Contributor: Darin L. Dufault
This video illustrates two cases of ampullary adenoma treated with endoscopic papillectomy (a.k.a.
endoscopic ampullectomy in many manuscripts). Along with local surgical ampullectomy and
pancreaticoduodenectomy, endoscopic papillectomy is an established treatment option for benign
lesions of the ampulla of Vater. For the majority of benign ampullary lesions, complete endoscopic
resection of ampullary lesions is usually feasible. Limitations to endoscopic therapy include deep
extension into the bile or pancreatic duct, > 50% lateral extension along the duodenal wall, and
carcinomatous transformation. In general, endoscopic resection should be considered equivalent to
local surgical ampullectomy in terms of its depth of dissection.
In the first case, the patient was noted to have adenomatous appearing change of the ampulla
on endoscopy. An electrocautery snare is used to remove the entire papilla. When technically feasible,
cholangiopancreatography should precede tissue resection to evaluate for intraductal extension and
identify the orifices for post-resection therapy. Since this was unsuccessful prior to resection, the
pancreatic duct is then cannulated and a pancreatogram is obtained. A pancreatic duct stent is then
placed after pancreatic sphincterotomy to minimize the risk of post-ampullectomy and ERCP
pancreatitis, and to prevent stenosis of the pancreatic orifice long-term. Then, a cholangiogram is
performed, confirming no intraductal extension and to facilitate a biliary sphincterotomy.
The second case is a patient referred for further evaluation of cholestatic liver function tests and
a dilated bile duct. Endoscopically, they were noted to have a protuberant papilla. Endoscopic
ultrasound (EUS) showed a mass between the bile and pancreatic ducts and within the ampulla of Vater,
along with a significantly dilated bile duct. The mass did not invade the duodenal wall, as showed by
preservation of the muscularis propria. In cases where malignancy is not suspected and in smaller
lesions, EUS may not be required. Prior to papillectomy, the pancreatic duct was cannulated and
methylene blue injected into the duct to allow easier identification of the duct following papillectomy.
The mass was also able to be seen on cholangiogram (green circle). It is preferred to remove the papilla
en bloc, as shown in case one, although this is not always possible. There was a small amount of
residual tissue at the core of the lesion that was further resected in piecemeal fashion using a hot snare
with blended cut and coagulation current. Biliary and pancreatic stents were then placed to minimize
the risk of post-ERCP pancreatitis, delayed post-ampullectomy bleeding, and orifice stenosis. These
stents are typically removed after 1-2 months, at which time the resection site may be surveyed for
residual adenomatous tissue. Last, a small amount of residual abnormal appearing tissue was ablated
Editor Recruited By: Jeffrey Matthews, MD