Endoscopic management of adenomatous ampullary lesions

Abstract

Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.

Keywords: Ampullary adenoma; Endoscopic ampullectomy; Endoscopic ultrasound; Pancreatitis; Papillary tumors.

Figure 1

Technique of en-bloc ampullectomy. A: Lesion is identified; B: Submucosal (saline + epinephrine) injection; C: With the snare tip anchored above the papillary mound the entire papilla is snared; D: Check mobility and ensure the snare is firmly closed; E: En-bloc ampullary resection. Biliary and pancreatic (guidewire) orifice is identified; F: Biliary and pancreatic stents are placed. Adjuvant APC therapy is applied; G: Tissue retrieval with the snare; H: Ampullectomy specimen; I: Ampullary adenoma: tubulovillous architecture that shows neoplastic epithelial cells with pseudostratified and enlarged hyperchromatic nuclei. Adjacent there is normal duodenal mucosa. (HE: 20 ×). (Courtesy of Mercedes Hernando, MD). APC: Argon plasma coagulation.