Endoscopic Papillectomy for Early Ampullary Tumors: Long-term Results of the First Large Multicenter Prospective Study

Adenoma of the ampulla of Vater is rare but represents a large proportion of benign tumors occurring in the small intestine. The symptoms are usually non specific or due to pancreaticobiliary obstruction . The diagnosis can also be made in asymptomatic patients during an upper gastrointestinal endoscopy. Finally, the adenoma can be discovered during a screening procedure in patients with Familial Adenomatous Polyposis (FAP). It has been demonstrated that ampullary adenomas have a malignant potential mimicking the "adenoma-adenocarcinoma" sequence already described in the colon. So, a complete removal is mandatory. The only exception is represented by subnormal ampulla with low grade dysplasia (LGD) adenoma discovered during screening follow-up of FAP patients. In these cases the situation can be stable during several years leading to simple, annual or biannual surveillance. Historically, the treatment was surgical, associated with a high mortality and morbidity rate for pancreaticoduodenectomy (PD) and a high recurrence rate for transduodenal resection (26 to 43%). Endoscopic papillectomy (EP) represents an alternative for patients with a benign or at least non-invasive ampullary tumor. Unlike thermal ablative methods by laser photoablation or argon plasma destruction, EP allows adequate histologic evaluation especially in case of en-bloc resection. This technique has been increasingly used in the last decade with very promising results. Nevertheless the long-term results have mainly been reported in retrospective monocentric series. We intended to evaluate, in the first large multicenter prospective study, the long-term results of endoscopic papillectomy.

Sex

All

Inclusion Criteria:

* Adenoma with at least low grade dysplasia (LGD) was required for inclusion

Two other criteria were needed in asymptomatic patients with LGD :

* an ampullary size \> 1 cm at endoscopy in case of Familial Adenomatous Polyposis (FAP) ;
* two series of positive biopsies in case of sporadic tumors
* uT1N0 lesion at EUS (tumor without invasion of the muscularis propria (MP) of the duodenum and no suspicious lymph nodes)
* without intraductal growth (pancreatic and/or common bile duct)

Exclusion criteria were:

* previously treated ampulloma;
* metastatic disease at CT-scan;
* advanced tumor at duodenoscopy (ulceration or induration involving the duodenal roof of the papilla);
* advanced tumor (uT2 = invasion of the MP without invasion of the pancreas ; uT3 = invasion of pancreas and/or N+ suspicious lymph nodes) and/or intraductal invasion at EUS
* absence of adenoma on the resected specimen.

Exclusion Criteria:

* adenoma not confirmed

• DERIVEDNapoleon B, Gincul R, Ponchon T, Berthiller J, Escourrou J, Canard JM, Boyer J, Barthet M, Ponsot P, Laugier R, Helbert T, Coumaros D, Scoazec JY, Mion F, Saurin JC; Societe Francaise d'Endoscopie Digestive (SFED, French Society of Digestive Endoscopy). Endoscopic papillectomy for early ampullary tumors: long-term results from a large multicenter prospective study. Endoscopy. 2014 Feb;46(2):127-34. doi: 10.1055/s-0034-1364875. Epub 2014 Jan 29. PMID 24477368