Endoscopic Ampullectomy

  • Michael B. McCabe
  • Andrew Y. WangEmail author


Ampullary adenomas can occur sporadically or in the setting of hereditary syndromes and are believed to follow an adenoma-to-carcinoma sequence for malignant transformation. Ampullary lesions are being increasingly discovered at earlier stages and with a lower incidence of underlying malignancy. While traditionally managed with surgical resection, minimally invasive endoscopic ampullectomy—or more properly described as endoscopic papillectomy—has evolved into a viable alternative for resection in many cases of ampullary adenomas. This chapter examines the current thinking regarding the diagnosis, staging, and resection of ampullary adenomas, as well as the complications and outcomes associated with endoscopic papillectomy.


Ampulla Ampullary adenoma Papillary adenoma Ampullectomy Papillectomy Endoscopic retrograde cholangiopancreatography (ERCP) Endoscopic ultrasound (EUS) Endoscopic mucosal resection (EMR) Familial adenomatous polyposis (FAP) 



Dr. Wang has received research support from Cook Medical on the topic of covered metal biliary stents. Dr. McCabe has nothing to disclose.

Supplementary material

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  1. 1.
    Bohnacker S, Seitz U, Nguyen D, Thonke F, Seewald S, deWeerth A, et al. Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth. Gastrointest Endosc. 2005;62(4):551–60.PubMedCrossRefGoogle Scholar
  2. 2.
    Patel R, Varadarajulu S, Wilcox CM. Endoscopic ampullectomy: techniques and outcomes. J Clin Gastroenterol. 2012;46(1):8–15.PubMedCrossRefGoogle Scholar
  3. 3.
    Posner S, Colletti L, Knol J, Mulholland M, Eckhauser F. Safety and long-term efficacy of transduodenal excision for tumors of the ampulla of Vater. Surgery. 2000;128(4):694–701.PubMedCrossRefGoogle Scholar
  4. 4.
    Offerhaus GJ, Giardiello FM, Krush AJ, Booker SV, Tersmette AC, Kelley NC, et al. The risk of upper gastrointestinal cancer in familial adenomatous polyposis. Gastroenterology. 1992;102(6):1980–2.PubMedCrossRefGoogle Scholar
  5. 5.
    Lindor NM, Greene MH. The concise handbook of family cancer syndromes. Mayo Familial Cancer Program. J Natl Cancer Inst. 1998;90(14):1039–71.PubMedCrossRefGoogle Scholar
  6. 6.
    Spigelman AD, Talbot IC, Penna C, Nugent KP, Phillips RK, Costello C, et al. Evidence for adenoma-carcinoma sequence in the duodenum of patients with familial adenomatous polyposis. The Leeds Castle Polyposis Group (Upper Gastrointestinal Committee). J Clin Pathol. 1994;47(8):709–10.PubMedPubMedCentralCrossRefGoogle Scholar
  7. 7.
    Baczako K, Buchler M, Beger HG, Kirkpatrick CJ, Haferkamp O. Morphogenesis and possible precursor lesions of invasive carcinoma of the papilla of Vater: epithelial dysplasia and adenoma. Hum Pathol. 1985;16(3):305–10.PubMedCrossRefGoogle Scholar
  8. 8.
    Yamaguchi K, Enjoji M. Carcinoma of the ampulla of vater. A clinicopathologic study and pathologic staging of 109 cases of carcinoma and 5 cases of adenoma. Cancer. 1987;59(3):506–15.PubMedCrossRefGoogle Scholar
  9. 9.
    Takashima M, Ueki T, Nagai E, Yao T, Yamaguchi K, Tanaka M, et al. Carcinoma of the ampulla of Vater associated with or without adenoma: a clinicopathologic analysis of 198 cases with reference to p53 and Ki-67 immunohistochemical expressions. Mod Pathol. 2000;13(12):1300–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Culver EL, McIntyre AS. Sporadic duodenal polyps: classification, investigation, and management. Endoscopy. 2011;43(2):144–55.PubMedCrossRefGoogle Scholar
  11. 11.
    Irani S, Arai A, Ayub K, Biehl T, Brandabur JJ, Dorer R, et al. Papillectomy for ampullary neoplasm: results of a single referral center over a 10-year period. Gastrointest Endosc. 2009;70(5):923–32.PubMedCrossRefGoogle Scholar
  12. 12.
    Cahen DL, Fockens P, de Wit LT, Offerhaus GJ, Obertop H, Gouma DJ. Local resection or pancreaticoduodenectomy for villous adenoma of the ampulla of Vater diagnosed before operation. Br J Surg. 1997;84(7):948–51.PubMedCrossRefGoogle Scholar
  13. 13.
    Heidecke CD, Rosenberg R, Bauer M, Werner M, Weigert N, Ulm K, et al. Impact of grade of dysplasia in villous adenomas of Vater's papilla. World J Surg. 2002;26(6):709–14.PubMedCrossRefGoogle Scholar
  14. 14.
    Farnell MB, Sakorafas GH, Sarr MG, Rowland CM, Tsiotos GG, Farley DR, et al. Villous tumors of the duodenum: reappraisal of local vs. extended resection. J Gastrointest Surg. 2000;4(1):13–21.. discussion 2-3.PubMedCrossRefGoogle Scholar
  15. 15.
    Clary BM, Tyler DS, Dematos P, Gottfried M, Pappas TN. Local ampullary resection with careful intraoperative frozen section evaluation for presumed benign ampullary neoplasms. Surgery. 2000;127(6):628–33.PubMedCrossRefGoogle Scholar
  16. 16.
    Onkendi EO, Naik ND, Rosedahl JK, Harmsen SW, Gostout CJ, Baron TH Sr, et al. Adenomas of the ampulla of Vater: a comparison of outcomes of operative and endoscopic resections. J Gastrointest Surg. 2014;18(9):1588–96.PubMedCrossRefGoogle Scholar
  17. 17.
    Ceppa EP, Burbridge RA, Rialon KL, Omotosho PA, Emick D, Jowell PS, et al. Endoscopic versus surgical ampullectomy: an algorithm to treat disease of the ampulla of Vater. Ann Surg. 2013;257(2):315–22.PubMedCrossRefGoogle Scholar
  18. 18.
    De Palma GD. Endoscopic papillectomy: indications, techniques, and results. World J Gastroenterol. 2014;20(6):1537–43.PubMedPubMedCentralCrossRefGoogle Scholar
  19. 19.
    Chathadi KV, Khashab MA, Acosta RD, Chandrasekhara V, Eloubeidi MA, Faulx AL, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc. 2015;82(5):773–81.PubMedCrossRefGoogle Scholar
  20. 20.
    Beger HG, Staib L, Schoenberg MH. Ampullectomy for adenoma of the papilla and ampulla of Vater. Langenbeck's Arch Surg. 1998;383(2):190–3.CrossRefGoogle Scholar
  21. 21.
    Morales TG, Hixson LJ. Acute pancreatitis following endoscopic biopsy of the ampulla in a patient with Gardner's syndrome. Gastrointest Endosc. 1994;40(3):367–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Gincul R, Ciocirlan M, Dumortier J, Guerrier B, Comte JM, Faure A, et al. Severe acute pancreatitis following endoscopic biopsy of the minor duodenal papilla. Endoscopy. 2009;41(Suppl 2):E195–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Yamaguchi K, Enjoji M, Kitamura K. Endoscopic biopsy has limited accuracy in diagnosis of ampullary tumors. Gastrointest Endosc. 1990;36(6):588–92.PubMedCrossRefGoogle Scholar
  24. 24.
    Meneghetti AT, Safadi B, Stewart L, Way LW. Local resection of ampullary tumors. J Gastrointest Surg. 2005;9(9):1300–6.PubMedCrossRefGoogle Scholar
  25. 25.
    Schwarz M, Pauls S, Sokiranski R, Brambs HJ, Glasbrenner B, Adler G, et al. Is a preoperative multidiagnostic approach to predict surgical resectability of periampullary tumors still effective? Am J Surg. 2001;182(3):243–9.PubMedCrossRefGoogle Scholar
  26. 26.
    Elek G, Gyori S, Toth B, Pap A. Histological evaluation of preoperative biopsies from ampulla vateri. Pathol Oncol Res. 2003;9(1):32–41.PubMedCrossRefGoogle Scholar
  27. 27.
    Yamaguchi K, Enjoji M. Adenoma of the ampulla of Vater: putative precancerous lesion. Gut. 1991;32(12):1558–61.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Ryan DP, Schapiro RH, Warshaw AL. Villous tumors of the duodenum. Ann Surg. 1986;203(3):301–6.PubMedPubMedCentralCrossRefGoogle Scholar
  29. 29.
    Martin JA, Haber GB. Ampullary adenoma: clinical manifestations, diagnosis, and treatment. Gastrointest Endosc Clin N Am. 2003;13(4):649–69.PubMedCrossRefGoogle Scholar
  30. 30.
    Bourgeois N, Dunham F, Verhest A, Cremer M. Endoscopic biopsies of the papilla of Vater at the time of endoscopic sphincterotomy: difficulties in interpretation. Gastrointest Endosc. 1984;30(3):163–6.PubMedCrossRefGoogle Scholar
  31. 31.
    Menzel J, Hoepffner N, Sulkowski U, Reimer P, Heinecke A, Poremba C, et al. Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study. Gastrointest Endosc. 1999;49(3 Pt 1):349–57.PubMedCrossRefGoogle Scholar
  32. 32.
    Bohra AK, McKie L, Diamond T. Transduodenal excision of ampullary tumours. Ulster Med J. 2002;71(2):121–7.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Di Giorgio A, Alfieri S, Rotondi F, Prete F, Di Miceli D, Ridolfini MP, et al. Pancreatoduodenectomy for tumors of Vater's ampulla: report on 94 consecutive patients. World J Surg. 2005;29(4):513–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of benign adenomas of the papilla of Vater. Gastrointest Endosc. 1993;39(2):127–31.PubMedCrossRefGoogle Scholar
  35. 35.
    Cheng CL, Sherman S, Fogel EL, McHenry L, Watkins JL, Fukushima T, et al. Endoscopic snare papillectomy for tumors of the duodenal papillae. Gastrointest Endosc. 2004;60(5):757–64.PubMedCrossRefGoogle Scholar
  36. 36.
    Zadorova Z, Dvofak M, Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater. Endoscopy. 2001;33(4):345–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, Takasawa O, et al. Preoperative evaluation of ampullary neoplasm with EUS and transpapillary intraductal US: a prospective and histopathologically controlled study. Gastrointest Endosc. 2007;66(4):740–7.PubMedCrossRefGoogle Scholar
  38. 38.
    Yamashita Y, Ito K, Fujita N, Noda Y, Kobayashi G, Obana T, et al. A case of early carcinoma of the papilla of Vater confined to the mucosa and continuative epithelium of glands in Oddi's sphincter (m-God) treated by endoscopic papillectomy. Intern Med. 2010;49(22):2447–50.PubMedCrossRefGoogle Scholar
  39. 39.
    Ponchon T, Berger F, Chavaillon A, Bory R, Lambert R. Contribution of endoscopy to diagnosis and treatment of tumors of the ampulla of Vater. Cancer. 1989;64(1):161–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Spigelman AD, Williams CB, Talbot IC, Domizio P, Phillips RK. Upper gastrointestinal cancer in patients with familial adenomatous polyposis. Lancet. 1989;2(8666):783–5.PubMedCrossRefGoogle Scholar
  41. 41.
    Sato T, Konishi K, Kimura H, Maeda K, Yabushita K, Tsuji M, et al. Adenoma and tiny carcinoma in adenoma of the papilla of Vater--p53 and PCNA. Hepato-Gastroenterology. 1999;46(27):1959–62.PubMedGoogle Scholar
  42. 42.
    Griffioen G, Bus PJ, Vasen HF, Verspaget HW, Lamers CB. Extracolonic manifestations of familial adenomatous polyposis: desmoid tumours, and upper gastrointestinal adenomas and carcinomas. Scand J Gastroenterol Suppl. 1998;225:85–91.PubMedCrossRefGoogle Scholar
  43. 43.
    Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: the expanding role of endoscopy. World J Gastrointest Endosc. 2011;3(12):241–7.PubMedPubMedCentralCrossRefGoogle Scholar
  44. 44.
    Burke CA, Beck GJ, Church JM, van Stolk RU. The natural history of untreated duodenal and ampullary adenomas in patients with familial adenomatous polyposis followed in an endoscopic surveillance program. Gastrointest Endosc. 1999;49(3 Pt 1):358–64.PubMedCrossRefGoogle Scholar
  45. 45.
    Hirota WK, Zuckerman MJ, Adler DG, Davila RE, Egan J, Leighton JA, et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63(4):570–80.PubMedCrossRefGoogle Scholar
  46. 46.
    Baron TH, Kozarek RA, Carr-Locke DL. ERCP. Philadelphia, PA: Elsevier; 2019.Google Scholar
  47. 47.
    Latchford AR, Neale KF, Spigelman AD, Phillips RK, Clark SK. Features of duodenal cancer in patients with familial adenomatous polyposis. Clin Gastroenterol Hepatol. 2009;7(6):659–63.PubMedCrossRefGoogle Scholar
  48. 48.
    Chen CH, Yang CC, Yeh YH, Chou DA, Nien CK. Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI. J Clin Ultrasound. 2009;37(1):18–25.PubMedCrossRefGoogle Scholar
  49. 49.
    Chen CH, Tseng LJ, Yang CC, Yeh YH. Preoperative evaluation of periampullary tumors by endoscopic sonography, transabdominal sonography, and computed tomography. J Clin Ultrasound. 2001;29(6):313–21.PubMedCrossRefGoogle Scholar
  50. 50.
    Rivadeneira DE, Pochapin M, Grobmyer SR, Lieberman MD, Christos PJ, Jacobson I, et al. Comparison of linear array endoscopic ultrasound and helical computed tomography for the staging of periampullary malignancies. Ann Surg Oncol. 2003;10(8):890–7.PubMedCrossRefGoogle Scholar
  51. 51.
    Cannon ME, Carpenter SL, Elta GH, Nostrant TT, Kochman ML, Ginsberg GG, et al. EUS compared with CT, magnetic resonance imaging, and angiography and the influence of biliary stenting on staging accuracy of ampullary neoplasms. Gastrointest Endosc. 1999;50(1):27–33.PubMedCrossRefGoogle Scholar
  52. 52.
    Maluf-Filho F, Sakai P, Cunha JE, Garrido T, Rocha M, Machado MC, et al. Radial endoscopic ultrasound and spiral computed tomography in the diagnosis and staging of periampullary tumors. Pancreatology. 2004;4(2):122–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Baillie J. Endoscopic ampullectomy. Am J Gastroenterol. 2005;100(11):2379–81.PubMedCrossRefGoogle Scholar
  54. 54.
    Ridtitid W, Schmidt SE, Al-Haddad MA, LeBlanc J, DeWitt JM, McHenry L, et al. Performance characteristics of EUS for locoregional evaluation of ampullary lesions. Gastrointest Endosc. 2015;81(2):380–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Gaspar J, Shami VM. The role of EUS in ampullary lesions: is the answer black and white? Gastrointest Endosc. 2015;81(2):389–90.PubMedCrossRefGoogle Scholar
  56. 56.
    Gaspar JP, Stelow EB, Wang AY. Approach to the endoscopic resection of duodenal lesions. World J Gastroenterol. 2016;22(2):600–17.PubMedPubMedCentralCrossRefGoogle Scholar
  57. 57.
    Kim JH, Moon JH, Choi HJ, Lee HS, Kim HK, Cheon YK, et al. Endoscopic snare papillectomy by using a balloon catheter for an unexposed ampullary adenoma with intraductal extension (with videos). Gastrointest Endosc. 2009;69(7):1404–6.PubMedCrossRefGoogle Scholar
  58. 58.
    Kahaleh M, Shami VM, Brock A, Conaway MR, Yoshida C, Moskaluk CA, et al. Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia. Am J Gastroenterol. 2004;99(12):2335–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Eswaran SL, Sanders M, Bernadino KP, Ansari A, Lawrence C, Stefan A, et al. Success and complications of endoscopic removal of giant duodenal and ampullary polyps: a comparative series. Gastrointest Endosc. 2006;64(6):925–32.PubMedCrossRefGoogle Scholar
  60. 60.
    Norton ID, Gostout CJ, Baron TH, Geller A, Petersen BT, Wiersema MJ. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc. 2002;56(2):239–43.PubMedCrossRefGoogle Scholar
  61. 61.
    Pandolfi M, Martino M, Gabbrielli A. Endoscopic treatment of ampullary adenomas. JOP. 2008;9(1):1–8.PubMedGoogle Scholar
  62. 62.
    Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc. 2005;62(3):367–70.PubMedCrossRefGoogle Scholar
  63. 63.
    Bassan M, Bourke M. Endoscopic ampullectomy: a practical guide. J Interv Gastroenterol. 2012;2(1):23–30.PubMedPubMedCentralCrossRefGoogle Scholar
  64. 64.
    Catalano MF, Linder JD, Chak A, Sivak MV Jr, Raijman I, Geenen JE, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc. 2004;59(2):225–32.PubMedCrossRefGoogle Scholar
  65. 65.
    Norton ID, Geller A, Petersen BT, Sorbi D, Gostout CJ. Endoscopic surveillance and ablative therapy for periampullary adenomas. Am J Gastroenterol. 2001;96(1):101–6.PubMedCrossRefGoogle Scholar
  66. 66.
    Saurin JC, Chavaillon A, Napoleon B, Descos F, Bory R, Berger F, et al. Long-term follow-up of patients with endoscopic treatment of sporadic adenomas of the papilla of vater. Endoscopy. 2003;35(5):402–6.PubMedCrossRefGoogle Scholar
  67. 67.
    Lienert A, Bagshaw PF. Treatment of duodenal adenomas with endoscopic argon plasma coagulation. ANZ J Surg. 2007;77(5):371–3.PubMedCrossRefGoogle Scholar
  68. 68.
    Vogt M, Jakobs R, Benz C, Arnold JC, Adamek HE, Riemann JF. Endoscopic therapy of adenomas of the papilla of Vater. A retrospective analysis with long-term follow-up. Dig Liver Dis. 2000;32(4):339–45.PubMedCrossRefGoogle Scholar
  69. 69.
    Desilets DJ, Dy RM, Ku PM, Hanson BL, Elton E, Mattia A, et al. Endoscopic management of tumors of the major duodenal papilla: refined techniques to improve outcome and avoid complications. Gastrointest Endosc. 2001;54(2):202–8.PubMedCrossRefGoogle Scholar
  70. 70.
    Poincloux L, Scanzi J, Goutte M, Pereira B, Devaud H, Joubert J, et al. Pancreatic intubation facilitated by methylene blue injection decreases the risk for postpapillectomy acute pancreatitis. Eur J Gastroenterol Hepatol. 2014;26(9):990–5.PubMedCrossRefGoogle Scholar
  71. 71.
    Singh P, Das A, Isenberg G, Wong RC, Sivak MV Jr, Agrawal D, et al. Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials. Gastrointest Endosc. 2004;60(4):544–50.PubMedCrossRefGoogle Scholar
  72. 72.
    Fazel A, Quadri A, Catalano MF, Meyerson SM, Geenen JE. Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study. Gastrointest Endosc. 2003;57(3):291–4.PubMedCrossRefGoogle Scholar
  73. 73.
    Freeman ML. Role of pancreatic stents in prevention of post-ERCP pancreatitis. JOP. 2004;5(5):322–7.PubMedGoogle Scholar
  74. 74.
    Baillie J. Endoscopic ampullectomy: does pancreatic stent placement make it safer? Gastrointest Endosc. 2005;62(3):371–3.PubMedCrossRefGoogle Scholar
  75. 75.
    Chang WI, Min YW, Yun HS, Lee KH, Lee JK, Lee KT, et al. Prophylactic pancreatic stent placement for endoscopic duodenal ampullectomy: a single-center retrospective study. Gut Liver. 2014;8(3):306–12.PubMedCrossRefGoogle Scholar
  76. 76.
    Elmunzer BJ, Scheiman JM, Lehman GA, Chak A, Mosler P, Higgins PD, et al. A randomized trial of rectal indomethacin to prevent post-ERCP pancreatitis. N Engl J Med. 2012;366(15):1414–22.PubMedPubMedCentralCrossRefGoogle Scholar
  77. 77.
    Han J, Kim MH. Endoscopic papillectomy for adenomas of the major duodenal papilla (with video). Gastrointest Endosc. 2006;63(2):292–301.PubMedCrossRefGoogle Scholar

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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Division of Gastroenterology and HepatologyUniversity of Virginia Health SystemCharlottesvilleUSA

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