Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Treatment of ampullary adenomas

INTRODUCTION

Benign neoplasms of the ampulla of Vater are rare. They represent less than 10 percent of periampullary neoplasms, the majority of which are malignant tumors arising from the duodenum, ampulla, or pancreas [1,2]. The most common benign lesions are villous and tubulovillous adenomas; others include hemangiomas, leiomyomas, leiomyofibromas, lipomas, lymphangiomas, and neurogenic tumors [3,4].

Ampullary adenomas can occur sporadically or in the setting of familial polyposis syndromes, such as familial adenomatous polyposis (FAP) and its related conditions. Approximately 40 to 100 percent of patients with FAP who have ampullary adenomas also have coexisting duodenal adenomatous polyps, which are frequently numerous and also have malignant potential [5-9]. (See "Clinical manifestations and diagnosis of familial adenomatous polyposis".)

The prevalence of ampullary adenomas has been estimated to be 0.04 to 0.12 percent in autopsy series [10-12]. However, they are being increasingly recognized premortem with the extensive availability of flexible endoscopy and the widespread application of screening and surveillance programs for high-risk patients, such as those with FAP [5,7,9,13,14].

The treatment of ampullary adenomas will be reviewed here. The clinical manifestations and diagnosis of ampullary adenomas and carcinomas are discussed separately. (See "Clinical manifestations and diagnosis of ampullary adenomas" and "Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging".)

NATURAL HISTORY

Although classified as benign, ampullary adenomas have the potential to undergo malignant transformation to ampullary carcinomas. This is thought to occur through an adenoma-to-carcinoma sequence as is seen elsewhere in the gastrointestinal tract [1,10,13,15-21]. As a result, their clinical significance extends beyond the need to treat any associated symptoms.

                       

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2014. | This topic last updated: Jan 24, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Park SH, Kim YI, Park YH, et al. Clinicopathologic correlation of p53 protein overexpression in adenoma and carcinoma of the ampulla of Vater. World J Surg 2000; 24:54.
  2. Park SW, Song SY, Chung JB, et al. Endoscopic snare resection for tumors of the ampulla of Vater. Yonsei Med J 2000; 41:213.
  3. Treitschke F, Beger HG. Local resection of benign periampullary tumors. Ann Oncol 1999; 10 Suppl 4:212.
  4. Allgaier HP, Schwacha H, Kleinschmidt M, et al. Ampullary hamartoma: A rare cause of biliary obstruction. Digestion 1999; 60:497.
  5. Lindor NM, Greene MH. The concise handbook of family cancer syndromes. Mayo Familial Cancer Program. J Natl Cancer Inst 1998; 90:1039.
  6. Heiskanen I, Kellokumpu I, Järvinen H. Management of duodenal adenomas in 98 patients with familial adenomatous polyposis. Endoscopy 1999; 31:412.
  7. Offerhaus GJ, Giardiello FM, Krush AJ, et al. The risk of upper gastrointestinal cancer in familial adenomatous polyposis. Gastroenterology 1992; 102:1980.
  8. Vasen HF, Bülow S, Myrhøj T, et al. Decision analysis in the management of duodenal adenomatosis in familial adenomatous polyposis. Gut 1997; 40:716.
  9. Galandiuk S, Hermann RE, Jagelman DG, et al. Villous tumors of the duodenum. Ann Surg 1988; 207:234.
  10. Sato T, Konishi K, Kimura H, et al. Adenoma and tiny carcinoma in adenoma of the papilla of Vater--p53 and PCNA. Hepatogastroenterology 1999; 46:1959.
  11. Shapiro PF, Lifvendahl RA. Tumors of the Extrahepatic Bile-ducts. Ann Surg 1931; 94:61.
  12. BAKER HL, CALDWELL DW. Lesions of the ampulla of Vater. Surgery 1947; 21:523.
  13. Stolte M, Pscherer C. Adenoma-carcinoma sequence in the papilla of Vater. Scand J Gastroenterol 1996; 31:376.
  14. van Stolk R, Sivak MV Jr, Petrini JL, et al. Endoscopic management of upper gastrointestinal polyps and periampullary lesions in familial adenomatous polyposis and Gardner's syndrome. Endoscopy 1987; 19 Suppl 1:19.
  15. Sellner FJ, Riegler FM, Machacek E. Implications of histological grade of tumour for the prognosis of radically resected periampullary adenocarcinoma. Eur J Surg 1999; 165:865.
  16. Asbun HJ, Rossi RL, Munson JL. Local resection for ampullary tumors. Is there a place for it? Arch Surg 1993; 128:515.
  17. Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol 1992; 87:37.
  18. Yamaguchi K, Enjoji M. Adenoma of the ampulla of Vater: putative precancerous lesion. Gut 1991; 32:1558.
  19. Ryan DP, Schapiro RH, Warshaw AL. Villous tumors of the duodenum. Ann Surg 1986; 203:301.
  20. Kozuka S, Tsubone M, Yamaguchi A, Hachisuka K. Adenomatous residue in cancerous papilla of Vater. Gut 1981; 22:1031.
  21. Perzin KH, Bridge MF. Adenomas of the small intestine: a clinicopathologic review of 51 cases and a study of their relationship to carcinoma. Cancer 1981; 48:799.
  22. Standards of Practice Committee, Adler DG, Qureshi W, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2006; 64:849.
  23. Matsumoto T, Iida M, Nakamura S, et al. Natural history of ampullary adenoma in familial adenomatous polyposis: reconfirmation of benign nature during extended surveillance. Am J Gastroenterol 2000; 95:1557.
  24. Burke CA, Beck GJ, Church JM, van Stolk RU. The natural history of untreated duodenal and ampullary adenomas in patients with familial adenomatous polyposis followed in an endoscopic surveillance program. Gastrointest Endosc 1999; 49:358.
  25. Kim JH, Kim JH, Han JH, et al. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol 2009; 16:2547.
  26. Bellizzi AM, Kahaleh M, Stelow EB. The assessment of specimens procured by endoscopic ampullectomy. Am J Clin Pathol 2009; 132:506.
  27. Grobmyer SR, Stasik CN, Draganov P, et al. Contemporary results with ampullectomy for 29 "benign" neoplasms of the ampulla. J Am Coll Surg 2008; 206:466.
  28. Rivadeneira DE, Pochapin M, Grobmyer SR, et al. Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies. Ann Surg Oncol 2003; 10:890.
  29. Ito K, Fujita N, Noda Y, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc 2007; 66:740.
  30. Chen CH, Yang CC, Yeh YH, et al. Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. J Clin Ultrasound 2009; 37:18.
  31. Beger HG, Treitschke F, Gansauge F, et al. Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients. Arch Surg 1999; 134:526.
  32. Chappuis CW, Divincenti FC, Cohn I Jr. Villous tumors of the duodenum. Ann Surg 1989; 209:593.
  33. Sharp KW, Brandes JL. Local resection of tumors of the ampulla of Vater. Am Surg 1990; 56:214.
  34. Sand JA, Nordback IH. Transduodenal excision of benign adenoma of the papilla of Vater. Eur J Surg 1995; 161:269.
  35. Komorowski RA, Cohen EB. Villous tumors of the duodenum: a clinicopathologic study. Cancer 1981; 47:1377.
  36. Gray G, Browder W. Villous tumors of the ampulla of Vater: local resection versus pancreatoduodenectomy. South Med J 1989; 82:917.
  37. Rosenberg J, Welch JP, Pyrtek LJ, et al. Benign villous adenomas of the ampulla of Vater. Cancer 1986; 58:1563.
  38. Farouk M, Niotis M, Branum GD, et al. Indications for and the technique of local resection of tumors of the papilla of Vater. Arch Surg 1991; 126:650.
  39. CATTELL RB, BRAASCH JW, KAHN F. Polypoid epithelial tumors of the bile ducts. N Engl J Med 1962; 266:57.
  40. Iwama T, Tomita H, Kawachi Y, et al. Indications for local excision of ampullary lesions associated with familial adenomatous polyposis. J Am Coll Surg 1994; 179:462.
  41. Cahen DL, Fockens P, de Wit LT, et al. Local resection or pancreaticoduodenectomy for villous adenoma of the ampulla of Vater diagnosed before operation. Br J Surg 1997; 84:948.
  42. Chijiiwa K, Yamashita H, Kuroki S. Wide ampullectomy for patients with villous adenoma of duodenal papilla and follow-up results of pancreaticobiliary tract. Int Surg 1994; 79:178.
  43. Branum GD, Pappas TN, Meyers WC. The management of tumors of the ampulla of Vater by local resection. Ann Surg 1996; 224:621.
  44. Alstrup N, Burcharth F, Hauge C, Horn T. Transduodenal excision of tumours of the ampulla of Vater. Eur J Surg 1996; 162:961.
  45. Rattner DW, Fernandez-del Castillo C, Brugge WR, Warshaw AL. Defining the criteria for local resection of ampullary neoplasms. Arch Surg 1996; 131:366.
  46. Winter JM, Cameron JL, Olino K, et al. Clinicopathologic analysis of ampullary neoplasms in 450 patients: implications for surgical strategy and long-term prognosis. J Gastrointest Surg 2010; 14:379.
  47. Kemp CD, Russell RT, Sharp KW. Resection of benign duodenal neoplasms. Am Surg 2007; 73:1086.
  48. Shemesh E, Nass S, Czerniak A. Endoscopic sphincterotomy and endoscopic fulguration in the management of adenoma of the papilla of Vater. Surg Gynecol Obstet 1989; 169:445.
  49. Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993; 39:127.
  50. Lambert R, Ponchon T, Chavaillon A, Berger F. Laser treatment of tumors of the papilla of Vater. Endoscopy 1988; 20 Suppl 1:227.
  51. Talamini MA, Moesinger RC, Pitt HA, et al. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg 1997; 225:590.
  52. Allema JH, Reinders ME, van Gulik TM, et al. Results of pancreaticoduodenectomy for ampullary carcinoma and analysis of prognostic factors for survival. Surgery 1995; 117:247.
  53. Chareton B, Coiffic J, Landen S, et al. Diagnosis and therapy for ampullary tumors: 63 cases. World J Surg 1996; 20:707.
  54. Yamao T, Isomoto H, Kohno S, et al. Endoscopic snare papillectomy with biliary and pancreatic stent placement for tumors of the major duodenal papilla. Surg Endosc 2010; 24:119.
  55. Ito K, Fujita N, Noda Y, et al. Impact of technical modification of endoscopic papillectomy for ampullary neoplasm on the occurrence of complications. Dig Endosc 2012; 24:30.
  56. Yoon SM, Kim MH, Kim MJ, et al. Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy? Gastrointest Endosc 2007; 66:701.
  57. Desilets DJ, Dy RM, Ku PM, et al. Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications. Gastrointest Endosc 2001; 54:202.
  58. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004; 60:757.
  59. Hornick JR, Johnston FM, Simon PO, et al. A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes. Surgery 2011; 150:169.
  60. Jordan PH Jr, Ayala G, Rosenberg WR, Kinner BM. Treatment of ampullary villous adenomas that may harbor carcinoma. J Gastrointest Surg 2002; 6:770.
  61. Tran TC, Vitale GC. Ampullary tumors: endoscopic versus operative management. Surg Innov 2004; 11:255.
  62. Hirota WK, Zuckerman MJ, Adler DG, et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 2006; 63:570.
  63. Roberts RH, Krige JE, Bornman PC, Terblanche J. Pancreaticoduodenectomy of ampullary carcinoma. Am Surg 1999; 65:1043.
  64. Sperti C, Pasquali C, Piccoli A, et al. Radical resection for ampullary carcinoma: long-term results. Br J Surg 1994; 81:668.
  65. Gertsch P, Matthews JB, Lerut J, et al. The technique of papilloduodenectomy. Surg Gynecol Obstet 1990; 170:254.
  66. Beger HG, Staib L, Schoenberg MH. Ampullectomy for adenoma of the papilla and ampulla of Vater. Langenbecks Arch Surg 1998; 383:190.
  67. Ahn KS, Han HS, Yoon YS, et al. Laparoscopic transduodenal ampullectomy for benign ampullary tumors. J Laparoendosc Adv Surg Tech A 2010; 20:59.
  68. Clary BM, Tyler DS, Dematos P, et al. Local ampullary resection with careful intraoperative frozen section evaluation for presumed benign ampullary neoplasms. Surgery 2000; 127:628.
  69. Posner S, Colletti L, Knol J, et al. Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater. Surgery 2000; 128:694.
  70. Yamaguchi K, Enjoji M. Carcinoma of the ampulla of vater. A clinicopathologic study and pathologic staging of 109 cases of carcinoma and 5 cases of adenoma. Cancer 1987; 59:506.
  71. Takashima M, Ueki T, Nagai E, et al. Carcinoma of the ampulla of Vater associated with or without adenoma: a clinicopathologic analysis of 198 cases with reference to p53 and Ki-67 immunohistochemical expressions. Mod Pathol 2000; 13:1300.
  72. Ponchon T, Berger F, Chavaillon A, et al. Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater. Cancer 1989; 64:161.
  73. Norton ID, Gostout CJ, Baron TH, et al. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 2002; 56:239.
  74. Ceppa EP, Burbridge RA, Rialon KL, et al. Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg 2013; 257:315.
  75. Catalano MF, Linder JD, Chak A, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59:225.
  76. Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006; 63:292.
  77. Hopper AD, Bourke MJ, Williams SJ, Swan MP. Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos). Gastrointest Endosc 2010; 71:967.
  78. Martin JA, Haber GB. Ampullary adenoma: clinical manifestations, diagnosis, and treatment. Gastrointest Endosc Clin N Am 2003; 13:649.
  79. Bertoni G, Sassatelli R, Nigrisoli E, Bedogni G. Endoscopic snare papillectomy in patients with familial adenomatous polyposis and ampullary adenoma. Endoscopy 1997; 29:685.
  80. Norton ID, Geller A, Petersen BT, et al. Endoscopic surveillance and ablative therapy for periampullary adenomas. Am J Gastroenterol 2001; 96:101.
  81. Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005; 62:367.
  82. Singh P, Das A, Isenberg G, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc 2004; 60:544.
  83. Hwang JC, Kim JH, Lim SG, et al. Endoscopic resection of ampullary adenoma after a new insulated plastic pancreatic stent placement: a pilot study. J Gastroenterol Hepatol 2010; 25:1381.
  84. Bohnacker S, Seitz U, Nguyen D, et al. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc 2005; 62:551.
  85. Kim JH, Moon JH, Choi HJ, et al. Endoscopic snare papillectomy by using a balloon catheter for an unexposed ampullary adenoma with intraductal extension (with videos). Gastrointest Endosc 2009; 69:1404.
  86. Vogt M, Jakobs R, Benz C, et al. Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up. Dig Liver Dis 2000; 32:339.
  87. Charton JP, Deinert K, Schumacher B, Neuhaus H. Endoscopic resection for neoplastic diseases of the papilla of Vater. J Hepatobiliary Pancreat Surg 2004; 11:245.
  88. Patel R, Davitte J, Varadarajulu S, Wilcox CM. Endoscopic resection of ampullary adenomas: complications and outcomes. Dig Dis Sci 2011; 56:3235.
  89. Nguyen N, Shah JN, Binmoeller KF. Outcomes of endoscopic papillectomy in elderly patients with ampullary adenoma or early carcinoma. Endoscopy 2010; 42:975.
  90. Irani S, Arai A, Ayub K, et al. Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period. Gastrointest Endosc 2009; 70:923.
  91. Hoyuela C, Cugat E, Veloso E, Marco C. Treatment options for villous adenoma of the ampulla of Vater. HPB Surg 2000; 11:325.
  92. Huibregtse K, Tytgat GN. Carcinoma of the ampulla of Vater: the endoscopic approach. Endoscopy 1988; 20 Suppl 1:223.
  93. Seyrig JA, Liguory C, Meduri B, et al. [Endoscopy in tumors of the Oddi region. Diagnostic and therapeutic possibilities]. Gastroenterol Clin Biol 1985; 9:103.
  94. Huibregtse K, Tytgat GN. Palliative treatment of obstructive jaundice by transpapillary introduction of large bore bile duct endoprosthesis. Gut 1982; 23:371.
  95. Rösch W. Endoscopic sphincterotomy in carcinoma of the ampulla of Vater. Gastrointest Endosc 1982; 28:203.
  96. Vallon AG, Shorvon PJ, Cotton PB. Duodenoscopic sphincterotomy for tumours of the papilla of Vater (abstract). Gut 1982; 23:A456.
  97. Toussaint J, De Toeuf J, Dunham F, Cremer M. [Periampullary tumors: clinical study and results of palliative or preoperative treatment by endoscopic sphincterotomy (author's transl)]. Acta Gastroenterol Belg 1981; 44:250.
  98. Alderson D, Lavelle MI, Venables CW. Endoscopic sphincterotomy before pancreaticoduodenectomy for ampullary carcinoma. Br Med J (Clin Res Ed) 1981; 282:1109.