TABLE 2.
Final consensus statements
| Statement | Agreement | Grading* |
|---|---|---|
| Diagnostic workup | ||
|
| ||
| 1. Gastroduodenoscopy with side-viewing instrument should always be performed before resection. | 100% | D |
|
| ||
| 2. Advanced imaging techniques (such as narrow-band imaging or chromoendoscopy) are not helpful to distinguish between benign and malignant lesions. | 71% | D |
|
| ||
| 3. Biopsy sampling should always be performed before resection. | 94% | D |
|
| ||
| 4. Either MRI/MRCP or EUS should be performed in case of cholestatic laboratory features with or without jaundice. | 81% | D |
|
| ||
| 5. Either CT, MRI/MRCP, or EUS should be performed in case of cholestatic laboratory features with or without jaundice. | 75% | D |
|
| ||
| 6. CT should be performed in case of jaundice. | 75% | D |
|
| ||
| 7. Either MRI/MRCP or EUS should be performed in case of a lesion larger than 2 cm. | 75% | D |
|
| ||
| 8. Either MRI/MRCP or CT should be performed in case of significant weight loss. | 81% | D |
|
| ||
| 9. Either MRI/MRCP or CT should be performed in case of endoscopic signs of malignancy. | 81% | D |
|
| ||
| Lesion assessment and staging | ||
|
| ||
| 10. No predefined classification system to determine if a papillary adenoma is most likely benign or malignant exists. | 89% | D |
|
| ||
| 11. When a lesion shows ulceration, this lesion should be defined as most likely malignant. | 94% | D |
|
| ||
| 12. The following characteristics are not a sole reason to define the lesion as most likely malignant: | ||
|
| ||
| a. Smooth surface | 96% | D |
|
| ||
| b. Spontaneous bleeding | 86% | D |
|
| ||
| c. Lesion size >4 cm | 86% | D |
|
| ||
| 13. Patient should be referred for surgical management in case of ingrowth in the PD >1 cm, considering patient is suitable for surgery. | 76% | D |
|
| ||
| 14. Patient should be referred for surgical management in case of ingrowth in the CBD >1 cm, considering patient is suitable for surgery. | 81% | D |
|
| ||
| 15. The following situations are not a sole reason to refer for surgical management: | ||
|
| ||
| a. Jaundice | 86% | D |
|
| ||
| b. Ingrowth in the PD ≤1 cm | 79% | D |
|
| ||
| c. Ingrowth in the CBD ≤1 cm | 86% | D |
|
| ||
| d. An umbilicated lesion | 82% | D |
|
| ||
| 16. If biopsy sample shows LGD and ulceration is present, the lesion could still be resected endoscopically; there is no need to refer the patient for surgical management based on this sole characteristic, considering the lesion seems favorable for endoscopic resection. | 88% | D |
|
| ||
| 17. If there is ingrowth in the CBD >1 cm, endoscopic resection can still be considered if the patient is not a surgical candidate because of age and/or comorbidity, considering the lesion seems favorable for endoscopic resection. | 81% | D |
|
| ||
| 18. If there is ingrowth in the CBD >1 cm, EP with radiofrequency ablation can be considered in a patient that is not a surgical candidate because of age and/or comorbidity, considering the lesion seems favorable for endoscopic resection. | 75% | C |
|
| ||
| 19. If biopsy sample shows adenocarcinoma in situ or well-differentiated adenocarcinoma, endoscopic resection can still be considered if the patient is not a surgical candidate because of age and/or comorbidity, considering the lesion seems favorable for endoscopic resection. | 75% | D |
|
| ||
| Technical aspects | ||
|
| ||
| 20. Submucosal injection should only be performed in case of a laterally spreading lesion. | 88% | C |
|
| ||
| 21. Resection of the lesion should be performed at the plane of the duodenal wall. | 94% | D |
|
| ||
| 22. EP should be performed with fractionated current. | 94% | D |
|
| ||
| 23. If pancreatic sphincterotomy is indicated, then it should be performed after resection. | 88% | D |
|
| ||
| 24. Biliary sphincterotomy should be performed in case of concomitant bile duct stones and in case drainage is deemed suboptimal. | 81% | D |
|
| ||
| 25. If biliary sphincterotomy is indicated, then it should be performed after resection. | 100% | D |
|
| ||
| 26. PD stent should be routinely placed to prevent postintervention pancreatitis. | 100% | B |
|
| ||
| 27. PD should be cannulated after resection. | 100% | D |
|
| ||
| 28. CBD stent should only be placed on indication, namely | 82% | D |
|
| ||
| a. If there are concerns for microperforations in the papillary region after resection. | 88% | D |
|
| ||
| b. In case of bleeding from the papillary region during the procedure. | 76% | D |
|
| ||
| 29. In case there are concerns for microperforations in the papillary region a fully covered self- expanding metal stent should be placed in the CBD. | 88% | D |
|
| ||
| Adverse events and management | ||
|
| ||
| 30. Rectal nonsteroidal anti-inflammatory drugs should be given before resection. | 82% | B |
|
| ||
| Follow-up | ||
|
| ||
| 31. In case initial pathology shows LGD | ||
|
| ||
| a. First follow-up (after removal of possible placed stents) should be performed within 6 months. | 81% | D |
|
| ||
| b. At first follow-up, biopsy specimens should only be taken when macroscopic abnormalities are present. | 94% | D |
|
| ||
| c. Follow-up interval should be 12 months or less. | 88% | D |
|
| ||
| d. At further follow-up, biopsy specimens should only be taken when macroscopic abnormalities are present. | 94% | D |
|
| ||
| e. Follow-up should be performed for at least 5 years. | 81% | D |
|
| ||
| 32. In case initial pathology shows HGD | ||
|
| ||
| a. First follow-up (after removal of possible placed stents) should be performed within 3 months. | 94% | D |
|
| ||
| b. At first follow-up, biopsy specimens should only be taken when macroscopic abnormalities are present. | 81% | D |
|
| ||
| c. Follow-up interval should be 6 months or less. | 94% | D |
|
| ||
| d. At further follow-up, biopsy specimens should only be taken when macroscopic abnormalities are present. | 81% | D |
|
| ||
| e. Follow-up should be performed for at least 5 years. | 75% | D |
CBD, Common bile duct; CT, computed tomography; EUS, endoscopic ultrasound; EP, endoscopic papillectomy; HGD, high-grade dysplasia; LGD, low-grade dysplasia; MRCP, magnetic resonance cholangiopancreatography; MRI, magnetic resonance imaging; PD, pancreatic duct.
*
Grading: A, level 1a-1b evidence; B, level 2a-3b evidence; C, level 4 evidence; D, level 5 evidence.