We describe the case of a 63-year-old patient with end-stage renal disease who underwent
endoscopic ampullectomy of a large ampullary adenoma.
A side-viewing duodenoscope was utilized to evaluate the mass. A large frond-like
villous mass, 40 mm in diameter, was seen at the major papilla ([Fig. 1]). The mass was resected using a dedicated thin-wire braided snare (cold snare) in
a piecemeal fashion, and retrieved with a retrieval net ([Video 1]). The snare deformed with repeated use and a total of four snares were required
to complete the procedure.
Fig. 1 Ampullary adenoma.
Video 1 Cold snare piecemeal resection of a large ampullary adenoma.
Following resection, the ventral pancreatic duct was deeply cannulated with a short-nosed
traction sphincterotome and guidewire. There was no extension of the polyp into the
pancreatic duct, and a temporary plastic stent was placed ([Fig. 2]). The patient tolerated the procedure without immediate complications. Pathology
from the specimen revealed adenoma with high-grade dysplasia.
Fig. 2 Ampullary mass following cold resection and stent placement.
Endoscopic ampullectomy is a safe and successful alternative to surgery for removal
of selected ampullary adenomas. Recent studies have suggested that ampullary adenomas
may be endoscopically removed either piecemeal or en bloc using electrocautery [1]. A recent study in Japan evaluated 136 patients with laterally spreading ampullary
adenomas [2]. A single treatment session was possible in 104 (83.2 %) of the 125 patients in
the en bloc resection group and in 8 (72.7 %) of the 11 in the piecemeal resection
group. The total resection rate including additional treatments was 98.4 % in the
en bloc group and 100 % in the piecemeal group. This suggests that piecemeal resection
using electrocautery is comparable to en bloc resection.
Cold snare resection of colonic polyps is gaining acceptance and there are reports
of cold snare removal of large polyps [3]. To our knowledge this is the first case to date of successful cold snare ampullectomy
in a patient at high risk for post-procedural bleeding.
Endoscopy_UCTN_Code_TTT_1AR_2AK
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
website at
https://mc.manuscriptcentral.com/e-videos
