Endoscopic management of proximal small bowel adenomas in familial adenomatous polyposis

In pts with Familial Adenomatous Polyposis (FAP), the major site of malignancy after colectomy is the proximal small bowel, especially the periampullary area, occurring in up to 12% of pts. Studies indicate that endoscopic therapy of periampullary adenoma (PAA) is feasible. The results of endoscopic surveillance, optimal form of endoscopic therapy and long-term results of this management are unknown. Aim: To determine the outcome of endoscopic management of proximal small bowel adenomas in FAP pts. Methods: Patients undergoing duodenal surveillance and/or endoscopic therapy since 1990 were identified from a comprehensive endoscopic database. Data was obtained from the pt record. Periampullary adenomas were defined as those on or within 2cm of the ampulla. Management comprised yearly inspection of the ampulla with a duodenoscope and push enteroscopy. Ampullary endoscopic management involved biopsy of abnormal tissue and thermal ablation, typically preceded by sphincterotomy. Duodenal lesions >5mm were biopsied and ablated. Results: Forty four FAP pts with duodenal involvement were identified since 1990. Presentation was during surveillance in 98% of cases. Mean age was 40 (range: 22-68). Seventy two percent of pts were female. A macroscopic lesion involved the periampullary region in 35 pts (79%). Mean duration of endoscopic surveillance was 34 months (range: 0-123). Thirty one pts underwent ablative therapy (mean: 2.9 sessions, range: 1-9). Laser photocoagulation was used on periampullary tissue on 7 occasions and non-periampullary tissue on 43 occasions. Non-laser ablation was used on the periampullary region on 44 occasions and non-periampullary tissue on 43 occasions. Twenty two pts underwent sphincterotomy preceding ablative therapy. Snare ampullectomy was performed on 1 pt. Complications of laser therapy were pancreatitis (1, mild); postcoagulation syndrome (1), duodenal stenosis (1) and cholangitis (2). Non-laser thermal ablation resulted in 1 episode of hemorrhage and 5 episodes of pancreatitis (all mild, 2 following sphincterotomy). Snare ampullectomy resulted in a significant hemorrhage. No pts developed malignancy during follow-up (124 patient-years). Three pts underwent surgery, all for high grade dysplasia (2 transduodenal resections and 1 Whipple). There was no mortality. To date, 2 pts have had subsequent normal periampullary biopsies. Conclusion: A gender prevalence of duodenal adenomas in FAP syndrome was seen. Endoscopic management is safe and requires continuing follow-up with adjunctive ablation. Invasive malignancy with endoscopic management did not occur.