Post written by Osamu Dohi, MD, PhD, from Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine Graduate School of Medical Science, Kyoto, Japan.

We performed endoscopic submucosal dissection (ESD) for a laterally spreading ampullary carcinoma 3 cm in size because it was expected to be difficult to completely resect the lesion by endoscopic papillectomy (EP).

A laterally spreading ampullary carcinoma is challenging for ESD because the duodenal wall is very thin, and endoscopic maneuverability is very poor. Moreover, the curative resection rate of EP with negative margin was limited to approximately 87% of patients with neoplastic ampullary lesions. Therefore, EP has a risk of local recurrence due to incomplete resection with positive margin.

We attempted ESD to completely resect for a laterally spreading duodenal papillary carcinoma in light of the development of a safe and efficient duodenal ESD using a scissor-type knife for nonampullary duodenal tumors. We described how to dissect the ampulla. Two submucosal tunnels were created to identify the dissection line of the ampulla. After that, the ampulla was removed directly using a scissor-type knife. Subsequently, a mucosal incision was performed, and en bloc resection was achieved.

Complete closing of mucosal defect after duodenal ESD is essential for preventing delayed adverse events. In addition, biliary and pancreatic stents were needed to prevent cholangitis and pancreatitis. It was easy to perform cannulation of the bile duct and pancreatic duct, owing to complete papillectomy. However, complete prophylactic closure of the mucosal defect was difficult to perform using only endoclips.

We successfully performed ESD for a laterally spreading ampullary carcinoma. Therefore, ESD should be considered as an alternative treatment to surgical resection, even for a laterally spreading ampullary carcinoma. Moreover, more cases are needed to confirm safety and feasibility of ESD for a large ampullary carcinoma.

White-light imaging of a laterally spreading tumor approximately 35 mm in size, which was a slightly elevated lesion with a central protrusion located on the ampulla. A, Oral side. B, Anal side of the tumor. Magnifying blue-laser imaging of the tumor: (C) irregular microstructure and microvessels at the edge of the lesion and (D) at the center of the lesion. Endoscopic ultrasonography: (E) the lesion was a hypoechoic mass with a clear margin from the ampulla, and (F) the bile and pancreatic duct walls were normal and nondilated.

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