We're going to talk about the basics of ampulectomy and restriction strategies for approximately the next 10 minutes or so. So ampullary adenomas are benign neoplasms with an overall prevalence of approximately 0.1%, with a two to threefold increase in patients with FAP. These lesions have a high potential for malignant transformation and removal is recommended in many cases. Current therapeutic options exist are surgical, including a Whipple procedure or local surgical excision or endoscopic ampullectomy. So our patient today is a 64-year-old female with FAP. She underwent a remote total proctocolectomy with endileostomy and desmoid removal approximately 40 years prior. On a recent surveillance upper endoscopy, it was found to have an 18-millimeter ampullary adenoma with biopsies revealing a tubulovillous lesion with low-grade dysplasia. No biochemical evidence of biliary obstruction, thus the patient was referred for additional endoscopic evaluation, potential endoscopic resection. So from my perspective, I think I tend to get the most done with a checklist. My work life and my personal life are no different, actually. So I like to use a checklist for patients who are being considered for ampullectomy. I think first and foremost, it's absolutely imperative that the presence of adenomatous tissue is confirmed by an expert GI pathologist. Ideally, at our institution, we like to have the tissue brought in if it's a referral from outside and evaluated prior to embarking on ampullectomy. The second thing I ask myself, is ampullectomy the best option for the patient? In certain cases, it's a very large lesion, significant lateral extension, surgical intervention may be a better option. On the other end of the spectrum, a patient with a really small adenoma, perhaps surveillance is the right way to go. So it's important to keep that into consideration before embarking on an endoscopic ampullectomy. Now, if I believe that's the right thing to do, the next step in my algorithm is to perform EUS prior to resection, generally in the same session, but definitely it's necessary to do an EUS to assess for the presence of ductal extension, either in the pancreas or the bile duct. Again, if under EUS, I see no introductal extension, I then perform a biliary cannulation clangiogram followed by pancreatic cannulation, pancreatogram before the actual ampullectomy. So in this particular case, on endoscopy, we see roughly two centimeter lesion. When I looked at this lesion, I didn't see anything ultra high risk or concerning that made me not want to proceed. So at this point, I'm still in the game in terms of endoscopic ampullectomy options. Next we perform EUS. On EUS here, you can see the lesion immediately deep to the probe. With a little bit of rotation, you're able to see first the bile duct, and then subsequently the pancreatic duct, neither of which have any evidence of introductal extension from my view. Is there anybody on the panel who would not go forward at this point? No, I think everything you're showing says that you can proceed. You could argue that if you have an adenoma that's less than a centimeter, maybe you don't need the EUS because it would be unlikely to have introductal involvement. So I agree. So again, we're going to continue to move forward. So we go forward with ERCP, first cannulating the bile duct, standard wire guided cannulation, angiogram to identify the distal bile duct, we'll see here shortly. There's nothing I can tell you as we do this, there's nothing I see on the bile duct that would change my mind either. Generally, I think there's probably a variety of approaches. I know people who will just get a double wire cannulation, take a picture of where the wires are fluoroscopically. I like to inject both ducts. After I access the bile duct, I tend to access the pancreatic duct as much as possible. In this particular case, we actually weren't able to access the pancreatic duct. I use a combination of full strength contrast and methylene blue in the pancreatic duct. So following polyprosection, anecdotally, I think it makes it easier to identify the pancreatic orifice, which is of significant importance. Now, in the context of not being able to cannulate the pancreatic duct ahead of time, is there anybody on the panel who would stop at this point and look for an alternative solution? Well, I don't really see it as necessary to get into the ducts beforehand. What I would routinely do is an MRCP, I have a good map, you've got an EUS, there may be no stones in the duct. I think it is helpful if it's easy, like, you know, you're going to that bile duct easily. It's nice to see because you may see a little bit of polypoid extension into a dilated duct that you didn't pick up on your EUS, it's possible. But I think that the downside of persisting with trying to get into the pancreas is that you may increase your risk of pancreatitis. If you have an MRCP beforehand that you're not worried about anything in particular, then I wouldn't try to get into the PD. Real quick for the panel, yes, no answers. How many would do as biliary sphincterotomy? No. No. See, I always do one. And then how many always inject the PD beforehand? I do. I do. And I also leave a wire in the PD and snare over it. So you maintain access. But again, just to show you, everyone on this panel has their own kind of preferred techniques. I think that's a bit also what has been said this morning. Everybody has his or her own preference and stick to it unless there's really a big change that you should try to learn. Otherwise, just keep your own algorithm. So we decided to go forward with ampulectomy. I tend to use a 20 millimeter spiral snare. I like to embed the snare tip at the proximal aspect of the polyploid lesion, work right to left to ensnare the entire lesion. Then I like to go back left to right and try and make sure I'm underneath the entirety of the lesion prior to snare closure. As I close the snare, it's also important to make sure that you advance your catheter to ensure that you don't leave any tissue on the inferior aspect. Cautery with endocuts applied and the tissues resected, you can see in 12 o'clock position is the bile duct. It does look as if there is some periampulary tissue that remains, and we'll get to that. One tip just for the snare, it helps to just shape it a little before you pass it down through the ERCP scope, because it may not open fully with the elevator. Good thought. Dr. Kumta? I think in these scenarios, also using a soft snare is particularly helpful and technique-wise, anchoring that snare tip at the apex and very gently controlled expansion of the snare as you move sort of more distally down to make sure you have good entrapment of the tissue within the snare itself. Thank you. Again, I go back to my checklist mentality here. Following ampulectomy, I think the single biggest thing is make sure you capture the resected tissue. That's always a little bit of a stressful couple of minutes to make sure that you capture the polyp. All of us have stories of a two-centimeter adenoma cannonball that rolls down to the fourth duodenum, and you have to use a pediatric colonoscope to get it out. I think that's foremost importance. Secondly, assess for any evidence of perforation at the defect. There's no evidence of perforation or nothing that needs to be immediately addressed. The next pressing issue is to access and stent the pancreatic duct, followed by accessing and stenting the common bile duct. After that, I look to see if there's any periampulary adenoma that requires resection. It's incredibly important at the completion of your procedure to ensure that there's no bleeding. There's a significant risk of post-procedure bleeding in patients who undergo this procedure. As much as you can stack the deck in your favor at the completion of your procedure is beneficial. It's also important to give rectal nonsteroidals. That would be in the setting of a patient who doesn't have a contraindication. This particular patient does. She doesn't have a rectum. We gave her high-volume lactated ringers in addition to having the pancreatic stent placed. So post-ampulectomy, here you can see grasping the resected tissue with the snare that we just used for resection. This is then retrieved from the mouth and then sent to pathology for formal evaluation. We then turn our attention to the pancreatic duct. In this particular case, it wasn't that difficult post-resection to access the pancreatic duct. Ultimately we were able to get a guide wire out to the tail of the pancreas and subsequently place a pancreatic duct stent. In this case, I think this is an 8 1⁄2 French by 12 centimeter wedge stent. Choice of stent is really, I think, up to the endoscopist. I think the importance is to make sure that it's not a short stent with no internal flanges that's going to fall out rapidly. After addressing the pancreatic duct, bile duct is then cannulated and similarly a biliary stent is placed. In this case, a 10 French by 5 centimeter stent. After stent placement is then the time where you can go and resect any remaining tissue. I like to do it in this order because this way I know that both ductal orifices are protected. I can also work off them with a snare. In this case, this is a dedicated 10 millimeter cold snare to remove adjacent tissue to complete the procedure. This was the final look at the completion of our index procedure. All right. Thank you very much. We'll go on to our next case. Just one question for the panel then. How many stent the bile duct every time? No. I don't because I do a sphincterotomy. So I was also a bit curious about what's the reason behind to do it. Would that be the main reason to overcome a stricture or to put a stent in the bile duct? Yeah, for me to prevent stricture. I think ampulectomy is such a procedure between just like six or seven panelists. Everybody's doing it a little differently. And I think that just goes to say, you take all the techniques and you work to what works for you and the patient. Was that final pathology malignancy? I saw something pop up. Yeah. Final pathology was intramucosal cancer with TVA and high and low grade dysplasia. So I think that's also very important to note that sometimes just the biopsies alone are not going to be necessarily diagnostic what the final pathology is. And that's where also using MRI, MRCP or EUS, you can also look for any invasive components or nodes that may tip you off that this is a potential malignancy as well. Okay. Last question. When are you bringing, what are you going to do for follow-up? Patient came back about two months later. Actually that patient got pancreatitis, which unfortunately a good portion of them do. But she came back at two months with no evidence of residual adenoma and plan for yearly surveillance. She also had additional downstream large adenomas, which we resected on subsequent procedures as well.

ampullectomy

ampullary adenomas

endoscopic evaluation

EUS

post-procedure care