Management of Duodenal Adenomas Involving the Ampulla of Vater - A Warning against Limited Resection

Abstract

Duodenal adenomas are uncommon, however, when present a proportion have dysplasia associated with the adenoma and therefore require treatment. The options range from less invasive endoscopic treatments to a pancreaticoduodenectomy. This case report describes two patients with adenomas involving the ampulla of Vater. One patient had familial adenomatous polyposis, the other was a renal transplant patient with a large adenoma. Both patients' adenomas contained high-grade dysplasia. Both patients underwent a pancreaticoduodenectomy. Histology of both specimens demonstrated that the adenoma had migrated up the bile duct for at least 7 mm, and the pancreatic duct for 8 mm in one patient. Limited resection of ampullary adenomas may leave residual adenomatous tissue in the bile duct with the risk of recurrent adenomatous disease and malignant transformation.

Keywords: Ampullary adenoma/carcinoma; Duodenal adenoma/carcinoma; High-grade dysplasia; Management; Surgery.

Fig. 1

Haematoxylin and eosin (H+E) stained specimen showing the duodenal villous adenoma.

Fig. 2

H+E specimen demonstrating migration of the adenoma (dark) up the common bile duct and a transition from normal to adenomatous tissue (arrow).

Fig. 3

H+E section of the adenoma in the pancreatic duct sectioned longitudinally. The adenomatous tissue appears darker (arrow).

Fig. 4

Gastroscopy demonstrated large villous adenoma of the 2nd part of the duodenum (black arrow); normal mucosa (white arrow).

Fig. 5

Histology (H+E) demonstrating migration of the dysplastic epithelium into the common bile duct (arrow).