papillectomy for ampullary adenomas, an educational overview and case-based demonstration. The major papilla includes the border between two different types of mucosa, the intestinal mucosa of the duodenum and the mucosa of the ampulla of water. Ampullary adenomas are dysplastic, prevalent lesions that arise from the duodenal mucosa of the major papilla, and like colonic adenomas, they can progress in an adenoma to carcinoma sequence. They are the most common benign lesions of the ampulla and can occur sporadically or in the setting of a polyposis syndrome, such as FAP or NAP. Sporadic adenomas have a higher risk of malignant transformation than those associated with polyposis syndrome, and they are most commonly seen in patients of 50 to 70 years of age. The rate of malignant transformation has been quoted to be up to 30%. Endoscopic resection has become the primary modality of treatment in recent years, and the ESGE recommend ampullectomy for lesions less than 2 to 3 cm, with less than 2 cm of intraductal extension, and without high-risk features of invasion. It is necessary to obtain confirmatory biopsies prior to resection attempts. Careful patient selection with endoscopic surveillance for those with significant comorbidities and small asymptomatic adenomas under 1 cm is acceptable. Employing a side-viewing viadenoscope for lesion inspection and utilizing MRCP and EUS to assess intraductal extension is recommended. Strategic positioning of the snare in a cranio-caudal fashion facilitates on-block resection, and studies have not demonstrated a benefit of the injection-lift technique. Consensus on biliary and pancreatic sphincter RRV is lacking, however, it can aid in pancreatic stent placement. Employing a paralyzing agent and promptly retrieving excised lesion prevents specimen loss. The overall rate of complications has been reported to be between 15 to 35%, and prophylactic pancreatic stent placement has shown to reduce the risk of pancreatitis from 11 to 6%. We present a case of an asymptomatic 65-year-old female with elevated alkaline phosphatase levels. An MRCP revealed biliary and pancreatic ductal dilatation, and a subsequent EUS demonstrated an ampullary lesion with a 9 mm intraductal extension. A fine-needle biopsy demonstrated atypical cells, and the patient was scheduled for an ERCP for resection. A roughly 2 cm ampullary adenoma was observed, originating from the major duodenum papilla. In preparation for ampullectomy, the pancreatic duct was cannulated, followed by a pancreatic sphincterotomy. A 27 mm wide hexagonal snare was used to meticulously capture the adenoma in a top-down fashion, ensuring the lesion was entirely enclosed within the snare. Subsequently, a blended cut current was applied to achieve on-lock resection. An intraductal extension of the adenoma was observed, spontaneously expelling from the pancreatic duct. Additionally, during cannulation of the pancreatic duct, an adenoma within the bile duct was also noted to spontaneously emerge from the biliary orifice. Following cannulation, a balloon sweep of the pancreatic duct disclosed the entirety of the intraductal adenoma. This lesion was then resected using the snare. A 5 French by 3 cm plastic stent was then inserted into the pancreatic duct. The resected specimen was promptly retrieved using a Rothnet to prevent migration to the small bowel. Attention was then shifted to the bile duct, which was deeply cannulated using a standard sphincter tube over a wire. A very sphincterotomy was performed thereafter. And the distal common bile duct revealed a filling defect on cholangiogram. Balloon sweeps of the bile duct using a 9 mm balloon catheter also uncovered an intraductal portion of the adenoma. This too was resected using a hot snare. Subsequently, an 8.5 French by 7 cm plastic stent was placed in the common bile duct. To mitigate the risk of recurrence, the resected margins of the ductal orifices and the major duodenal papilla were ablated with soft coagulation using the snare tape. The patient did well post-procedure without any complications. Pathology demonstrated adenoma with high-grade dysplasia, and the patient was scheduled for repeat EUS and ERCP in 3 months' time as per the ESGE surveillance algorithm. On repeat ERCP, it was observed that the previously placed plastic stent had migrated out of the duct and was no longer present in the major papilla. The biliary stent remained in place and was removed using a snare. Narrowband imaging examination of the papilla did not reveal any signs of residual adenoma. Sludge was detected emerging from the bile duct during balloon sweeps, and neither biliary non-pancreatic balloon sweeps revealed any residual adenoma within the ducts. Consequently, a decision was made to perform pancreatic and biliary ductoscopy. Ductoscopy of the pancreatic duct revealed normal ductal epithelium with no evidence of adenomatous tissue. This was followed by biliary cholangioscopy, which similarly demonstrated normal ductal epithelium. An area of erythema in the common bile duct, potentially caused by local inflammation from the previously placed stent, was biopsied. Inclusion cholangiogram and pancreatogram did not reveal any filling defects. Additionally, biopsies of the mucosa surrounding the papilla were taken with cold forceps to confirm the complete eradication of the lesion. An endoscopic ultrasound was then performed to ensure the absence of residual intraductal extension of the adenoma. This examination confirmed that both the bile duct and the pancreatic duct were free of any lesions. Biopsies from the major papilla, common bile duct, and common hepatic duct showed no evidence of adenoma, and a follow-up EUS-ERCP is planned in six months for surveillance. Endoscopic ampulectomy effectively manages adenomas with limited intraductal growth and offers a less invasive alternative to surgery. Our innovative approach of margin ablation using snare-tip soft coag followed by surveillance ductoscopy has proven effective as evidenced by absence of adenoma on surveillance. The ESGE advocates for long-term monitoring starting at three months, then six months, and then yearly for five years in resected ampullary adenomas.

papillectomy

ampullary adenomas

endoscopic resection

prophylactic pancreatic stent

long-term monitoring