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case_images: (a) Contrast-enhanced abdominal computed tomography scan showing distal common bile duct polypoid lesion (red arrow). (b) Endoscopic ultrasound revealed a papillary mass with intraductal extension (white arrow). (c) Intraductal extension of the papillary mass measured 1.13 x 0.4 cm on endoscopic ultrasound. (d) Cholangiogram showed a filling defect within the papilla of Vater, extending proximally into the intraductal portion of the common bile duct.
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case_images: Contrast-enhanced computed tomography (CT) scan revealed a 0.5cm isodense nodule at the distal common bile duct (CBD) with upstream dilation of the CBD and intrahepatic ducts (Figure 1a). Endoscopic ultrasound (EUS) further showed a dilated CBD and an isoechoic polypoid mass at the papilla (Figure 1b) with intraductal extension to the CBD measuring 1.13 x 0.4 cm (Figure 1c). In addition, a filling defect was identified within the papilla of Vater, extending proximally into the intraductal portion of the CBD (Figure 1d).
case_images: (a) Duodenal papilla with small papillary projections and uneven surface texture. (b) Balloon catheter-assisted traction of papillary mass after sphincterotomy. (c) Narrow band imaging revealed an adenoma-like pattern of the papillary mass. (d) Papillectomy using an electrocautery-assisted polypectomy snare.
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case_images: Examination of the duodenal papilla revealed the presence of small papillary projections with an uneven surface texture, but the intraductal extension of the papillary mass was not seen on duodenoscopy (Figure 2a). A biliary sphincterotomy was performed, followed by the use of a fusion extraction balloon (Cook Medical) to facilitate traction of the papillary mass towards the duodenum (Figure 2b). Further assessment with narrow-band imaging demonstrated an adenoma-like pattern on the surface of the lesion (Figure 2c). EP through piecemeal resection was performed using a combination of electrocautery-assisted polypectomy snare (Anrei Medical; Figure 2d) and endoscopic forceps.
case_images: (a) Common bile duct and pancreatic duct plastic stents were inserted post-papillectomy. (b) Hemoclips deployed for closure of the post-resection defect. (c) The largest fragment of a papillary mass specimen following piecemeal resection. (d) Villous adenoma with high-grade intraepithelial neoplasia (Specimen under high power field).
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case_images: The placement of plastic stents within the CBD and pancreatic duct was done for prophylaxis of post-procedural CBD stricture and pancreatitis, respectively (Figure 3a). Multiple hemoclips were deployed to close the post-resection defect (Figure 3b). The largest resected specimen, measuring 0.8 x 0.5 cm (Figure 3c), along with several additional tissue samples, was submitted for examination. Histopathological analysis revealed a villous adenoma with high-grade intraepithelial neoplasia (Figure 3d).
case_images: (a) Common bile duct and papilla 2 months post-papillectomy showed no residual lesion on endoscopic ultrasound. (b) Examination of the common bile duct during endoscopic ultrasound (higher magnification). (c) Papilla 2 months post-papillectomy.
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case_images: EUS was performed to assess for any residual disease. EUS did not reveal any evidence of residual adenoma (Figure 4a,b). Subsequently, ERCP (Figure 4c) was performed with the placement of a plastic CBD stent to prevent stricture.