endoscopic somnucosal dissection for ampullary pyloric gland adenoma. These are our disclosures. Ampullary adenomas have malignant potential and resection should be conceded. Endoscopic papillotomy has gained popularity over surgery due to its lower pre-procedural risk. Conventional endoscopic papillotomy carries risk of incomplete resection with local recurrence rate up to 33%. Endoscopic somnucosal dissection for superficial non-ampullary duodenal epithelial tumors had been proven to be safe with high curative resection rate and it can be applied to ampullary lesions as well. Here we present a case of successful and block resection of ampullary adenoma by means of endoscopic somnucosal dissection. A 48-year-old lady with history of hemidectomy complained of chronic epigastric discomfort. Upper gear endoscopy found prominent papilla and biopsy confirmed adenoma of low-grade dysplasia. She was then referred to us for further management. Endoscopy was repeated in our center which showed 2cm pale sex-out lesion at papilla and magnified MBI reveals the presence of regular white opaque substance over the entire lesion. Features are compatible with biopsy-proven adenoma. U.S. showed no introductory extension therefore endoscopic resection was decided after discussion with patient. A therapeutic upper GI endoscope with a transparent hood was used. We begin with somnucosal injection with mixture of saline and deco-carmine. Mucosal injection was first started at distal part of the lesion with a water-jet needle-type endoscoping knife. This defined a distal resection margin. We then move back to the proximal part of the lesion and again somnucosal is raised with saline injection. Mucosal injection is made using the same endoscopic knife. A clearance of mucosal pain can be observed after trimming of the mucosa. The mucosal injection is extended on both sides of the lesion. Until circumferential incision is completed. Repeated somnucosal injection is made with the water-jet endo knife to avoid muscle injury. We change to tapered transparent hood during somnucosal dissection to enhance operative feel. Somnucosal dissection is performed bit by bit. Here you can see the biliary pancreatic orifice and it is dissected free from the lesion. Here endoscopic dissection was completed and end block resection was achieved. After retrieving the specimen, scope was reintroduced to look for any muscle injury. In this case, the muscle layer was intact. We then perform hemostasis to visible vessels using monopolar hemostatic forceps. The mucosal defect is partially caused with endoclips. Clips were applied on both sides of the defect, and attention is made not to compromise the billowy pancreatic orifice. After that, we switch to a side-view duodenoscope for pancreatic stenting. The pancreatic duct is cannulated using wire-guide sphinctrotome. The guide wire was advanced, but some resists denoted. Contrast injection confirmed pancreatic duct. Using angled guide wire, we are able to negotiate the acute turn of pancreatic duct and direct the guide wire to the pancreatic tail. A 7-inch, 5cm, single-pigtail pancreatic stent was chosen, and it was inserted under fluoroscopic guidance. The procedure was completed. Rectal endomephasin was administered to patient as well to reduce risk of pancreatitis. Patient resumed the diet on day two after ESD. She complained of mild epigastric discomfort, but serum amylase level was normal. No other complication was identified and she was discharged on post-op day five. To our surprise, the final pathology was pyloric gland adenoma. It is based on dilated glands which was shown on dissections and are positive for MUC6 immunostain. Resection margins were clear. And block resection of ampullary adenoma by means of endoscopic submucosal dissection is technically feasible and safe. ESD can be applied to large size lesion or laterally spreading adenoma with extra papillary extension. And it has the potential advantage of higher complete resection rate. Sporadic pyloric gland adenoma at duodenum major papilla is extremely rare. The endoscopic appearance remains elusive and can mimic as the usual tubervillous adenoma. In conclusion, end block resection of ampullary adenoma could be achieved with ESD in a safe manner. And ESD should be considered as a viable alternative to the conventional endoscopic papillotomy.

endoscopic submucosal dissection

ampullary pyloric gland adenoma

malignant risk

conventional endoscopic papillotomy

block resection