UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Ampullary adenomas: Management

Author
John A Martin, MD
Section Editor
John R Saltzman, MD, FACP, FACG, FASGE, AGAF
Deputy Editor
Shilpa Grover, MD, MPH, AGAF

INTRODUCTION

Adenomas are the most common benign lesions of the ampulla but have the potential to undergo malignant transformation to ampullary carcinomas [1-10]. Approximately 15 to 60 percent of ampullary adenomas harbor small foci of adenocarcinoma [7,11-15]. Ampullary adenomas can occur sporadically or in the setting of an adenomatous polyposis syndrome (eg, familial adenomatous polyposis and MUTYH-associated polyposis). This topic reviews the management of ampullary adenomas. The clinical manifestations and diagnosis of ampullary adenomas and the management of ampullary carcinoma are discussed separately. (See "Ampullary adenomas: Clinical manifestations and diagnosis" and "Ampullary carcinoma: Epidemiology, clinical manifestations, diagnosis and staging".)

MANAGEMENT

General approach — In the absence of randomized trials comparing different treatment strategies, recommendations for the management of ampullary adenomas are based on observational studies and clinical experience.

Sporadic ampullary adenoma – We excise all sporadic ampullary adenomas. Excision is particularly important in patients with adenomas that are causing symptoms or that have foci of high-grade dysplasia. In patients who do not undergo excision, we perform surveillance duodenoscopy (upper endoscopy using a side-viewing endoscope) every 6 to 12 months, performing multiple cold-forceps biopsies of the papilla of Vater.

Adenomatous polyposis syndrome – We also resect ampullary adenomas in patients with an adenomatous polyposis syndrome. The choice and timing of excision in patients with a familial polyposis syndrome should be individualized based on the patient's age and the number of concurrent duodenal adenomas, and is discussed in detail separately. (See "Familial adenomatous polyposis: Screening and management of patients and families", section on 'Duodenal polyps'.)

Selection of a treatment modality — The choice of treatment modality depends on the characteristics of the adenoma, the presence of concurrent duodenal polyposis, the presence of endoscopic expertise, and the willingness of the patient to undergo long-term endoscopic surveillance following endoscopic papillectomy or surgical ampullectomy [16]. The role of endoscopy in ampullary adenomas was reviewed in a guideline statement published by the American Society for Gastrointestinal Endoscopy in 2006 [16]. The following discussion is largely consistent with the guideline recommendations. (See 'Post-treatment follow-up' below.)

                  
To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Oct 10, 2017.
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 ©2017 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. 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.
  3. 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.
  4. Stolte M, Pscherer C. Adenoma-carcinoma sequence in the papilla of Vater. Scand J Gastroenterol 1996; 31:376.
  5. Asbun HJ, Rossi RL, Munson JL. Local resection for ampullary tumors. Is there a place for it? Arch Surg 1993; 128:515.
  6. 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.
  7. Yamaguchi K, Enjoji M. Adenoma of the ampulla of Vater: putative precancerous lesion. Gut 1991; 32:1558.
  8. Ryan DP, Schapiro RH, Warshaw AL. Villous tumors of the duodenum. Ann Surg 1986; 203:301.
  9. Kozuka S, Tsubone M, Yamaguchi A, Hachisuka K. Adenomatous residue in cancerous papilla of Vater. Gut 1981; 22:1031.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. 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.
  16. Standards of Practice Committee, Adler DG, Qureshi W, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc 2006; 64:849.
  17. Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc 1993; 39:127.
  18. 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.
  19. Cheng CL, Sherman S, Fogel EL, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc 2004; 60:757.
  20. 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.
  21. 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.
  22. Lambert R, Ponchon T, Chavaillon A, Berger F. Laser treatment of tumors of the papilla of Vater. Endoscopy 1988; 20 Suppl 1:227.
  23. 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.
  24. 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.
  25. Catalano MF, Linder JD, Chak A, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59:225.
  26. Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc 2006; 63:292.
  27. 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.
  28. 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.
  29. 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.
  30. 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.
  31. Martin JA, Haber GB. Ampullary adenoma: clinical manifestations, diagnosis, and treatment. Gastrointest Endosc Clin N Am 2003; 13:649.
  32. Bertoni G, Sassatelli R, Nigrisoli E, Bedogni G. Endoscopic snare papillectomy in patients with familial adenomatous polyposis and ampullary adenoma. Endoscopy 1997; 29:685.
  33. Norton ID, Geller A, Petersen BT, et al. Endoscopic surveillance and ablative therapy for periampullary adenomas. Am J Gastroenterol 2001; 96:101.
  34. 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.
  35. Rustagi T, Irani S, Reddy DN, et al. Radiofrequency ablation for intraductal extension of ampullary neoplasms. Gastrointest Endosc 2017; 86:170.
  36. Park SW, Song SY, Chung JB, et al. Endoscopic snare resection for tumors of the ampulla of Vater. Yonsei Med J 2000; 41:213.
  37. 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.
  38. 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.
  39. Patel R, Davitte J, Varadarajulu S, Wilcox CM. Endoscopic resection of ampullary adenomas: complications and outcomes. Dig Dis Sci 2011; 56:3235.
  40. Nguyen N, Shah JN, Binmoeller KF. Outcomes of endoscopic papillectomy in elderly patients with ampullary adenoma or early carcinoma. Endoscopy 2010; 42:975.
  41. 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.
  42. Hoyuela C, Cugat E, Veloso E, Marco C. Treatment options for villous adenoma of the ampulla of Vater. HPB Surg 2000; 11:325.
  43. Mendonça EQ, Bernardo WM, Moura EG, et al. Endoscopic versus surgical treatment of ampullary adenomas: a systematic review and meta-analysis. Clinics (Sao Paulo) 2016; 71:28.
  44. Galandiuk S, Hermann RE, Jagelman DG, et al. Villous tumors of the duodenum. Ann Surg 1988; 207:234.
  45. 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.
  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. Sand JA, Nordback IH. Transduodenal excision of benign adenoma of the papilla of Vater. Eur J Surg 1995; 161:269.
  48. Alstrup N, Burcharth F, Hauge C, Horn T. Transduodenal excision of tumours of the ampulla of Vater. Eur J Surg 1996; 162:961.
  49. Talamini MA, Moesinger RC, Pitt HA, et al. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg 1997; 225:590.
  50. 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.
  51. Chareton B, Coiffic J, Landen S, et al. Diagnosis and therapy for ampullary tumors: 63 cases. World J Surg 1996; 20:707.
  52. Jordan PH Jr, Ayala G, Rosenberg WR, Kinner BM. Treatment of ampullary villous adenomas that may harbor carcinoma. J Gastrointest Surg 2002; 6:770.
  53. Tran TC, Vitale GC. Ampullary tumors: endoscopic versus operative management. Surg Innov 2004; 11:255.
  54. 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.
  55. Roberts RH, Krige JE, Bornman PC, Terblanche J. Pancreaticoduodenectomy of ampullary carcinoma. Am Surg 1999; 65:1043.
  56. Sperti C, Pasquali C, Piccoli A, et al. Radical resection for ampullary carcinoma: long-term results. Br J Surg 1994; 81:668.
  57. 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.
  58. Branum GD, Pappas TN, Meyers WC. The management of tumors of the ampulla of Vater by local resection. Ann Surg 1996; 224:621.
  59. Gertsch P, Matthews JB, Lerut J, et al. The technique of papilloduodenectomy. Surg Gynecol Obstet 1990; 170:254.
  60. Beger HG, Staib L, Schoenberg MH. Ampullectomy for adenoma of the papilla and ampulla of Vater. Langenbecks Arch Surg 1998; 383:190.
  61. Ahn KS, Han HS, Yoon YS, et al. Laparoscopic transduodenal ampullectomy for benign ampullary tumors. J Laparoendosc Adv Surg Tech A 2010; 20:59.
  62. Huibregtse K, Tytgat GN. Carcinoma of the ampulla of Vater: the endoscopic approach. Endoscopy 1988; 20 Suppl 1:223.
  63. 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.
  64. Huibregtse K, Tytgat GN. Palliative treatment of obstructive jaundice by transpapillary introduction of large bore bile duct endoprosthesis. Gut 1982; 23:371.
  65. Rösch W. Endoscopic sphincterotomy in carcinoma of the ampulla of Vater. Gastrointest Endosc 1982; 28:203.
  66. Vallon AG, Shorvon PJ, Cotton PB. Duodenoscopic sphincterotomy for tumours of the papilla of Vater (abstract). Gut 1982; 23:A456.
  67. 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.
  68. Alderson D, Lavelle MI, Venables CW. Endoscopic sphincterotomy before pancreaticoduodenectomy for ampullary carcinoma. Br Med J (Clin Res Ed) 1981; 282:1109.
  69. Valente R, Urban O, Del Chiaro M, et al. ERCP-directed radiofrequency ablation of ampullary adenomas: a knife-sparing alternative in patients unfit for surgery. Endoscopy 2015; 47 Suppl 1 UCTN:E515.
  70. Mehendiratta V, Desilets DJ. Use of radiofrequency ablation probe for eradication of residual adenoma after ampullectomy. Gastrointest Endosc 2015; 81:1055.
  71. 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.
  72. Treitschke F, Beger HG. Local resection of benign periampullary tumors. Ann Oncol 1999; 10 Suppl 4:212.