Endoscopic Papillectomy Versus Surgery for Ampullary Tumors: A Prospective Multicenter Cohort Study

Investigation of the Indications and Clinical Outcomes of Endoscopic Papillectomy Versus Surgery for Ampullary Tumors

The aim of this study is to compare the efficacy and safety of endoscopic treatment (endoscopic papillectomy [EP] with or without intraductal radiofrequency ablation [RFA]) and surgical treatment (transduodenal ampullectomy [TSA] and pancreatoduodenectomy [PD]) in patients with ampullary tumors (ampullary adenoma and early ampullary carcinoma), focusing on residual disease, recurrence, postoperative complications, and overall costs.

Study Overview

• Status: Not yet recruiting
• Conditions: Ampullary Adenoma; Ampullary Neoplasm
• Intervention / Treatment: Procedure: Endoscopic treatment group; Procedure: Surgical treatment group

Detailed Description

This is a multicenter, two-arm, prospective cohort study. The diagnosis of ampullary adenoma must be confirmed by biopsy.

The endoscopic treatment group receives EP; patients without intraductal extension receive EP alone, while patients with intraductal extension receive additional RFA in the same or a subsequent session. The surgical treatment group receives TSA or PD. Patients are followed up at 3, 6, and 12 months after the initial treatment, then annually for at least 5 years, with side-viewing duodenoscopy, targeted biopsy, and CT assessment. To control confounding between the two groups, propensity score matching and inverse probability of treatment weighting will be applied.

• Study Type: Observational
• Enrollment (Estimated): 306

Contacts and Locations

• Study Contact: Name: Zhen Li, MD; Phone Number: 18560086106; Email: qilulizhen@sdu.edu.cn
• Study Contact Backup: Name: Ning Zhong, MD; Phone Number: 18560086096; Email: zhongning@email.sdu.edu.cn

Study Locations

• China
  • Shandong
    • Jinan, Shandong, China, 250012
      • Qilu Hospital of Shandong University
      • Contact: Zhen Li; Phone Number: 18560086106; Email: qilulizhen@sdu.edu.cn

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

• Sampling Method: Non-Probability Sample

Study Population

Adult patients with histologically confirmed ampullary adenoma or early ampullary carcinoma (Tis/T1) without invasion into the duodenal muscularis propria, staged M0/N0 by EUS , MRCP and CT , with intraductal tumor extension ≤ 20 mm on EUS, MRCP, or IDUS, undergoing endoscopic papillectomy or surgery.

Description

Inclusion Criteria:

1. Patients aged ≥18 years
2. Patients with histologically confirmed ampullary adenoma or early ampullary carcinoma (Tis/T1) based on endoscopic biopsy (i.e., without tumor invasion into the duodenal muscularis propria).
3. Preoperative staging by endoscopic ultrasound (EUS) , magnetic resonance cholangiopancreatography (MRCP) or computed tomography (CT) showing no distant metastasis (M0) and no lymph node metastasis (N0).
4. Intraductal tumor extension (ITE) ≤ 20 mm assessed by EUS, MRCP or Intraductal ultrasound (IDUS ).
5. Planned to undergo EP, with or without intraductal RFA, or surgical treatment (TSA or PD).
6. Patients who provide written informed consent.

Exclusion Criteria:

1. Patients unable to tolerate general anesthesia or surgery.
2. Ectopic duodenal papilla.
3. Contraindications to endoscopic procedures (e.g., severe esophageal stenosis, gastric outlet obstruction, or other conditions precluding endoscopic access to the papilla).
4. Major upper abdominal surgery or previous biliary surgery history.
5. Uncorrectable coagulopathy (INR > 1.5) or thrombocytopenia (platelet count < 50,000/μL), or inability to withhold antithrombotic (anticoagulant or antiplatelet) therapy for the planned endoscopic or surgical procedure..
6. Pregnant or lactating women.

Study Plan

How is the study designed?

Design Details

• Observational Models: COHORT
• Time Perspectives: PROSPECTIVE

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Endoscopic treatment group; Patients undergoing EP with or without RFA.	Procedure: Endoscopic treatment group; Endoscopic papillectomy (EP); EP combined with intraductal RFA for lesions with intraductal tumor extension.
Surgical treatment group; Patients undergoing surgical treatment.	Procedure: Surgical treatment group; TSA or PD

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Recurrence rate at 12 months	Recurrence confirmed by endoscopic biopsy after an interval ≥ 3 months from the end of treatment, assessed at the 12-month follow-up.	At 12 months after the initial treatment

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
R0 resection rate	Proportion of patients with complete resection achieved at the first endoscopic or surgical intervention and confirmed by histology (negative margins).	Periprocedural
Procedure-related adverse event rate	Proportion of patients who experienced at least one adverse event attributable to the initial endoscopic or surgical procedure within 30 days after the procedure, irrespective of severity.	Up to 90 days after the initial treatment
Recurrence rate at 6 months	Recurrence confirmed by endoscopic biopsy after an interval ≥ 3 months from the end of treatment, assessed at the 6-month follow-up.	At 6 months after the initial treatment
Residual lesion rate	Presence of residual adenoma tissue at the next endoscopy after treatment.	Up to 3 months after the initial treatment
Clinical success rate	Proportion of patients who achieved complete excision of the lesion (regardless of the number of procedures) with no histologically confirmed adenoma regrowth, no evidence of invasive cancer, and without the need for surgical resection, during follow-up up to 5 years after the initial treatment.	Up to 5 years after the initial treatment
Endoscopic treatment failure rate	Inability to completely resect the lesion endoscopically (regardless of the number of procedures), histopathologically invasive malignancy, or recurrence no longer amenable to endoscopic treatment.	Up to 12 months after the initial treatment
Total number of readmissions within 12 months	All readmissions due to disease-related symptoms (e.g., cholangitis, pancreatitis, obstructive jaundice) or treatment-related events (e.g., bleeding, perforation, anastomotic problems).	Up to 12 months after the initial treatment
Technical success rate	Proportion of patients in whom the planned procedure was completed as intended.	Periprocedural
Total treatment cost	All direct medical costs from admission to 12 months after the initial treatment (including procedure, anesthesia, hospitalization, medication, examinations, and readmission costs).	Up to 12 months after the initial treatment
Index hospitalization length of stay	Number of calendar days from the date of admission for the initial treatment to the date of discharge for the initial treatment,including the day of admission	Periprocedural
Total length of stay within 12 months	Total number of calendar days spent in hospital within 12 months after the initial treatment, including the index hospitalization and all readmissions due to disease-related symptoms or treatment-related events.	Up to 12 months after the initial treatment
Postprocedural pancreatitis rate	Defined by two of three criteria: characteristic abdominal pain; amylase or lipase > 3× upper limit of normal; imaging features of pancreatitis; severity graded mild / moderate / severe per protocol.	Up to 90 days after the initial treatment
Postprocedural bleeding rate	Proportion of patients with clinically significant post-procedural bleeding within 30 days after the procedure, defined as any of the following after achieving primary haemostasis: overt bleeding symptoms (hematemesis, melena, hematochezia, or blood aspirated via nasogastric tube); haemodynamic instability attributable to bleeding; a decrease in haemoglobin greater than 2 g/dL; or direct endoscopic evidence of bleeding from the papillectomy site.	Up to 90 days after the initial treatment
Postprocedural perforation rate	Direct visualization of a transmural defect during endoscopy, or radiographic evidence of extraluminal free air on abdominal CT or plain radiograph.	Up to 90 days after the initial treatment
Postprocedural cholangitis rate	New onset temperature >38 °C for more than 24 hours combined with cholestasis. Severity will be graded separately according to the TG18 severity classification (Grade I / II / III) and reported descriptively.	Up to 90 days after the initial treatment
Cumulative recurrence rate	Cumulative recurrence during annual follow-up up to 5 years	Through study completion, an average of 5 years

Collaborators and Investigators

• Sponsor: Qilu Hospital of Shandong University
• Collaborators: The First Affiliated Hospital of Nanchang University; LanZhou University; Beijing Friendship Hospital; Shandong Provincial Hospital; Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine; Sir Run Run Shaw Hospital; Sichuan Provincial People's Hospital; Shandong First Medical University
• Investigators: Principal Investigator: Zhen Li, MD, Qilu Hospital of Shandong University

Publications and helpful links

General Publications

• Cotton PB, Eisen GM, Aabakken L, Baron TH, Hutter MM, Jacobson BC, Mergener K, Nemcek A Jr, Petersen BT, Petrini JL, Pike IM, Rabeneck L, Romagnuolo J, Vargo JJ. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc. 2010 Mar;71(3):446-54. doi: 10.1016/j.gie.2009.10.027. No abstract available.
• Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Perez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021 Apr;53(4):429-448. doi: 10.1055/a-1397-3198. Epub 2021 Mar 16.
• Kiriyama S, Kozaka K, Takada T, Strasberg SM, Pitt HA, Gabata T, Hata J, Liau KH, Miura F, Horiguchi A, Liu KH, Su CH, Wada K, Jagannath P, Itoi T, Gouma DJ, Mori Y, Mukai S, Gimenez ME, Huang WS, Kim MH, Okamoto K, Belli G, Dervenis C, Chan ACW, Lau WY, Endo I, Gomi H, Yoshida M, Mayumi T, Baron TH, de Santibanes E, Teoh AYB, Hwang TL, Ker CG, Chen MF, Han HS, Yoon YS, Choi IS, Yoon DS, Higuchi R, Kitano S, Inomata M, Deziel DJ, Jonas E, Hirata K, Sumiyama Y, Inui K, Yamamoto M. Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30. doi: 10.1002/jhbp.512. Epub 2018 Jan 5.
• Abraham NS, Barkun AN, Sauer BG, Douketis J, Laine L, Noseworthy PA, Telford JJ, Leontiadis GI. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. Am J Gastroenterol. 2022 Apr 1;117(4):542-558. doi: 10.14309/ajg.0000000000001627.
• Karam E, Hollenbach M, Ali EA, Auriemma F, Gulla A, Heise C, Regner S, Gaujoux S; on the Pancreas 2000 Research Group; Regimbeau JM, Kahler G, Seyfried S, Vaillant JC, De Ponthaud C, Sauvanet A, Birnbaum D, Regenet N, Truant S, Perez-Cuadrado-Robles E, Bruzzi M, Lupinacci RM, Brunel M, Belfiori G, Barbier L, Salame E, Souche FR, Schwarz L, Maggino L, Salvia R, Gagniere J, Del Chiaro M, Leung G, Hackert T, Kleemann T, Paik WH, Caca K, Dugic A, Muehldorfer S, Schumacher B, Albers D. Outcomes of rescue procedures in the management of locally recurrent ampullary tumors: A Pancreas 2000/EPC study. Surgery. 2023 May;173(5):1254-1262. doi: 10.1016/j.surg.2022.12.011. Epub 2023 Jan 13.
• Fritzsche JA, Fockens P, Barthet M, Bruno MJ, Carr-Locke DL, Costamagna G, Cote GA, Deprez PH, Giovannini M, Haber GB, Hawes RH, Hyun JJ, Itoi T, Iwasaki E, Kylanpaa L, Neuhaus H, Park JY, Reddy DN, Sakai A, Bourke MJ, Voermans RP. Expert consensus on endoscopic papillectomy using a Delphi process. Gastrointest Endosc. 2021 Oct;94(4):760-773.e18. doi: 10.1016/j.gie.2021.04.009. Epub 2021 Apr 19.
• Abe S, Sakai A, Masuda A, Miki M, Harada Y, Nagao K, Inomata N, Kohashi S, Uemura H, Masuda S, Ashina S, Gonda M, Yamakawa K, Tsujimae M, Yamada Y, Tanaka T, Kobayashi T, Nakano R, Shiomi H, Tsugawa D, Yanagimoto H, Ajiki T, Kanzawa M, Fukumoto T, Itoh T, Kodama Y. Advantage of endoscopic papillectomy for ampullary tumors as an alternative treatment for pancreatoduodenectomy. Sci Rep. 2022 Sep 7;12(1):15134. doi: 10.1038/s41598-022-19439-3.
• Hollenbach M, Heise C, Abou-Ali E, Gulla A, Auriemma F, Soares K, Leung G, Schattner MA, Jarnagin WR, Wang T, Caillol F, Giovannini M, Dahel Y, Hackert T, Paik WH, Zerbi A, Nappo G, Napoleon B, Arnelo U, Haraldsson E, Halimi A, Waldthaler A, Will U, Saadeh R, Masaryk V, van der Wiel SE, Bruno MJ, Perez-Cuadrado-Robles E, Deprez P, Sauvanet A, Bolm L, Keck T, Souche R, Fabre JM, Musquer N, Kahler G, Seyfried S, Petrone MC, Mariani A, Zaccari P, Belfiori G, Crippa S, Falconi M, Partelli S, Yilmaz B, Demir IE, Ceyhan GO, Satoi S, Regimbeau JM, Gagniere J, Repici A, Anderloni A, Vollmer C, Casciani F, Del Chiaro M, Oba A, Schulick RD, Berger A, Maggino L, Salvia R, Schemmer P, Wichmann D, Inoue Y, Dinis-Ribeiro M, Laranjo A, Libanio D, Kleemann T, Sandru V, Ilie M, Ahola R, Laukkarinen J, Schumacher B, Albers D, Curdia Goncalves T, Barbier L, Salame E, Weismuller TJ, Heling D, Alves A, Karam E, Regenet N, Dugic A, Muehldorfer S, Truant S, Caca K, Meier B, Miutescu BP, Tantau M, Birnbaum D, Miksch RC, Wedi E, Salzmann K, Bruzzi M, Lupinacci RM, David P, De Ponthaud C, Schmidt A, Regner S, Gaujoux S; ESAP study group. Endoscopic papillectomy versus surgical ampullectomy for adenomas and early cancers of the papilla: a retrospective Pancreas2000/European Pancreatic Club analysis. Gut. 2025 Feb 6;74(3):397-409. doi: 10.1136/gutjnl-2022-327996.

Study record dates

Study Major Dates

• Study Start (Estimated): October 20, 2026
• Primary Completion (Estimated): October 20, 2032
• Study Completion (Estimated): October 20, 2036

Study Registration Dates

• First Submitted: October 18, 2026
• First Submitted That Met QC Criteria: November 2, 2026
• First Posted (Actual): November 4, 2026

Study Record Updates

• Last Update Posted (Actual): November 4, 2026
• Last Update Submitted That Met QC Criteria: November 2, 2026
• Last Verified: October 1, 2026

More Information

Terms related to this study

• Keywords: pancreaticoduodenectomy; ampullary carcinoma; endoscopic papillectomy; ampullary adenoma; intraductal radiofrequency ablation; transduodenal ampullectomy
• Other Study ID Numbers: 2026SDU-QILU-6

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No