Endoscopic management of ampullary adenomas: experience at a tertiary centre

Introduction

Once mainstay of therapy, surgery has now been replaced by endoscopic ampullectomy, as the primary therapeutic modality for non-invasive ampullary adenomas. The present study aims to analyse endoscopic ampullectomy as a therapeutic approach in a large single-centre series.

Methods

This is a retrospective study of fifty consecutive patients who underwent endoscopic ampullectomy over an eleven-year period (January 2011 to December 2021) for ampullary adenomas. The analysis includes demographical features, diagnostic findings, technique of intervention (sedation choices, pre-intervention protocols, interventions), histology, technical, clinical success and adverse events.

Results

Fifty consecutive patients who underwent endoscopic ampullectomy during this period; with 27(54%) females and a mean age 67.62(+/- 12.13) years were included. Out of these, 44(88%) were sporadic and 6(12%) were Familial adenomatous polyposis (FAP) cases. Forty-two (84%) patients underwent pre-ampullectomy endoscopic ultrasound (EUS) evaluation. Pancreatic divisum was found in 6(12%) patients. Laterally spreading adenomas were seen in 15(30%) patients. In total, 35(70%) patients underwent ampullectomy under general anaesthesia, whereas in 15(30%) patients conscious sedation was used. Mean size of ampullary adenoma was 20.5mm (+/- 12.09mm, range 10–90mm). Single piece snare ampullectomy was performed in 33(66%) patients while remaining 17(34%) patients underwent piecemeal resection. Pancreatic stent placement as a prophylaxis against pancreatitis was achieved in 42(84%) patients and rectal Diclofenac was administered in 31(62%) patients. Bile duct stent placement was required in 21(42%) patients to prevent post-procedure cholangitis. Overall, in 20(40%) patients prophylactic haemoclip application to prevent post-procedure bleed was performed. Three patients were referred to surgery post ampullectomy for T2 adenocarcinoma, intraductal extension and high-grade dysplasia respectively. Overall, technical success was achieved in 46 (92%) patients while clinical success in 45(90%) patients. After a mean follow up was 20.84(+/-15.21) months (1–63 months), recurrence occurred in 4(8%) cases. All recurrences were treated endoscopically to eradication. Adverse events were noted in five (10%) patients; two (4%) each of pancreatitis and bleeding whilst one perforation occurred, requiring endoscopic clip closure.

Conclusion

Endoscopic ampullectomy is a safe and effective first line therapy for ampullary adenomas confined to mucosa. Meticulous patient selection through a multidisciplinary team approach, strict protocol-based management including endoscopic surveillance are essential for optimal outcomes.