Su1452 Endoscopic Ampullectomy of Adenoma of the Major Duodenal Papilla (MPD): Long-Term Outcome

Abstract

Endoscopic Ampullectomy of Adenoma of the Major Duodenal Papilla (MPD): Long-Term Outcome Marc F. Catalano, Naeem Aslam, Robbie Taha, Nalini M. Guda, Joseph E. Geenen Wisconsin Center for Advanced Research, GI Associates, LLC, Milwaukee, WI; Pancreatobiliary, St. Luke’s Medical Center, Milwaukee, WI Adenoma of MPD is more likely to undergo malignant transformation than adenoma elsewhere in duodenum. Pts w/ FAP have increased likelihood of papillary neoplasm. Treatment of ampullary adenomas is surgical excision. Endoscopic ampullectomy is a relatively new treatment option. Aim: Determine efficacy of endoscopic resection of ampullary adenoma. Methods: Consecutive pts w/ ampullary adenomas over 10yr were reviewed. Criteria for ampullectomy included: previously untreated, endoscopically accessible lesions w/ benign features. Pts w/ biliary or pancreatic extension of lesion were excluded. Imaging suggesting advanced disease (EUS, CT) was an exclusion criteria whereas presence of dysplasia w/o frank carcinoma was not. Ampullectomy technique: Standard polypectomy snare; blended current; dual sphincterotomy (pancreatic & biliary). Pancreatic duct (PD) stent placement was performed to prevent ampullary stenosis. Endoscopic success determined as complete excision & absence of recurrence during 2yr F/U. Endoscopic failure defined as inability to completely remove lesion, recurrence treated surgically, discovery of carcinoma beyond mucosal layer. Ampullectomy complications; early (pancreatitis, bleeding, perforation) & late (post-ampullectomy stenosis). Results: 58 pts; 31W; age 20-72 met inclusion criteria. 41 had sporadic adenomas & 17 had FAP. Presenting Sx: jaundice/cholangitis/pain (n 22); acute pancreatitis (AP) (n 11), bleeding (n 6); no Sx (n 19). Mean F/U was 38 mos (24-78). 49 pts (85%) had long-term success & 9 (15%) unsuccessful (initial failure, recurrent adenoma) including 6 initial failures, & 3 recurrences. High grade dysplasia present in 8; 3 had focal adeno CA. Lesions size was 10-40mm. Pts w/ successful ampullectomy had significantly smaller lesions (18.5vs28.3). FAP pts were significantly younger compared to sporadic (32.6vs58.4). FAP pts had significantly smaller lesions compared to sporadic (18.7vs25.2). Success rate in pts w/ FAP (n 17) was 94% (16/17) vs 80% (33/41) for sporadic. Adjunctive thermal ablation was used in 18/ 58 pts in (14 APC, 4 multipolar). Success was similar among pts who had ablation (15/18) vs w/o (34/40). Predictors of success included age 45 &, size of 24 mm. PD stent (5-7 Fr) was placed in all but 2 pts w/ accessible ducts. All but 14 pts underwent biliary stents based on clinically. All stents were removed w/in 8wks. There were 4 procedural complications in 58pts: AP (n 2), bleeding (n 1) & late papillary stenosis (n 1). AP occurred only in pts w/o PD stents. Papillary stenosis occurred more frequently in pts w/o PD stents (50%vs2%). Conclusion: Endoscopic treatment of ampullary adenomas in selective pts is highly successful & safe. Dual sphincterotomy/stenting may prevent postprocedural complications. Adjunctive thermoablation may prevent postampullectomy recurrence.