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Unprecedented case of duodenal papillary disinsertion after endoscopic papillectomy for a neuroendocrine tumor

figura-01Disinsertion of the ampulla of Vater is a serious but rare event during gastric resection. Injury to this area is possible during any operation on the duodenum, but occurs most frequently in the presence of scarring or inflammation that causes secondary shortening of the duodenal bulb [1–4]. Endoscopic papillectomy is a "high risk" procedure: the reported complication rate varying from 8% to 35%, with acute pancreatitis the most common complication (5%–15%) [5, 6]; however, disinsertion of the ampulla of Vater has not been reported in the literature after endoscopic papillectomy.

We present the first report of a patient developing papillary disinsertion after endoscopic papillectomy for a papillary neuroendocrine tumor. The patient was a 77-year-old woman who had undergone Billroth II gastrectomy 3 years previously for a gastrointestinal stromal tumor (GIST; >2.5cm and Ki67>10%). A papillary neuroendocrine tumor was identified during a follow-up endoscopy ( Fig.1) and the patient was referred for endoscopic treatment.

Endoscopic ultrasound (EUS) revealed a lesion that was restricted to the duodenal wall without invasion of the common bile duct, main pancreatic duct, or pancreas ( Fig.2; Video1). The tumor was removed with a snare (Fig.3a) and, immediately after its removal, the site of the resection appeared to be in excellentcondition (Fig.3b).

After the specimen had been recovered (Fig.4), the echoendoscope was reintroduced in order to observe the outcome of the procedure. At this point, we observed complete disconnection of the duodenal papilla from the duodenal bulb wall (Fig.5). The diagnosis was confirmed by injection of contrast with the endoscope positioned in front of the site of the resection (Fig.6).

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figura-05  figura-06

 

figura-02Video 1

Images of the lesion, its removal, and the signs of papillary disinsertion, including fluoroscopy that showed retroperitoneal contrast, and the final pancreaticoduodenectomy specimen.


In our experience with endoscopic papillectomy in 56 patients treated since 2010, this adverse event has never previously occurred. We assume that the most important factor related to this event was the altered anatomy caused by the antrectomy with Billroth II reconstruction, which hindered the progression of the endoscope into the afferent loop and its positioning in front of the duodenal papilla. Another key point was the kinking of the jejunal loop that occurred during the positioning of the endoscope in front of the duodenal papilla.

figura-03  

The prognosis of this adverse event is related to early diagnosis. In this case, treatment success was achieved by the patient undergoing pancreaticoduodenectomy, with lymph node removal in the same procedure as she had a papillary neuroendocrine tumor of greater than 2.0cm in size.

  

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Competing interests: None

José Celso Ardengh (1), Michele Lemos de Bonotto (2,3), Rodrigo Surjan (1), Julio Pereira Lima (2,3), Marcel Autran Machado (1)
1. Echoendoscopy Unit, 9 de Julho Hospital, University of São Paulo, São Paulo, Brazil
2. Rio Grande do Sul Foundation of Gastroenterology (FUGAST), Porto Alegre, Brazil
3. Department of Gastroenterology and Hepatology, Santa Casa Hospital/Federal University of Health Sciences of Porto Alegre (UFCSPA), Porto Alegre, Brazil

References

1. Florence MG, Hart MJ, White TT. Ampullary disconnection during the course of biliary and duodenal surgery. Am J Surg 1981; 142: 100–105
2. Schmitt JC, Sava G, Seror J. Accidental papillary disinsertions during astroduodenectomies. Report of two cases. Acta Chir Belg 1978; 77: 355–363
3. Cady J, Mercadier M. A case of papillary disinsertion during gastro-duo-denectomy for ulcer of the second part of the duodenum and its repair by a "physiological" reconstruction. J Chir (Paris) 1979; 116: 119–122
4. Boutboul R, Campan P, Ival M et al. Late complications of papillary disinsertion. Review of the literature apropos of a case. Ann Chir 1986; 40: 323–327
5. Patel R, Varadarajulu S, Wilcox CM. Endoscopic ampullectomy: techniques and outcomes. J Clin Gastroenterol 2012; 46: 8–15
6. Ito K, Fujita N, Noda Y et al. Impact of technical modification of endoscopic papillectomy for ampullary neoplasm on the occurrence of complications. Dig Endosc 2012; 24: 30–35

Bibliography

DOI http://dx.doi.org/10.1055/s-0034-1391339
Endoscopy 2015; 47: E127–E128
© Georg Thieme Verlag KG
Stuttgart • New York
ISSN 0013-726X

Corresponding author

José Celso Ardengh, MD
Echoendoscopy Unit
9 de Julho Hospital
São Paulo - Brazil
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