Endoscopic papillectomy: Indications, techniques, and results

Endoscopic papillectomy(EP) is currently accepted as a viable alternative therapy to surgery in sporadic ampullary adenoma and has been reported to have high success and low recurrence rates. At present, the indications for EP are not yet fully established. The accepted criteria for EP include size(up to 5 cm), no evidence of intraductal growth, and no evidence of malignancy on endoscopic findings(ulceration, friability, and spontaneous bleeding). Endoscopic ultrasound(EUS) is the imaging modality of choice for local T staging in ampullary neoplasms. Data reported in the literature have revealed that linear EUS is superior to helical computed tomography in the preoperative assessment of tumor size, detection of regional nodal metastases and detection of major vascular invasion. Endoscopic ampullectomy is performed using a standard duodenoscope in a similar manner to snare polypectomy of a mucosal lesion. There is no standardization of the equipment or technique and broad EP methods are described. Endoscopic ampullectomy is considered a "high-risk’’ procedure due to complications. Complications of endoscopic papillectomy can be classified as early(pancreatitis, bleeding, perforation, and cholangitis) and late(papil-lary stenosis) complications. The appropriate use of stenting after ampullectomy may prevent post-procedural pancreatitis and papillary stenosis. Tumor recurrence of benign lesions occurs in up to 20% of patients and depends on tumor size, final histology, presence of intraductal tumor, coexisting familial adenomatous polyposis(FAP), and the expertise of the endoscopist. Recurrent lesions are usually benign and most can be retreated endoscopically.