Endoscopic Amphilectomy Perforation to Clip or Not to Clip, Primary Author Sandeep Lattakia Additional Authors Anirudh Pratap Singh, Pradev Inoulu, Azimuddin Haja and Mohan Ramchandani A 65-year-old male with no comorbidities was detected to have large ampullary lesion during endoscopic surveillance. He was referred for further evaluation and management. His Dotanoc PET scan was positive for uptake in the ampullary lesion with no distant spread. A linear echoendoscope with water installation into the second part of the duodenum was used to dilate the lesion. PD and CBD were found to be dilated and free from the tumor. Duodenoscope showed a large ampullary lesion in the second part of the duodenum. A polypectomy snare was used to encircle the lesion, keeping it en face with a stable scope position. Snare was then tightened and using the settings of EndoCutQ with effect 3, ampullectomy was completed and the specimen was retrieved using the same snare. Base of the ampullectomy showed a large mucosal defect with minimal oozing from the edges. It also showed a suspected large perforation at the base of the defect. Attempts to cannulate the pancreatic duct failed and guide wire repeatedly went into the common bile duct. On fluoroscopy there was no obvious extradural air and further probing of the large hole, guide wire went into the pancreatic duct which confirmed that this hole was not a perforation but was a large pancreatic duct near the ampulla. Pancreatic duct was stented using 5 French 7 centimeter single pitille stent. Retrieved specimen was around 3.5 x 2.5 x 1.6 cm. Histopathological examination of the ampullectomy specimen was positive for somatostatinoma. Follow-up showed scarred epithelium at the ampullectomy site with no recurrence at one year. Careful inspection of the ampullectomy site is important to manage associated complications. In our case the defect initially looked like perforation but turned out to be dilated pancreatic duct. Inadherent hemoclip placement would have led to adverse outcomes. To conclude, ampullectomy site should be carefully inspected for any evidence of bleeding and perforation. Dilated pancreatic duct or common bile duct can mimic small perforation at the base of the defect. Pre-identification can avoid inadherent clipping preventing atrogenic complications like pancreatitis. Do I have to type the whole thing? Hmm? I'll save it.

endoscopic amphilectomy

ampullary lesion

polypectomy snare

dilated pancreatic duct

somatostatinoma