The Role of Endoscopy in Ampullary and Duodenal Adenomas
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GUIDELINE The role of endoscopy in ampullary and duodenal adenomas This is one of a series of statements discussing the use and mortality rates ranging from 1% to 9%,1,5-7 although of gastrointestinal endoscopy in common clinical situa- complication rates tend to be related to surgical case tions. The Standards of Practice Committee of the Amer- volume. ican Society for Gastrointestinal Endoscopy prepared this Endoscopic approaches for the evaluation and treat- text. In preparing this guideline, MEDLINE and PubMed ment of ampullary adenomas now represent a viable alter- databases were used to search publications through the native to surgical therapy. last 15 years related to ampullary and duodenal adeno- mas by using the keyword(s) ‘‘ampullary adenoma’’ and Evaluation of ampullary lesions before each of the following: ‘‘ampullectomy,’’ ‘‘duodenal endoscopic therapy adenoma,’’ and ‘‘familial adenomatous polyposis.’’ Ampullary adenomas cannot always be distinguished The search was supplemented by accessing the ‘‘related from ampullary carcinomas or nonadenomatous polyps articles’’ feature of PubMed with articles identified on (carcinoid tumors, gangliocytic paragangliomas, etc) on MEDLINE and PubMed as the references. Pertinent studies the basis of endoscopic appearance alone. Suspicious am- published in English were reviewed. Studies or reports pullary lesions should be biopsied before endoscopic re- that described fewer than 10 patients were excluded section is attempted. Brush cytology may offer additional from analysis if multiple series with greater than 10 information to biopsy for the detection of malignancy in patients addressing the same issue were available. selected cases.8 Recommendations were made on the basis of the re- There is no consensus on which ampullary adenomas viewed studies and were graded as to the strength of the should be kept under surveillance and which lesions ( ). supporting evidence Table 1 should be removed endoscopically or surgically. An inci- Guidelines for appropriate use of endoscopy are based dental, small ampullary adenoma may not require further on a critical review of the available data and expert con- evaluation or therapy, depending on the clinical context. sensus. Further controlled clinical studies may be needed Lesions with high-grade dysplasia often warrant therapy to clarify aspects of this statement, and revision may because they may harbor malignancy missed on biopsy be necessary as new data appear. Clinical considera- and to prevent progression to malignancy.9 tion may justify a course of action at variance to these Several authors have advocated that endoscopic re- . recommendations section should only be performed in patients without evidence of invasive cancer.10-12 Although endoscopic re- AMPULLARY ADENOMAS moval of ampullary adenocarcinoma has been described, it cannot be endorsed for routine management.13,14 The Adenomas of the major duodenal papilla, also known finding of high-grade dysplasia is not a contraindication as ampullary adenomas, can occur sporadically or in the to endoscopic removal, but it should prompt removal of context of genetic syndromes such as familial adenoma- the lesion by either endoscopic or surgical means rather tous polyposis (FAP). These lesions have the potential to than management by surveillance on the basis of health 15 undergo malignant transformation to ampullary cancer.1 status. Ampullary adenomas have historically been treated surgi- There are no definitive guidelines as to the size or cally. Surgical options include pancreaticoduodenectomy diameter above which endoscopic removal of ampullary (Whipple’s procedure) or transduodenal ampullectomy adenomas should not be attempted. Many authors recom- R (which can occasionally leave behind residual adenoma- mend that lesions 4 to 5 cm not be treated endoscopi- tous tissue).2-4 Surgical management often allows complete cally, although there are reports of successful endoscopic 10-12,16 removal but carries morbidity, including anastomotic dehis- resection of ampullary lesions of greater size. The cence and fistulae in 9% and 14% of patients, respectively, size of the lesion, however, can affect the endoscopic approach to resection, as discussed below. Endoscopic features such as firmness, ulceration, non- Copyright ª 2006 by the American Society for Gastrointestinal Endoscopy lifting with attempted submucosal injection to create 0016-5107/$32.00 a submucosal fluid cushion, and friability suggest possible doi:10.1016/j.gie.2006.08.044 malignancy and such lesions should be considered for www.giejournal.org Volume 64, No. 6 : 2006 GASTROINTESTINAL ENDOSCOPY 849 The role of endoscopy in ampullary and duodenal adenomas TABLE 1. Grades of recommendation* Grade of Methodologic strength recommendation Clarity of benefit of supporting evidence Implications 1A Clear Randomized trials without Strong recommendation; can be important limitations applied to most clinical settings 1B Clear Randomized trials with important Strong recommendation; likely to limitations (inconsistent results, apply to most practice settings nonfatal methodologic flaws) 1Cþ Clear Overwhelming evidence from Strong recommendation; can apply observational studies to most practice settings in most situations 1C Clear Observational studies Intermediate-strength recommendation; may change when stronger evidence is available 2A Unclear Randomized trials without Intermediate-strength important limitations recommendation; best action may differ depending on circumstances or patients’ or societal values 2B Unclear Randomized trials with important Weak recommendation; alternative limitations (inconsistent results, approaches may be better under nonfatal methodologic flaws) some circumstances 2C Unclear Observational studies Very weak recommendation; alternative approaches likely to be better under some circumstances 3 Unclear Expert opinion only Weak recommendation; likely to change as data become available *Adapted from Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action. Grading recommendationsda qualitative approach. In: Guyatt G, Rennie D, editors: Users’ guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608. surgical resection even in the absence of malignancy on curate imaging study with an accuracy superior to that of biopsy specimens.12 EUS.22 Role of endoscopic retrograde cholangiopancrea- There is disagreement as to whether all patients with tography and endoscopic ultrasound. ERCP and EUS ampullary adenomas should undergo EUS before therapy, provide useful information in the assessment of ampullary with some experts proposing that lesions less than 1 cm in adenomas. EUS and intraductal US (IDUS) have emerged diameter or those that do not have suspicious signs of ma- as useful techniques to assess the depth of involvement in lignancy (ulceration, induration, bleeding) do not require patients with ampullary neoplasms. These modalities al- ultrasonographic evaluation before endoscopic removal.23 low the assessment and extent of intraductal extension If available, EUS examination should be considered before and extension beyond the muscularis propria and can al- endoscopic or surgical resection is performed. low evaluation of periampullary lymph nodes in those pa- ERCP with both biliary and pancreatic duct evaluation tients suspected of having cancer. EUS or IDUS of lesions should be performed at the time of endoscopic resection that appear suspicious for harboring cancer may help to to assess for evidence of extension into either ductal sys- select which patients can be considered candidates for en- tem. Several authors have used evidence of intraductal doscopic versus surgical therapy and for guiding the surgi- extension as a criterion for surgical referral.24-26 Other in- cal therapy. EUS has been shown to be superior to CT, vestigators have shown that less than 1 cm of extension magnetic resonance imaging, or transabdominal ultraso- into the common bile duct or pancreatic duct does not nography for tumor staging.17-21 Magnetic resonance im- preclude endoscopic therapy because tissue invading to aging has been found to be superior to EUS for nodal this level may be endoscopically exposed and ablated.27,28 staging in this setting, whereas CT scans and positron emission tomographic scans can detect metastases not Endoscopic resection techniques seen on EUS or IDUS.19,20 One prospective study compar- Techniques of endoscopic removal of ampullary ade- ing EUS, IDUS, and CT scan favored IDUS as the most ac- nomas remain unstandardized, likely because of the 850 GASTROINTESTINAL ENDOSCOPY Volume 64, No. 6 : 2006 www.giejournal.org The role of endoscopy in ampullary and duodenal adenomas relatively small number of formal investigations into this reported using a combination of en bloc and piecemeal practice. Importantly, the term ‘‘ampullectomy’’ refers to resection techniques as the types of lesions treated were removal of the entire ampulla of Vater and is a surgical of mixed size and architecture.10,25,33,37-39 term for procedures that require surgical reimplantation Electrocautery settings. There is no consensus as to of the distal common bile duct and pancreatic duct within which type of current should be used during endoscopic the duodenal wall. Technically, when endoscopic resec- papillectomy. Both pure cutting current and blended cur- tions of lesions at the major papilla are performed, only rent have been used and neither has been proven to be tissue from the papilla can be removed endoscopically,