Aims
Endoscopic papillectomy (EP) is an effective treatment for papillary adenomas, but intraductal extension (IDE) is a known risk factor for incomplete resection and recurrence. Accurate histological assessment of IDE is often challenging due to specimen orientation. We evaluated whether ex-vivo guidewire cannulation of specimens improved histological assessment.
Methods
Consecutive Patients undergoing EP with ex-vivo guidewire cannulation of major papilla at a tertiary centre over 30 months, to Oct 2025 were included. Specimens with non-adenomatous histopathology were excluded. Propensity score matching (1:1) was performed for size, en-bloc resection, and laterally spreading component (LSL) against a prior cohort. Outcomes included histological identification of the biliary duct orifice and intraductal extension.
Results
60 patients were included, 30 with ex-vivo guidewire cannulation (wired) and 30 propensity-matched controls without guidewire (non-wired). The groups were balanced for age (mean 64 years), sex (16 males per group), median lesion size (25 mm), en-bloc resection (21 per group), and lateral spreading component >10 mm (12 per group). Histopathology comprised tubular adenomas with low-grade dysplasia (LGD) in 38 patients (20 wired, 18 non-wired), tubulovillous adenomas with LGD in 15 (10 wired, 5 non-wired), high-grade tubulovillous adenomas in 2 (1 wired, 1 non-wired), and carcinoma in 9 (5 wired, 4 non-wired). The common bile duct orifice was identified in 23/30 (77%) wired versus 13/30 (43%) non-wired specimens (p = 0.017), and histologic intraductal extension was detected in 17/30 (57%) wired versus 10/30 (33%) non-wired specimens (p = 0.119).
Conclusions
Ex-vivo guidewire cannulation of papillary specimens improved identification of the CBD orifice by 33% and nearly doubled the detection of intraductal adenoma. This technique allows identification of a subgroup at risk of intraductal recurrence, the primary means by which papillary adenomas reoccur. These findings have important implications for subsequent surveillance and therapy.