Ampullary and periampullary adenomas

Benign neoplasms of the ampulla of Vater and periampullary region are uncommon. They are mostly villous and tubulo-villous adenomas arising from the ampullary epithelium or from the duodenal mucosa. Adenomas have the potential to undergo malignant transformation to carcinomas, similar to the adenoma-to-carcinoma sequence that occurs elsewhere in the gastrointestinal tract.

Symptoms are caused by the obstruction of the ampullary outflow, that results in jaundice and may predispose to acute pancreatitis. Duodenal obstruction is less common.

Despite uncommon, ampullary and periampullary adenomas are being increasingly recognized with the extensive availability of upper endoscopy and endoscopic ultrasound, as well as because of the widespread application of screening and surveillance programs for high-risk patients. Ampullary adenomas occur sporadically and in the setting of familial polyposis syndromes, such as familial adenomatous polyposis (FAP). Almost all FAP patients will develop ampullary adenomas and duodenal adenomatous polyps, which are frequently numerous and also have malignant potential.

Indications for excision of an ampullary adenoma include treatment of immediate symptoms as well as prevention of malignant degeneration. Periampullary duodenal polyps can be excised endoscopically, similarly to colonic polyps.   

Ampullary polyps may treated by local endoscopic excision (endoscopic ampullectomy). This procedure is less invasive than pancreaticoduodenectomy, possesses the advantages of lower morbidity (0%-25%), essentially nil mortality, and possibly decreased length of hospital stay, but decidedly higher recurrence rates (generally 5%-30%) and the need for postoperative endoscopic surveillance. Ampullectomy can be performed in benign polyps and in lesions with high grade dysplasia/carcinoma in situ. Because it has been shown that small ampullary carcinomas that grow outside the ampullary mucosa may invade regional lymph nodes, local excision may not be oncologically adequate. In such cases, pancreaticoduodenectomy should be the treatment of choice.  







Although pancreaticoduodenectomy has long been considered the standard procedure for ampullary carcinoma, much controversy exists regarding the procedure of choice for ampullary adenoma. Radical surgery (pancreaticoduodenectomy) possesses the advantage of low recurrence rate but at the expense of higher morbidity (25%-65%) and mortality (0%-10%).


 Snare ampullectomy is a newer endoscopic excisional technique for which limited data are available; advantages compared with radical surgery mirror those of local surgical excision, with apparent lower mortality (0%-1%) and lower morbidity (12%). Presumed advantages compared with local surgical excision include lack of necessity for general anesthesia and laparotomy with comparable morbidity. Disadvantages seem to include limited availability of experienced operators, procedural complexity sometimes requiring adjunctive modalities such as fulguration, the need for multiple procedures (mean, 2.0 procedures) to effect complete excision, and recurrence rates approaching 30%, with a requirement for continued endoscopic surveillance. Ultimately, choice is driven by availability of local expertise, patient tolerance of or expected compliance with long-term endoscopic surveillance programs, presence or absence of coexisting familial polyposis syndromes, medical comorbidities, and overall life expectancy.