Endoscopic management of ampullary adenomas. A report of eight patients

Benign ampullary adenoma not associated with familial adenomatous polyposis is an uncommon condition. Adenomas are felt to be neoplastic precursors to malignancy, as they may harbor dysplasia or malignancy in the deeper portions. Pancreaticoduodenectomy is the procedure of choice in patients with good surgical candidacy, and poor candidates for this procedure often undergo local surgical excision. Endoscopic removal of ampullary adenomas has also been reported, and relies on snare excision or hot biopsy ablation. We herein report our experience with a modification of this endoscopic technique. METHODS: Eight patients with poor surgical candidacy (4M/4F, mean age at diagnosis 74.3 years, range 59-82) had biopsy-proven ampullary adenoma. All adenomas were resected endoscopically (ampullectomy) with snares, followed by biliary and pancreatic stenting in the same sitting in all patients but the first, who underwent only pancreatic stenting. YAG Laser photocoagulation of the base of the adenoma followed in 6/8 patients in a separate procedure, and stents were removed during yet another procedure. RESULTS: A mean of 3.5 procedures (range 2-5) were performed in this group of patients to complete endoscopic ampullectomy, excluding index and follow-up studies. Cholangitis after laser photocoagulation occurred in the first patient of this series, who had not undergone biliary stenting. Over a mean follow-up period of 12.1 months (range 1-34) 2/8 patients have undergone pancreaticoduodenectomy for recurrence. These 2 patients had dysplastic tissue at the time of initial snare resection, and adenocarcinoma in the surgical specimen. They remain free of disease at 18 and 26 postoperative months respectively. All other patients remain free of symptoms and disease. CONCLUSIONS: (1) Endoscopic management of ampullary adenomas is safe and often effective therapy for poor surgical candidates; however further experience and longer follow-up are necessary. (2) This therapy should not be used in place of pancreaticoduodenectomy in good surgical candidates or in patients with dysplasia. (3) Preservation of biliary and pancreatic drainage during therapy is an important goal. (4) Laser photocoagulation may ablate residual adenomatous tissue; careful endoscopic follow-up is prudent.