Endoscopic management of sporadic periampullary adenomas

The duodenum and, more so, the periampullary region are the most commonest sites of adenomatous change in the small bowel, and a recognized cause of biliary and pancreatic obstruction. Endoscopic management of periampullary adenomas (PAA) has been described, however optimal management is not known. Aim: To determine the outcome of endoscopic management for sporadic (non-polyposis syndrome) PAA. Methods: PAA were defined as benign adenomatous lesions located on or within 2cm of the ampulla. Patients were identified from a comprehensive endoscopic database. Data was obtained from the patient record. Patients presenting with malignancy were excluded. Endoscopic management involved initial ERCP, thermal ablation (NdYAG laser, monopolar or bipolar coagulation), typically preceded by endoscopic sphincterotomy (ES). Follow up was obtained every 3 months with biopsy and adjunctive ablative therapy. Results: Twenty three pts with sporadic PAAs were identified. Presentation was incidental in 11; abdominal pain in 5; recurrent pancreatitis in 4 and jaundice in 3. Mean age at diagnosis was 61yrs (range: 28-88). Mean age in incidental cases was 59 yrs. Male:female ratio was 1.3:1. The lesions were single in all cases and involved the ampulla in 21/23 pts (91%). Three pts underwent surgery ftransduodenal resection (TDR)] immediately because of youth (age 25), histology (severe dysplasia) and an extensive lesion. Nineteen of the 20 remaining pts underwent endoscopic therapy, with a mean of 3.2 sessions (range 1-9). Snare ampullectomy was performed on 1 pt without complication. Non-laser thermal ablation after ES has been used on 37 occasions in 15 pts, complicated by pancreatitis on 5 occasions (all mild). Nd-YAG laser was used on ampullary tissue on 15 occasions in 5 pts after ES, complicated by cholangitis on 2 occasions. Laser was also used on 10 occasions in 2 pts with juxta-ampullary lesions without complication. Mean endoscopic surveillance was 21 months (range: 0-60, total follow-up 40 patient-years). During follow-up 2 pts (10%) developed intraepithelial carcinoma and underwent surgical resection (1 TDR, 1 Whipple); 1 pt developed high grade dysplasia and underwent resection (TDR). There was no mortality. Four endoscopically managed pts have no histological evidence of adenomas on follow-up biopsy (mean number of ablative sessions: 4.2). Patients with incidental PAA have not had surgery or complications of therapy. Conclusion: Endoscopie management of PAAs is effective and well tolerated. Complete ablation requires multiple sessions. Development of malignancy with endoscopic management is rare.