Clinical Case Summary
Background: The landscape of ampullary submucosal tumor treatment is evolving, with endoscopic resection techniques slowly gaining acceptance due to their lower invasiveness compared to surgery. A number of studies have demonstrated the feasibility and safety of endoscopic resection for ampullary submucosal tumors with both endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) techniques1-4. We present a case of successful hybrid ESD via duodenoscope for an ampullary neuroendocrine tumor (NET).
Case: A 63-year-old male was referred due to a one-month history of epigastric pain. Magnetic resonance cholangiopancreatography demonstrated a distal common bile duct (CBD) calculus with upstream dilation of CBD and main pancreatic duct (PD). There was a well-circumscribed, 2.1 cm x 2.3 cm hypoechoic mass at the ampulla. EUS elastography demonstrated hard tissue stiffness consistent with a solid lesion. ERCP with stenting was done. Following a multidisciplinary team discussion with the family, the consensus was to prioritize endoscopic resection over surgical approach.
Procedure: Submucosal injection was performed at the 6 o’clock, 4 o’clock, and 8 o’clock positions. A layered multi-knife submucosal dissection technique was done, using GoldKnife and IT knife nano. Encountering significant dissection challenges and bleeding necessitated a shift to a hybrid ESD approach. A 7Fr single-pigtail biliary stent (3 cm) and a 7Fr single-pigtail pancreatic stent (7 cm) were inserted to prevent biliary stricture and pancreatitis, respectively. A total of 7 hemoclips were deployed to close the post-ESD defect. The combined widest diameter of the 2 specimens was 1.9 cm. Histopathology showed a well-differentiated NET (G1), confined to the mucosal lamina propria and muscularis propria. Resection margins were negative for tumor. The patient was discharged on the seventh day of hospitalization and clopidogrel therapy was subsequently resumed.
References
1. Nelsen EM, Akhter A, Benson ME, Gopal DV. EMR of large periampullary neuroendocrine tumor. VideoGIE. 2017 Dec 1;2(12):336.
2. Keshava VE, Henien SR, Kumar AR. Endoscopic ampullectomy of a large neuroendocrine tumor using underwater EMR technique. VideoGIE. 2020 Jul 1;5(7):314-7.
3. Kulkarni AS, Karwat T, Dubewar S, Mukewar S, Mukewar S. Endoscopic resection of a large ampullary tumor using a hybrid endoscopic submucosal dissection and mucosal resection technique. Endoscopy. 2023 Dec;55(S 01):E1114-5.
4. Yi H, Wu C, Mou Y, Liu W, Li J, Zhang Q, Luo R, Tang MC, Hu B. Successful en bloc resection of papillary neuroendocrine tumors by duodenoscope using endoscopic submucosal dissection method. Clinics and Research in Hepatology and Gastroenterology. 2012 Oct 1;36(5):e100-3.
