Papillectomy and Ampullectomy

Abstract Ampullary neoplasms (benign and malignant) are rare, with a reported prevalence of less than 0.1% in autopsy series. Other etiologies such as papillitis, gastric foveolar metaplasia, and pancreatic acinar hyperplasia can also lead to enlarged or abnormal papillae. Ampullary tumors can arise from epithelium (e.g., adenomas, adenocarcinomas, lymphomas) or the subepithelium (e.g., neuroendocrine tumors, lipomas). The incidence of ampullary adenomas is increased two- to threefold in genetic polyposis syndromes. 4 Early lesions are often asymptomatic, while larger lesions can cause obstruction, presenting with cholestasis, cholangitis, and pancreatitis. Although some authors perform endoscopic ultrasound (EUS) on all lesions, many perform EUS only for worrisome features such as weight loss, jaundice, and lesions larger than 2 cm. After performing pancreatography and cholangiography, snare excision is performed, ideally without saline injection and en bloc, if feasible. Preresection sphincterotomy and stent placement are not routinely performed, while postresection sphincterotomy is usually performed unless there is a concern it might lead to perforation. Postresection pancreatic stenting is recommended due to the high risk of post-ERCP pancreatitis, but biliary stenting is performed based on perceived poor biliary drainage after the papillectomy. The most common adverse events of papillectomy include pancreatitis and bleeding. Postpapillectomy surveillance should be performed 3 months following resection, and once confirmed to be completely removed, continued surveillance should be considered as frequently as every 6 months for the subsequent 2 years. Complete tumor eradication rates of 80% or more are reported in larger series. Surgery is usually recommended for treatment of operative patients who have lesions that harbor invasive cancer.