duct stent insertion; PDS: Pancreatic duct stent insertion.

Table 5 Risk factors of non-curative resection

	Simple logistic regression (Univariate analysis)		Multiple logistic regression (Multivariate analysis)
	OR (95% CI)	P value	OR (95% CI)	P value
Age, > 65 yr	1.485 (0.595-3.703)	0.397
Sex, Male	1.256 (0.503-3.141)	0.625
Body mass index > 25 kg/m2	3.340 (1.090-10.235)	0.035	2.942 (0.855-10.117)	0.087
Symptomatic	2.905 (1.133-7.466)	0.026	3.509 (0.942-9.914)	0.058
EUS	1.455 (0.572-3.699)	0.431
Cholangiogram	1.222 (0.475-3.148)	0.678
Pancreatogram	2.877 (0.615-13.458)	0.179
Submucosal lifting	3.636 (0.484-27.302)	0.209
Piecemeal resection	4.625 (1.510-14.162)	0.007	5.424 (1.582-18.600)	0.007
Thermal ablation	1.185 (0.410-3.427)	0.754
BDS	1.464 (0.526-4.076)	0.466
PDS	1.949 (0.601-6.322)	0.266
Size, > 15 mm	1.452 (0.543-3.881)	0.457
Initial pathology
Benign	Ref
LGD	0.446 (0.098-2.036)	0.297
HGD	0.556 (0.065-4.755)	0.592
Positive/uncertain resection margin	1.839 (0.648-5.220)	0.252
Complication	1.778 (0.656-4.817)	0.258

OR: Odds ratio; EUS: Endoscopic ultrasound; BDS: Bile duct stent insertion; PDS: Pancreatic duct stent insertion; LGD: Low grade dysplasia; HGD: High grade dysplasia.

Table 6 Adverse events of endoscopic papillectomy

	n (%) (n = 106)
Early
Pancreatitis	14 (13.2)
Delayed bleeding	11 (10.4)
Cholangitis	6 (5.7)
Perforation	1 (0.9)
Late
Papillary stenosis	0 (0.0)
Mortality	0 (0.0)
Total	26 (24.5)

Table 7 Univariate and multivariate analysis of risk factors for pancreatitis and bleeding

	Pancreatitis				Bleeding
	Univariate analysis		Multivariate analysis		Univariate analysis		Multivariate analysis
	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value	OR (95%CI)	P value
Age, > 65 yr	0.722 (0.225-2.323)	0.585			0.753 (0.206-2.745)	0.667
Sex, Male	1.486 (0.481-4.590)	0.491			1.800 (0.513-6.319)	0.359
Body mass index > 25 kg/m2	0.412 (0.071-3.902)	0.635			0.533 (0.063-4.480)	0.563
Symptomatic	0.144 (0.018-1.153)	0.068			1.994 (0.562-7.073)	0.285
EUS	2.067 (0.664-6.428)	0.210			1.641 (0.465-5.788)	0.442
FAP	15.167 (1.277-180.166)	0.031	9.363 (0.429-204.392)	0.155	4.650 (0.386-55.945)	0.226
Cholangiogram	1.550 (0.493-4.870)	0.453			3.983 (1.081-14.669)	0.038	2.235 (0.323-15.460)	0.415
Pancreatogram	0.278 (0.087-0.885)	0.030	0.534 (0.106-2.678)	0.446	2.338 (0.281-19.450)	0.432
Piecemeal resection	0.929 (0.187-4.606)	0.928			6.364 (1.661-24.375)	0.007	6.698 (1.599-28.057)	0.009
Thermal ablation	4.412 (1.366-14.250)	0.013	4.128 (1.005-17.128)	0.048	2.143 (0.570-8.052)	0.259
BDS	0.868 (0.222-3.393)	0.838			4.800 (1.323-17.418)	0.017	2.647 (0.398-17.619)	0.314
PDS	0.102 (0.030-0.349)	0.000	0.205 (0.044-0.945)	0.042	1.607 (0.325-7.951)	0.561
Size, > 15 mm	1.072 (0.308-3.731)	0.913			2.465 (0.690-8.812)	0.165
Initial pathology
Benign	Ref				Ref
LGD	0.975 (0.109-8.693)	0.982			0.293 (0.050-1.697)	0.171
HGD	2.333 (0.167-32.584)	0.529			0.429 (0.031-5.985)	0.529
Positive/uncertain resection margin	3.562 (1.086-11.685)	0.036			0.833 (0.167-4.167)	0.824

OR: Odds ratio; EUS: Endoscopic ultrasound; FAP: Familial adenomatous polyposis; BDS: Bile duct stent insertion; PDS: Pancreatic duct stent insertion; LGD: Low grade dysplasia; HGD: High grade dysplasia.