Endoscopic Ampullectomy

Myron C Stokes, MD, Kirpal Singh, MD FACS. St. Vincent/Indiana University Fellowship of Advanced Laparoscopy, Endoscopy & Ultrasound

Ampullary neoplasms account for approximately five percent of all gastrointestinal neoplasms. Local resection of the Ampulla of Vater was first described in 1899 by Halsted. It was not until the 1980’s that the first endoscopic ampullectomy was described. Thirty years later there is still no consensus statement or guidelines regarding the endoscopic management of these lesions or duodenal lesions in general. We present a 65 year old male with significant medical comorbidities that was discovered to have had an ampullary mass while undergoing endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis after an acute bout of cholecystitis managed non-operatively. Biopsies at the time of ERCP were negative for adenocarcinoma but diagnostic for high grade dysplasia. An endoscopic ultrasound (EUS) was performed and no frank invasion into the muscularis propia was appreciated. Biopsies at the time of EUS confirmed high grade dysplasia. The patient was then offered endoscopic ampullectomy versus laparoscopic ampullectomy or pancreaticoduodenectomy (PD) with the risks and benefits of each procedure explained in detail. He successfully underwent endoscopic ampullectomy. We describe our procedure in the video abstract. Unfortunately his pathology returned as moderately differentiated adenocarcinoma. He subsequently underwent a pylorus preserving PD. As the indications and management of duodenal lesions continue to evolve, here is another instance where an inconclusive diagnosis can be further elucidated with minimal morbidity and managed accordingly.