Ampullary adenomas and option for follow-up

Abstract

We read with great interest the study by Laleman et al. [1] and congratulate the authors on this excellent piece of work. The authors found that endoscopic resection is an efficient procedure for adenomas of the Vaterian papilla with low and moderate dysplasia; however, in high-grade dysplastic adenomas, lesions need complete resection for excellent outcome. Although classified as benign, ampullary adenomas have the potential to undergo malignant transformation to ampullary carcinomas. As a result, their clinical significance extends beyond the need to treat any associated symptoms and degree of dysplasia. Endoscopic ampullectomy has been considered a high-risk procedure associated with a higher complication rate of bleeding, perforation, and pancreatitis compared with conventional endoscopic retrograde cholangiopancreatography (ERCP) [2]. A variety of techniques, equipment, and different power settings of the electrosurgical unit have been attempted in patients with ampullary adenomas; however, the results are not satisfactory. Periodic biopsy from ampullary adenomas is other option for follow-up, especially in adenomas with low dysplasia. We hereby describe a patient with secondary sclerosing cholangitis (SSC) due to ampullary adenoma, which was successfully treated with endoscopic sphincterotomy (ES), and considered periodic biopsy for follow-up. A 59-year-old man presented with jaundice. His medical history included hypertension, diabetes and a 2-year history of cholecystectomy due to cholelithiasis. Magnetic resonance cholangiopancreatography (MRCP) revealed a homogeneous hyperechogenicity of the liver parenchyma with no focal lesion, dilated intrahepatic and common bile ducts, and a choledoct with a diameter of 10 mm. Moreover, MRCP displayed beadings (both strictures and dilations) of the intrahepatic and extrahepatic bile ducts (Fig. 1A). These findings were also consistent on ERCP, with pruned-tree appearance, blunting termination at the end of the distal choledoc, and papillary mucosal irregularities (Fig. 1B). After ES, effective biliary drainage was achieved and the patient’s jaundice was dramatically improved. The biopsies obtained from papillary mucosal irregularities suggest that there was a low degree of epithelial dysplasia. The patient was diagnosed with SSC due to ampullary adenoma with low dysplasia. MRCP performed post-ERCP showed that ES recovered the beading of the intrahepatic and extrahepatic bile ducts within 10 days (Fig. 1C). ES is seen as adequate management for SSC due to ampullary adenomas. Periodic biopsy is considered as the ideal follow-up process for such cases. Moreover, we suggest that this finding should be confirmed by more comprehensive clinical studies. H. Akinci F. Karaahmet (&) M. Hamamci I. Yuksel Department of Gastroenterology, Diskapi Yildirim Beyazit Educational and Research Hospital, 06080 Altindag, Ankara, Turkey e-mail: fatih_ares@yahoo.com.tr