Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period

Background

Tumors arising from the duodenal papilla account for approximately 5% of GI neoplasms, but are increasingly identified.

Objective

To describe the clinical characteristics and outcomes in a large single-center experience with patients referred for ampullary lesions.

Design

A retrospective review of the Virginia Mason Medical Center endoscopy and hospital service database.

Setting

Tertiary referral center.

Patients

One hundred ninety-three patients referred for ampullary lesions from 1997 to 2007.

Interventions

Endoscopic management of ampullary lesions.

Main Outcome Measurements

The relationship of demographic and clinical data with endoscopic treatment and clinical outcomes in these patients.

Results

One hundred ninety-three patients underwent endoscopy for ampullary lesions. Fifteen juxta-ampullary lesions and 10 normal variants were excluded. Among 168 patients, there were 112 (67%) adenomas, 38 (23%) adenocarcinomas, and 18 (10%) nonadenomatous lesions. There were 88 men and 80 women, with a mean age of 64 years. Clinical presentation included cholestasis/cholangitis (72 patients), abdominal pain (54 patients), incidental/asymptomatic (51 patients), pancreatitis (9 patients), and bleeding (7 patients). Of the 57 patients referred to surgery, 42 were sent directly without papillectomy, and 16 were sent after papillectomy. Papillectomies were performed in 102 patients with adenomatous lesions. The mean tumor size was 2.4 cm (range 0.5-6 cm). The papillectomy complication rate was 21%: mild pancreatitis in 10 (10%) patients, cholangitis in 1, retroperitoneal perforation in 1 (adenocarcinoma), intraperitoneal perforation in 1 (lateral extension), bleeding in 5 (lateral extension in 2 of these 5), and delayed papillary stenosis in 3. Recurrences were seen in 8%. The endoscopic success rate was 84%. Factors affecting success were a smaller adenoma size and the absence of dilated ducts.

Conclusions

Most ampullary adenomas are amenable to endoscopy. Underlying malignancy and lateral extension may be risk factors for bleeding and perforation. Smaller lesion size and the absence of dilated ducts are factors favorably affecting success.

Abbreviations: APC, argon plasma coagulation, FAP, familial adenomatous polyposis