ASGE Postgraduate Course at ACG 2022: Expanding the Scope of Fundamental and Advanced Endoscopy (On-Demand)

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This document discusses the evaluation and resection of ampullary lesions. It highlights that ampullary adenomas have a low prevalence but are associated with a significant increase in polyposis syndrome. The use of a side-viewing scope is recommended for examination, but there may be limitations due to lack of comfort or training. The document also suggests that cap-assisted endoscopy has a higher success rate in evaluating the major papilla compared to standard endoscopy. <br /><br />In terms of resection, a case example is provided where an endoscopic papillectomy was performed for a patient with a duodenal mass. The pathology revealed gangliocytic paraganglioma, and a complete resection was achieved. <br /><br />The document emphasizes several key points. It advises resecting only biopsy-proven lesions and raises the question of whether all ampullary adenomas require resection, particularly in cases of familial adenomatous polyposis. Pre-resection imaging with magnetic resonance cholangiopancreatography and endoscopic ultrasound is recommended, especially for lesions larger than 2 cm, cholestasis, or jaundice. Other recommendations include not using submucosal injection, cannulating the pancreatic duct before resection, using a thin wire snare for resection, and employing the EndoCut Q technique. Specimen retrieval, re-cannulation of the pancreatic duct, and pancreatic duct stenting are also highlighted. The document suggests that decisions on biliary stenting and sphincterotomy should be based on the presence of concomitant stones or suboptimal drainage. <br /><br />Regarding surgical evaluation, the document states that ingrowth into the pancreatic duct or common bile duct of more than 1 cm should prompt consideration for surgical intervention. The use of clipping at the distal margin after stent placement is mentioned as a potential protective measure against delayed bleeding, although the statistical significance of this effect is not mentioned. <br /><br />Overall, the document provides a summary of considerations and recommendations for the evaluation and resection of ampullary lesions.

Keywords

evaluation

resection

ampullary lesions

ampullary adenomas

polyposis syndrome

side-viewing scope

cap-assisted endoscopy

endoscopic papillectomy

gangliocytic paraganglioma

familial adenomatous polyposis