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Approaches to endoscopic ampullectomy

Wong, Robert F.; DiSario, James A.

Current Opinion in Gastroenterology: September 2004 - Volume 20 - Issue 5 - p 460-467
Endoscopy
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Purpose of review Ampullary tumors, usually adenomas, are often encountered during endoscopic evaluation, especially in patients with familial adenomatous polyposis (FAP). Because of the risk of progression to adenocarcinoma, ampullary adenomas should be treated. Endoscopic therapy is an appropriate option and recent experience highlights the effectiveness and safety of this approach.

Recent findings Several authors have published experiences with endoscopic ampullectomy. In the current era, endoscopic ampullectomy is performed like a snare polypectomy using a side-viewing duodenoscope. Tumors are removed either en bloc or in a piecemeal fashion with retrieval of all tissue. Because of the potential for incidental carcinoma when all tissue is removed, complete retrieval is essential. Although initially used as primary therapy, thermal ablation, such as ionized argon coagulation (IAC), is now commonly used as adjunctive therapy. Prophylactic pancreatic or biliary stent placement is also performed to minimize risks of pancreatitis, jaundice, cholangitis, and stenosis. Endoscopic therapy is effective in removing more than 80% of adenomas, though several sessions may be necessary. Complications are reported in 20% of patients from most series and include acute pancreatitis, bleeding, perforation, orifice stenosis, and, rarely death. Recurrence of the adenoma can occur, especially in FAP patients, and warrants periodic surveillance.

Summary Endoscopic ampullectomy appears to be an effective method for treating ampullary tumors. However, complications are significant and only well-trained and experienced endoscopists should perform ampullectomy. Future research should focus on multicenter, randomized clinical trials to determine the best therapeutic approach for patients with ampullary tumors and to determine methods to decrease complication rates associated with endoscopic therapy.

Division of Gastroenterology, University of Utah, School of Medicine, Salt Lake City, Utah, USA

Correspondence to James A. DiSario, Professor of Internal Medicine, Division of Gastroenterology, University of Utah, School of Medicine, and Huntsman Cancer Institute, 30 North 1900 East Room 4R118, Salt Lake City, UT 84132, USA, Tel: 801 581 7802; fax: 801 581 7476; e-mail: James.DiSario@hsc.utah.edu

© 2004 Lippincott Williams & Wilkins, Inc.