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Endoscopic Resection of Early Ampullary Carcinoma in Medically Frail Patients


Zia, Hassaan A. MD1; Salem, George MD2; Chaudrey, Khadija MD3; Maple, John DO2

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American Journal of Gastroenterology: October 2015 - Volume 110 - Issue - p S115
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Introduction: There is scarcity of data for the role and outcomes of Endoscopic Ampullectomy for ampullary carcinomas. While pancreaticoduodenectomy (PD) is the primary surgical approach for ampullary carcinoma, age and medical comorbidities may limit its use. We report two cases of endoscopic resection of early ampullary carcinomas.

Case 1: An 82 year-old male presented elsewhere with jaundice and biliary dilatation on abdominal ultrasound. Endoscopic Retrograde Cholangiopancreaticography (ERCP) revealed a fungating, mildly ulcerated, friable ampullary mass. Forceps biopsies revealed a tubulovillous adenoma with high grade dysplasia. Upon referral to our center, endoscopic ultrasound (EUS) identified a 2.5 cm ampullary mass, staged T1N0M0. Owing to patient and surgeon's refusal to pursue PD, endoscopic ampullectomy was requested. At ERCP, the ampullary mass was resected en bloc with a 27 mm oval polypectomy snare using ERBE Endocut current (ERBE USA, Marietta, GA). Histopathology demonstrated mucinous adenocarcinoma arising in a tubulovillous adenoma, not involving the resection margins. On a 4 month surveillance ERCP, an 8 mm sessile polyp at the ampullectomy site was resected, consistent with tubular adenoma on histopathology. A 10 month surveillance ERCP, showed no gross or histopathologic evidence of residual or recurrent neoplasia at ampullectomy scar site. A primary care clinic visit 2.5 years later remained reassuring.

Case 2: A 72 year-old male with history of COPD and peptic ulcer disease status-post partial gastrectomy presented with abdominal pain, diarrhea and raised alkaline phosphatase levels. Computerized tomography of the abdomen showed intra- and extrahepatic biliary dilatation. At EUS a 2.8 cm polypoid ampullary mass was identified (image 1), staged T1N0M0. Forceps biopsies demonstrated tubular adenoma. At subsequent ERCP the ampullary lesion was completely resected en bloc using a polypectomy snare with ERBE Endocut current (image 2). Histopathology showed a low grade ampullary adenocarcinoma extending to the surgical margins with no lymphovascular invasion. Owing to chronic lung disease, surgical consultation was deferred, patient now awaits a planned surveillance ERCP.

Conclusion: Endoscopic ampullectomy has decreased associated morbidity and mortality compared to local or radical surgical resections and may deserve consideration in aged and medically unfit patients. This remains an area for further interest and investigation.

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