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Endoscopic papillectomy is widely performed to treat duodenal papillary tumors, particularly at highvolume centers. It is indicated for adenomas without intraductal extension of the bile or pancreatic ducts. However, despite numerous reports of carcinomas that expand the indications to include well-differentiated adenocarcinomas that do not invade the sphincter of Oddi, the low agreement between biopsy and final pathological diagnosis, as well as the current inability of imaging modalities to diagnose sphincter of Oddi invasion, makes it difficult to consider expanding indications. Although complications can be prevented by certain methods, such as pancreatic duct stenting, and the frequency of severe complications has decreased, the safety of the procedure remains unconfirmed. In the future, this technology is expected to progress and enable wider applications, including those in tumors with extensive horizontal spread and those with intraductal extension of the bile and pancreatic ducts. Such technology may also improve the safety and accuracy of diagnosis. [ABSTRACT FROM AUTHOR]

We present a case of a fish bone impacted in the papilla of Vater resulting in dyspepsia and mild elevation in liver function tests, which was subsequently treated endoscopically. Fish bones are one of the most commonly encountered swallowed foreign bodies. However, involvement of the biliary tract, such as the one described by us, represents an extremely rare complication of fish bone ingestion. The diagnosis of a foreign body in the biliary tract can be difficult, and early endoscopic or surgical extraction may be required to avoid complications such as biliary stone formation, obstructive jaundice, cholangitis or cholecystitis, and/or biliary sepsis. Prompt endoscopic treatment can avoid severe biliary complications or surgical therapy. [ABSTRACT FROM AUTHOR]

Pancreaticobiliary maljunction (PBM) is a congenital malformation that is associated with biliary cancer development. When patients are diagnosed with PBM, a diversion operation is recommended. Although a risk remains for developing residual bile duct carcinoma following diversion, the development of a carcinoma of the ampulla of Vater after a diversion operation for PBM is rare. We present a treated case of carcinoma of the ampulla of Vater after a diversion operation for PBM. A 65-year-old woman presented with abdominal pain. She had undergone extrahepatic bile duct resection and cholecystectomy 2 years 9 months previously for the treatment of type Ic PBM according to the Todani classification. At the current admission for evaluation of the abdominal pain, computed tomography and magnetic resonance imaging showed only dilation of the main pancreatic duct. However, gastrointestinal endoscopy showed a tumor at the papilla of Vater, and biopsy revealed adenocarcinoma of the papilla of Vater. We performed pylorus-preserving pancreaticoduodenectomy, and the pathological diagnosis was moderately differentiated tubular adenocarcinoma of the papilla of Vater with no metastasis to the lymph nodes. The patient remained in good health for 3 years postoperatively. Carcinoma of the papilla of Vater after a diversion operation for PBM is rare. In this case, a diagnosis could not be made by computed tomography or magnetic resonance imaging; the definitive diagnosis was obtained with gastrointestinal endoscopy. Careful postoperative follow-up with gastrointestinal endoscopy in addition to imaging examination may be needed after a diversion operation for PBM. [ABSTRACT FROM AUTHOR]

Abstracts of the oral and poster presentations and video festivals presented at the 26th World Congress of the International Association of Surgeons, Gastroenterologists and oncologists (IASGO) that will be held on September 8-10, 2016 in Seoul, South Korea are presented.

The aim of this study was to evaluate the association between juxtapapillary diverticulum (JD) and acute cholangitis (AC), and to analyze laboratory data to reveal the underlying mechanism. We conducted a retrospective review of 139 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between April 2008 and March 2013 for diagnosis or treatment of biliary tract conditions. The Wilcoxon signed-rank test was used for comparison of variables between patients with or without JD. The ...² test was used to analyze the association between JD and AC duct dilatation. Logistic regression analysis was performed to identify variables with strong correlation with AC. ERCP was attempted in 139 patients, but in one patient the endoscope did not reach the papilla of Vater because of a partial gastrectomy, and in two patients evaluation for JD was not possible because of duodenal or papilla of Vater cancer. Therefore, 136 patients were included in this study. JD was significantly associated with AC (PC0.0001) and bile-duct dilatation (P=0.0107), and AC was strongly associated with bile duct dilatation (P=0.0013). Alkaline phosphatase levels were significantly elevated in patients with JD (P=0.0237). In AC patients without JD, ...² for C-reactive protein was 4.48 (P=0.0342), whereas in AC patients with JD, ...² values for the white blood cell count, alkaline phosphatase, and aspartate aminotransferase were 2.62, 3.1, and 3.61, respectively (P=0.025, 0.015, and 0.0336, respectively). JD was strongly associated with AC. Logistic regression analysis suggested that bile flow was disturbed with JD. [ABSTRACT FROM AUTHOR]

Background: Endoscopic ampullectomy is established as a valuable treatment for adenomas of the Vaterian papilla. Few large series are available, however, let alone any with long-term follow-up. Moreover, multiple tangible issues remain. The aim of our study was to evaluate efficacy, safety, and outcome of endoscopic ampullectomy and compare it to existing literature Methods: This is a single-center, retrospective study with a minimal follow-up of 3 years including 91 patients, including familial adenomatous polyposis (FAP) and non-FAP, who had an endoscopic ampullectomy between 2000 and 2008. Outcome parameters included ampulloma characteristics, biotical accuracy as well as safety, efficacy, recurrence rate, and survival after endoscopic ampullectomy. Results: Endoscopic resection was successful in 71 patients (78 %). Histological review of the resected specimens revealed nonspecific changes (13.8 %), low or medium grade dysplasia (52.9 %), high grade dysplasia (21.8 %) and carcinoma (18.3 %). Bioptic accuracy was 38.3 %. Overall complications were observed in 23 patients (25.2 %): pancreatitis (15.4 %), hemorrhage (12.1 %) and cholangitis (4.9 %). Recurrence occurred in 18.3 %. Fourteen patients underwent pancreaticoduodenectomy. Survival after complete endoscopic ampullectomy was excellent for patients with low to moderate grade dysplasia and high grade dysplasia. Incomplete endoscopic resection of high grade dysplasia or invasive carcinoma was associated with unfavorable outcome when treated merely endoscopically. Conclusions: Endoscopic ampullectomy is obligatory for assessment of the true histological nature of an ampulloma. Endoscopic resection is a safe and efficient procedure for adenomas with low to moderate dysplasia but also for high grade dysplastic lesions, provided that a complete endoscopic resection is achieved. [ABSTRACT FROM AUTHOR]

The major duodenal papilla (papilla of Vater) is the point where the dilated junction of the bile and pancreatic ducts (ampulla of Vater) enter the duodenum. The ampulla is surrounded by the sphincter of Oddi, which not only controls the flow of bile and pancreatic juice into the duodenum, but also prevents the reflux of duodenal contents, bile and pancreatic juice into the bile and pancreatic ducts. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background/Aims: Patterns of lymph node involvement in carcinoma of the papilla of Vater (CPV) have not been studied in detail to date, and factors associated with lymphatic metastases and surgical outcome of this disease remain to be determined. Methods: Lymph node involvement and surgical outcome of 51 CPV patients were evaluated by extended lymphadenectomy specimens. Results: Lymph nodes with high metastatic potential were posterosuperior pancreaticoduodenal nodes (group 13a, 18%), posterior-inferior pancreaticoduodenal nodes (group 13b, 22%), and nodes around the superior mesenteric artery (group 14, 18%). Gross appearance of the primary tumor and depth of tumor invasion correlated with lymph node involvement (p < 0.05, respectively). A correlation with positivity was also found in groups 13 and 14. Disease-specific survival correlated with the gross appearance of the primary tumor and nodal involvement. However, there was no relationship between survival and the level of nodal involvement. Multivariate analysis indicated that the gross appearance of the tumor was the only significant independent predictor of a poor outcome. Conclusions: Gross appearance of the tumor is the most important prognosticator of lymph node metastases in CPV. Nodal dissection around the superior mesenteric artery may improve survival except in patients without invasion of the sphincter of Oddi. Pylorus-preserving pancreaticoduodenectomy is the treatment of choice. Copyright © 2010 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Safer procedures for performing endoscopic papillectomy on papillary tumors should be established. Fourteen patients underwent endoscopic papillectomy between January 2000 and February 2007. Before papillectomy, tumors were slightly elevated by submucosal injection of glycerol, followed by semi-circular mucosal incision of the anal border of the lesion in five cases. In nine cases, balloon-catheter-assisted endoscopic snare papillectomy was performed. All patients routinely underwent endoscopic nasobiliary drainage tube placement in the bile duct. A pancreatic stent was inserted only in patients with non-patent minor papilla. The rate of positive margins was lower in patients who received balloon-catheter-assisted papillectomy than in patients who received papillectomy without a balloon catheter. Of three patients with local recurrence, only one patient required surgery. Post-procedural complications included hemorrhage in eight patients, pancreatitis in one patient, and perforation in one patient. No perforation occurred after submucosal injection and mucosal incision. In three of four patients with early hemorrhage, bleeding was noticed as hemobilia through the nasobiliary drainage tube; this appears to be useful for early diagnosis of bleeding. No pancreatitis occurred in patients with patent minor papilla, suggesting that pancreatic stent placement is unnecessary in patients with patent minor papilla. [ABSTRACT FROM AUTHOR]

Carcinoid of papilla of the Vater is a rare entity. Detailed prognostic factors of this tumor have not yet been elucidated, and treatment choices include local resection and pancreatoduodenectomy with excision of lymph nodes. A 59-year-old woman, who was diagnosed with liver dysfunction and underwent a cholecystectomy, was referred to our institution with a suspected ampullary tumor. Computed tomography showed 1 cm of enhancement at the duodenal ampulla, but no visible lymph adenopathy. In the duodenoscopic view, her papilla was slightly enlarged without orifice, so that forceps biopsy was performed from the common ampullary channel after needle-knife incision. Tissue obtained by biopsy revealed a possible carcinoid tumor, with 1.1% of Ki-67 labeling index. Pancreatoduodenectomy was performed, and the resected specimen showed a carcinoid tumor of the ampulla, 1.2 cm in diameter, with metastases to regional lymph nodes and a 4% Ki-67 labeling index. It is suggested that despite the small size and low proliferation index, an ampullary carcinoid may not be cured by local resection. Clinicians must pay careful attention to the choice of treatment and monitoring after the resection. [ABSTRACT FROM AUTHOR]

Proper identification of the Vaterian papilla is a vital prerequisite for success in endoscopic retrograde cholangiopancreatography. Overall, a "hidden papilla" situation is uncommon, often attributable to, for example, intradiverticular localizations in a setting of periampullary diverticulum. Stacked duodenal folds precluding proper endoscopic visualization of the papilla is less well discussed, with virtually no systematic data available. A concurrent presence of the former potential obstacles to an immediate recognition of the papilla has not been reported before. With a view of the sometimes challenging task of finding (and cannulating) a periampullary diverticulum‐related papilla, suggestions are made to first scrutinize curtaining duodenal folds, for example, by endoscopic probing with an endoscopic retrograde cholangiopancreatography catheter as this may represent a more easily remediable cause underlying a "hidden papilla." [ABSTRACT FROM AUTHOR]

Most adenomas and carcinomas of the small intestine and extrahepatic bile ducts arise in the region of the papilla of Vater. In familial adenomatous polyposis (FAP) it is the main location for carcinomas after proctocolectomy. In many cases symptoms due to stenosis lead to diagnosis at an early tumor stage. In about 80%, curative intended resection is possible. Operability is the most relevant prognostic factor. Most ampullary carcinomas resp. carcinomas of the papilla of Vater develop from adenomatous or flat dysplastic precursor lesions. They can be sited in the ampulloduodenal part of the papilla of Vater, which is lined by intestinal mucosa. They also can develop in deeper parts of the ampulla, which are lined by pancreaticobiliary duct mucosa. Intestinal-type adenocarcinoma and pancreaticobiliary-type adenocarcinoma represent the main histological types of ampullary carcinoma. Furthermore, there exist unusual types and undifferentiated carcinomas. Many carcinomas of intestinal type express the immunohistochemical marker profile of intestinal mucosa (keratin 7−, keratin 20+, MUC2+). Carcinomas of pancreaticobiliary type usually show the immunohistochemical profile of pancreaticobiliary duct mucosa (keratin 7+, keratin 20−, MUC2−). Even poorly differentiated carcinomas, as well as unusual histological types, may conserve the marker profile of the mucosa they developed from. These findings underline the concept of histogenetically different carcinomas of the papilla of Vater which develop either from intestinal- or from pancreaticobiliary-type mucosa of the papilla of Vater. Molecular alterations in ampullary carcinomas are similar to those of colorectal as well as pancreatic carcinomas, although they appear at different frequencies. In future studies, molecular alterations in ampullary carcinomas should be correlated closely with the different histologic tumor types. Consequently, the histologic classification should reflect the histogenesis of ampullary tumors from the two different types of papillary mucosa. [ABSTRACT FROM AUTHOR]

Background. The opening of the papilla of Vater represents the orifice of the embryonic hepatic diverticulum from which the ventral pancreas, common bile duct, and liver are derived. Recently, we found a strong association between congenital biliary dilatation (CBD), certain types of pancreatic ductal anatomy (PDA), and ectopic distal location of the papilla of Vater which prompted us to study the relationship between the location of the papilla of Vater and abnormal PDA. Methods. A total of 118 patients with CBD were studied. Cholangiograms documented the presence of pancreaticobiliary malunion (PBMU), the location of the papilla of Vater, and the PDA. Eleven age-matched patients with intermittent jaundice were used as controls. Results. In the control group, the papilla of Vater was located normally in the descending portion of the duodenum in all cases. In the 118 CBD patients, the papilla of Vater was located normally in 38 (32.2%), but in 80 (67.8%), the papilla was located distal to the descending portion of the duodenum. When the papilla was located distally, the incidences of the specific types of PDA studied were significantly higher than when the papilla was located normally (p<0.01). Pancreatic duct dilatation was also more frequent if the papilla was located distally (28.7%) compared with CBD patients with a normal papilla (7.9%) or normal controls (0%) (both p<0.01). PBMU was present in all CBD patients and absent in all controls. Conclusion. Our study strongly suggests that abnormalities occurring during early embryological development of the hepatic diverticulum are responsible for the association between abnormal PDA and ectopic distal location of the papilla of Vater in CBD. [ABSTRACT FROM AUTHOR]

Background: Several studies and our own results prove that endoscopic therapy in selected cases of benign adenomas is safe and technically feasible. In patients refusing surgery or patients with high comorbidity and poor physical health status, endoscopic resection is an excellent alternative. Discussion: The decision for endoscopic or surgical excision of adenomas is determined by general health status, histology, size, location, and depth of the lesion. In carcinoma of the papilla of Vater it is important to assess the tumoral ductal infiltration correctly to determine whether endoscopic resection is a viable option. Intraductal ultrasound is essential before initiating treatment and it therefore contributes to conservative therapy in patients with tumors of the papilla of Vater. Temporary placement of a short pancreatic duct stent may protect against pancreatitis and might allow more excessive ablation of adenomatous tissue, especially around the pancreatic duct orifice. After endoscopic sphincterotomy, biliary and pancreatic endoprostheses can be inserted easily in cases of obstructed pathways or cholangitis and pancreatitis due to tumor obstruction. Argon plasma coagulation can be used to treat oozing tumor hemorrhages or to vaporize tumoral residues after endoscopic snare resection. Endoscopic surveillance is essential after surgical or endoscopic resection of adenomas of the papilla of Vater. [ABSTRACT FROM AUTHOR]

Antegrade electropapillotomy using the percutaneous transcystic approach was successfully performed in 11 of 16 dogs. When the intervention was effective, the pressure gradient between common bile duct and duodenum decreased from 6 to 1.3 mm Hg on average and returned to gradients slightly below the initial values after 4 weeks, owing to reactivation of the sphincter mechanism. Ineffective cutting, however, resulted in a temporary pressure rise. In one dog a papillary stenosis developed and was relieved by antegrade electrocutting. Irrespective of the success of the papillotomy, rises in levels of serum glutamine oxaloacetic and pyruvic transaminase, alkaline phosphatase, serum amylase and leukocytes were seen. Although the method is technically feasible, its clinical significance is not so much for antegrade papillotomy but rather for transhepatic incision of stenoses after hepaticojejunostomy. [ABSTRACT FROM AUTHOR]

The findings in 107 cases of perivaterian diverticulum diagnosed by endoscopic retrograde cholangiopancreatography (ERCP) were discussed in relation to complicated biliary tract disease. [ABSTRACT FROM AUTHOR]

Histological, histochemical and clinical features of an endocrine duodenal tumour situated in the papillary region were studied. The tumour had a remarkable mixed histological growth pattern, consisting of epithelial glandular structures which showed a gradual transition into a spindle-cell tumour, resembling a neurogenic tumour. The neoplasm was considered malignant since it had infiltrated into the muscular layer of the duodenal wall. The tumour was non-argentaffin and non-argyrophil. No serotonin could be demonstrated histochemically. Immunoreactive pancreatic polypeptide (HPP) was detected by indirect immunofluorescence in the majority of tumour cells of the epithelial glandular structures, whereas areas with a spindlecell pattern were almost unreactive to the HPP-antiserum. No reaction was found with antibodies against gastrin, insulin, glucagon, vasoactive intestinal polypeptide or somatostatin. The patient had no endocrine symptoms that could be ascribed to the production of HPP by the neoplasm. Twenty-four months postoperatively, the patient's serum HPP concentration had begun to rise, suggesting recurrence of the tumour. [ABSTRACT FROM AUTHOR]

A histopathologic investigation of the duodenal wall and adjacent tissues in the vicinity of the papilla of Vater was performed in 37 autopsied cases of congenital biliary atresia which were treated in the Department of Pediatric Surgery of the Juntendo University Hospital during the past 11 years. A high incidence of the association of a congentially abnormal junction of the common bile duct and pancreatic duct, that is, a long common channel and a poorly developed sphincter musculature, were found in congenital biliary atresia. This suggests the possibility that reflux of pancreatic juice into the biliary system, followed by nonsuppurative chronic inflammation of bile ducts, may ultimately lead to the obstructive cholangiopathy seen in biliary atresia. [ABSTRACT FROM AUTHOR]

Copyright of Langenbecks Archiv fuer Chirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Langenbecks Archiv fuer Chirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

We report a case of villous tumor of the papilla of Vater associated with hypopotassemia. The patient was a 73-year-old woman who presented with jaundice and fever. She had a history of diabetes mellitus and liver dysfunction. Laboratory studies revealed that levels of total bilirubin, alkaline phosphatase, and C-reactive protein, and the white blood cell count were elevated (suggestive of cholangitis) and that the serum potassium level was markedly reduced, to 1.9 mEq/l (normal value 3.5–5.0 mEq/l). Duodenoscopy showed a villous tumor arising in the papilla of Vater. Percutaneous transhepatic biliary drainage was performed. Approximately 700–1500 ml of bile with viscous mucoid fluid was drained daily. Percutaneous transhepatic cholangioscopy showed a papillary lesion in the distal common bile duct. Biopsied specimens from both percutaneous transhepatic cholangioscopy and duodenoscopy disclosed tubulovillous adenoma. Endoscopic ultrasonography showed that the tumor had spread to the main pancreatic duct as well as to the common bile duct. The patient underwent pylorus-preserving pancreaticoduodenectomy. Pathology examination disclosed well differentiated adenocarcinoma, carcinoma in situ, in tubulovillous adenoma. The cancer cells were observed at the bottom of the tumor spreading in the common bile duct. This is a rare case of a patient presenting with hypopotassemia associated with a tubulovillous tumor of the papilla of Vater that secreted mucoid material. [ABSTRACT FROM AUTHOR]

Eighty of 89 patients who underwent radical resection (resectability 89.9%) for carcinoma of the papilla of Vater between 1976 and 1992 were retrospectively reviewed. Seventy-three patients underwent pancreaticoduodenectomy (PD) and 7 underwent pylorus-preserving pancreaticoduodenectomy (PPPD). The postoperative mortality rate was only 3.8% (3 patients). The 3- and 5-year survival rates were 63.6% and 57.4%, respectively. Important factors influencing long-term survival were Stage (clinical stage = Stage), microscopic lymph node metastasis (n), duodenal wall invasion (d), vascular invasion (v), and the epithelium of origin. Early carcinoma of the papilla of Vater is defined as tumor in which invasion is limited within the papilla of Vater; in particular, carcinomatous invasion is within the muscle of Oddi (d) with n. PD and/or PPPD with radical lymph node dissection should be performed for carcinoma of the papilla of Vater, as these procedures can be performed with low morbidity and mortality. [ABSTRACT FROM AUTHOR]

Carcinoma in adenoma of the papilla of Vater is extremely rare. We now report a case of adenocarcinoma in adenoma of the papilla of Vater and the clinicopathological findings are discussed. A 73-year-old Japanese woman was endoscopically diagnosed as a case of carcinoma combined with adenoma of the papilla of Vater. She underwent pancreatoduodenectomy and the postoperative course was statisfactory. Histological examination of the resected tissues revealed a superficial adenocarcinoma in the adenoma of the papilla of Vater. In certain cases, carcinoma of the papilla of Vater may develop from a pre-existing adenoma in the region. Therefore, we recommend that pancreatoduodenectomy should be done when an adenoma presents in this region. [ABSTRACT FROM AUTHOR]

Ganglioneuromas (GNs) are rare benign tumors and their association with neurofibromatosis type 1 (NF-1) is especially uncommon. We report in this article the case of a young woman, subjected to diagnostic work-up because of abdominal pain. Endoscopy and histology revealed not only a GN in the papilla of Vater, but also NF-1. Because of the size and macroscopic features of the lesion, we performed pancreatoduodenectomy, from which she recovered uneventfully. Histological examination of the resected tumor confirmed a diagnosis of GN. [ABSTRACT FROM AUTHOR]

We report a case of a male cadaver aged 72 years with an ectopic location of the papilla of Vater. The ectopic papilla was situated at the supero-posterior border of the 3rd portion of the duodenum at a distance of 0.9 cm from the limit of the 2nd and 3rd portions of the duodenum. The frequency of this anomaly fluctuates between 0 and 11.83% and when the papilla is located distal to its usual position the usual location is in the proximal 2 cm of the 3rd part of the duodenum. We refer to the possible difference in the papilla's location between patients and cadavers and call attention to the differential diagnosis with spontaneous or surgical fistulae. [ABSTRACT FROM AUTHOR]

This report describes the technique and results of endoscopic fistulotomy as a drainage procedure in cases of malignant obstruction of the biliary system from bulky and friable growths in the papilla of Vater. Fistulotomy, coupled with insertion of stents, was successful in seven of eight patients and was associated with relief of jaundice. It is suggested that the method be applied when conventional transpapillary insertion of stents is impossible either due to distortion of the papilla or bleeding of the growth on touch. [ABSTRACT FROM AUTHOR]

Case Report: A 20 month old girl was admitted for intractable vomiting over several days, with no other symptoms. Family and personal history were not contributive. Clinical and neurological examination, and routine blood tests and investigations (plain abdominal x ray, upper gastrointestinal tract contrast study, abdominal ultrasonography) were normal. The upper gastrointestinal endoscopy showed a mild antral gastritis and the second portion of duodenum was occupied by a tough, fibrous mass partially embedded into the papilla of Vater. The foreign body was removed and proved to be vegetable fibre (pineapple). Symptoms subsided immediately and the child was discharged with gastroprotective therapy. After two months, on endoscopic examination, the signs of gastropathy had cleared; the papilla of Vater was undamaged, but unchomped food debris was again found in the duodenum.Discussion: There are sporadic reports of foreign bodies retained into the papilla of Vater, all of them in adults. This child, though her papilla was tiny, had no jaundice or pancreatitis, unlike most of the reported cases. This is the first report of this finding in a child. The cause of the vomiting was not shown on abdominal ultrasonography or contrast study. It should be added to the list of unusual causes of vomiting. [ABSTRACT FROM AUTHOR]