Endoscopic Ampullectomy: Who, When, and How

  • Matthew E. Feurer
  • Eric G. Hilgenfeldt
  • Peter V. DraganovEmail author


Endoscopic ampullectomy has emerged as the primary means for therapeutic management of ampullary adenomas, a precancerous lesion of the duodenal papilla. Appropriate staging of these lesions with increasingly available modalities such as endoscopic ultrasound and endoscopic retrograde cholangiopancreatography can help guide management therapy. While surgery remains the preferred curative procedure for ampullary adenocarcinoma, the role of endoscopy continues to expand and endoscopic resection of lesions displaying high-grade dysplasia and, in selected cases, intraductal involvement continues to be explored. Special consideration is given for adenomas that arise in the setting of familial adenomatous polyposis as this impacts treatment and surveillance decisions. This chapter reviews the role of imaging and endoscopy in the evaluation and treatment of ampullary adenomas. An overview of endoscopic resection techniques and surveillance recommendations is provided.


Endoscopic ampullectomy Ampullary adenoma Ampullectomy Duodenal papilla Familial adenomatous polyposis Papillectomy Endoscopic ultrasound Endoscopic retrograde cholangiopancreatography 

Supplementary material

Video 10.1

Endoscopic ampullectomy (MOV 130,921 kb).


  1. 1.
    Brandt LJ. Clinical practice of gastroenterology. Philadelphia: Current Medicine; 1999.Google Scholar
  2. 2.
    Baczako K, Büchler 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.CrossRefPubMedGoogle Scholar
  3. 3.
    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.CrossRefPubMedGoogle Scholar
  4. 4.
    Stolte M, Pscherer C. Adenoma-carcinoma sequence in the papilla of Vater. Scand J Gastroenterol. 1996;31(4):376–82.CrossRefPubMedGoogle Scholar
  5. 5.
    Fischer HP, Zhou H. Pathogenesis of carcinoma of the papilla of Vater. J Hepatobiliary Pancreat Surg. 2004;11(5):301–9.CrossRefPubMedGoogle Scholar
  6. 6.
    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.CrossRefPubMedGoogle Scholar
  7. 7.
    Seifert E, Schulte F, Stolte M. Adenoma and carcinoma of the duodenum and papilla of Vater: a clinicopathologic study. Am J Gastroenterol. 1992;87(1):37–42.PubMedGoogle Scholar
  8. 8.
    Patel R, Varadarajulu S, Wilcox CM. Endoscopic ampullectomy: techniques and outcomes. J Clin Gastroenterol. 2012;46(1):8–15.CrossRefPubMedGoogle Scholar
  9. 9.
    Baker HL, Caldwell DW. Lesions of the ampulla of Vater. Surgery. 1947;21(4):523–31.PubMedGoogle Scholar
  10. 10.
    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. Hepatogastroenterology. 1999;46(27):1959–62.PubMedGoogle Scholar
  11. 11.
    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.CrossRefPubMedGoogle Scholar
  12. 12.
    Yao T, Ida M, Ohsato K, Watanabe H, Omae T. Duodenal lesions in familial polyposis of the colon. Gastroenterology. 1977;73(5):1086–92.PubMedGoogle Scholar
  13. 13.
    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.PubMedGoogle Scholar
  14. 14.
    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.CrossRefPubMedGoogle Scholar
  15. 15.
    Halsted W. Contributions to the surgery of the bile passages, especially of the common bile duct. Boston Med Surg J. 1899;141:645–54.CrossRefGoogle Scholar
  16. 16.
    Bohra AK, McKie L, Diamond T. Transduodenal excision of ampullary tumours. Ulster Med J. 2002;71(2):121–7.PubMedPubMedCentralGoogle Scholar
  17. 17.
    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.CrossRefPubMedGoogle Scholar
  18. 18.
    Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF, Jaques DP. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg. 2007;204(3):356–64.CrossRefPubMedGoogle Scholar
  19. 19.
    Suzuki K, Kantou U, Murakami Y. Two cases with ampullary cancer who underwent endoscopic excision. Prog Digest Endosc. 1983;23:236–9.Google Scholar
  20. 20.
    Han J, Lee SK, Park DH, Choi JS, Lee SS, Seo DW, et al. Treatment outcome after endoscopic papillectomy of tumors of the major duodenal papilla. Korean J Gastroenterol. 2005;46(2):110–9.PubMedGoogle Scholar
  21. 21.
    Talamini MA, Moesinger RC, Pitt HA, Sohn TA, Hruban RH, Lillemoe KD, et al. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg. 1997;225(5):590–9. discussion 599–600.CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Guzzardo G, Kleinman MS, Krackov JH, Schwartz SI. Recurrent acute pancreatitis caused by ampullary villous adenoma. J Clin Gastroenterol. 1990;12(2):200–2.CrossRefPubMedGoogle Scholar
  23. 23.
    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.CrossRefPubMedGoogle Scholar
  24. 24.
    Elek G, Gyôri S, Tóth B, Pap A. Histological evaluation of preoperative biopsies from ampulla vateri. Pathol Oncol Res. 2003;9(1):32–41.CrossRefPubMedGoogle Scholar
  25. 25.
    Blackman E, Nash SV. Diagnosis of duodenal and ampullary epithelial neoplasms by endoscopic biopsy: a clinicopathologic and immunohistochemical study. Hum Pathol. 1985;16(9):901–10.CrossRefPubMedGoogle Scholar
  26. 26.
    Grobmyer SR, Stasik CN, Draganov P, Hemming AW, Dixon LR, Vogel SB, et al. Contemporary results with ampullectomy for 29 “benign” neoplasms of the ampulla. J Am Coll Surg. 2008;206(3):466–71.CrossRefPubMedGoogle Scholar
  27. 27.
    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.CrossRefPubMedGoogle Scholar
  28. 28.
    Ogawa T, Ito K, Fujita N, Noda Y, Kobayashi G, Horaguchi J, et al. Endoscopic papillectomy as a method of total biopsy for possible early ampullary cancer. Dig Endosc. 2012;24(4):291.CrossRefPubMedGoogle Scholar
  29. 29.
    Skordilis P, Mouzas IA, Dimoulios PD, Alexandrakis G, Moschandrea J, Kouroumalis E. Is endosonography an effective method for detection and local staging of the ampullary carcinoma? A prospective study. BMC Surg. 2002;2:1.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Chen CH, Tseng LJ, Yang CC, Yeh YH, Mo LR. The accuracy of endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, computed tomography, and transabdominal ultrasound in the detection and staging of primary ampullary tumors. Hepatogastroenterology. 2001;48(42):1750–3.PubMedGoogle Scholar
  31. 31.
    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.CrossRefPubMedGoogle Scholar
  32. 32.
    Okano N, Igarashi Y, Hara S, Takuma K, Kamata I, Kishimoto Y, et al. Endosonographic preoperative evaluation for tumors of the ampulla of Vater using endoscopic ultrasonography and intraductal ultrasonography. Clin Endosc. 2014;47(2):174–7.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Artifon EL, Couto D, Sakai P, da Silveira EB. Prospective evaluation of EUS versus CT scan for staging of ampullary cancer. Gastrointest Endosc. 2009;70(2):290–6.CrossRefPubMedGoogle Scholar
  34. 34.
    Kubo H, Chijiiwa Y, Akahoshi K, Hamada S, Matsui N, Nawata H. Pre-operative staging of ampullary tumours by endoscopic ultrasound. Br J Radiol. 1999;72(857):443–7.CrossRefPubMedGoogle Scholar
  35. 35.
    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.CrossRefPubMedGoogle Scholar
  36. 36.
    Baillie J. Endoscopic ampullectomy: does pancreatic stent placement make it safer? Gastrointest Endosc. 2005;62(3):371–3.CrossRefPubMedGoogle Scholar
  37. 37.
    Chini P, Draganov PV. Diagnosis and management of ampullary adenoma: the expanding role of endoscopy. World J Gastrointest Endosc. 2011;3(12):241–7.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Adler DG, Qureshi W, Davila R, Gan SI, Lichtenstein D, Rajan E, et al. The role of endoscopy in ampullary and duodenal adenomas. Gastrointest Endosc. 2006;64(6):849–54.CrossRefPubMedGoogle Scholar
  39. 39.
    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.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Gaspar J, Shami VM. The role of EUS in ampullary lesions: is the answer black and white? Gastrointest Endosc. 2015;81(2):389–90.CrossRefPubMedGoogle Scholar
  41. 41.
    Hopper AD, Bourke MJ, Williams SJ, Swan MP. Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos). Gastrointest Endosc. 2010;71(6):967–75.CrossRefPubMedGoogle Scholar
  42. 42.
    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.CrossRefPubMedGoogle Scholar
  43. 43.
    Catalano MF, Linder JD, Chak A, Sivak Jr MV, Raijman I, Geenen JE, et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc. 2004;59(2):225–32.CrossRefPubMedGoogle Scholar
  44. 44.
    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.CrossRefPubMedGoogle Scholar
  45. 45.
    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.CrossRefPubMedGoogle Scholar
  46. 46.
    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.CrossRefPubMedGoogle Scholar
  47. 47.
    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.CrossRefPubMedGoogle Scholar
  48. 48.
    Silvis SE. Endoscopic snare papillectomy. Gastrointest Endosc. 1993;39(2):205–7.CrossRefPubMedGoogle Scholar
  49. 49.
    El Hajj II, Coté GA. Endoscopic diagnosis and management of ampullary lesions. Gastrointest Endosc Clin N Am. 2013;23(1):95–109.CrossRefPubMedGoogle Scholar
  50. 50.
    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.CrossRefPubMedGoogle Scholar
  51. 51.
    Jung MK, Cho CM, Park SY, Jeon SW, Tak WY, Kweon YO, et al. Endoscopic resection of ampullary neoplasms: a single-center experience. Surg Endosc. 2009;23(11):2568–74.CrossRefPubMedGoogle Scholar
  52. 52.
    Ito K, Fujita N, Noda Y. Endoscopic diagnosis and treatment of ampullary neoplasm (with video). Dig Endosc. 2011;23(2):113–7.CrossRefPubMedGoogle Scholar
  53. 53.
    Small AJ, Baron TH. Successful endoscopic resection of ampullary adenoma with intraductal extension and invasive carcinoma (with video). Gastrointest Endosc. 2006;64(1):148–51.CrossRefPubMedGoogle Scholar
  54. 54.
    Fukushima H, Yamamoto H, Nakano H, Nakazawa K, Sunada K, Wada S, et al. Complete en bloc resection of a large ampullary adenoma with a focal adenocarcinoma by using endoscopic submucosal dissection (with video). Gastrointest Endosc. 2009;70(3):592–5.CrossRefPubMedGoogle Scholar
  55. 55.
    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.CrossRefPubMedGoogle Scholar
  56. 56.
    Baron TH. Ampullary adenoma. Curr Treat Options Gastroenterol. 2008;11(2):96–102.CrossRefPubMedGoogle Scholar
  57. 57.
    Björk J, Akerbrant H, Iselius L, Bergman A, Engwall Y, Wahlström J, et al. Periampullary adenomas and adenocarcinomas in familial adenomatous polyposis: cumulative risks and APC gene mutations. Gastroenterology. 2001;121(5):1127–35.CrossRefPubMedGoogle Scholar
  58. 58.
    Yoon SM, Kim MH, Kim MJ, Jang SJ, Lee TY, Kwon S, et al. Focal early stage cancer in ampullary adenoma: surgery or endoscopic papillectomy? Gastrointest Endosc. 2007;66(4):701–7.CrossRefPubMedGoogle Scholar
  59. 59.
    Seewald S, Omar S, Soehendra N. Endoscopic resection of tumors of the ampulla of Vater: how far up and how deep down can we go? Gastrointest Endosc. 2006;63(6):789–91.CrossRefPubMedGoogle Scholar
  60. 60.
    Kim JH, Han JH, Yoo BM, Kim MW, Kim WH. Is endoscopic papillectomy safe for ampullary adenomas with high-grade dysplasia? Ann Surg Oncol. 2009;16(9):2547–54.CrossRefPubMedGoogle Scholar
  61. 61.
    Pandolfi M, Martino M, Gabbrielli A. Endoscopic treatment of ampullary adenomas. JOP. 2008;9(1):1–8.PubMedGoogle Scholar
  62. 62.
    Kim MH, Lee SK, Seo DW, Won SY, Lee SS, Min YI. Tumors of the major duodenal papilla. Gastrointest Endosc. 2001;54(5):609–20.CrossRefPubMedGoogle Scholar
  63. 63.
    Yamao T, Isomoto H, Kohno S, Mizuta Y, Yamakawa M, Nakao K, et al. Endoscopic snare papillectomy with biliary and pancreatic stent placement for tumors of the major duodenal papilla. Surg Endosc. 2010;24(1):119–24.CrossRefPubMedGoogle Scholar
  64. 64.
    Boix J, Lorenzo-Zúñiga V, Moreno de Vega V, Domènech E, Gassull MA. Endoscopic resection of ampullary tumors: 12-year review of 21 cases. Surg Endosc. 2009;23(1):45–9.CrossRefPubMedGoogle Scholar
  65. 65.
    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.CrossRefPubMedGoogle Scholar
  66. 66.
    Wong RF, DiSario JA. Approaches to endoscopic ampullectomy. Curr Opin Gastroenterol. 2004;20(5):460–7.CrossRefPubMedGoogle Scholar
  67. 67.
    Ghidirim G, Mişin I, Istrate V, Cazacu S. Endoscopic papillectomy into the treatment of neoplastic lesions of Vater papilla. Curr Health Sci J. 2009;35(2):92–7.PubMedPubMedCentralGoogle Scholar
  68. 68.
    Saurin JC, Chavaillon A, Napoléon 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.CrossRefPubMedGoogle Scholar
  69. 69.
    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.CrossRefPubMedGoogle Scholar
  70. 70.
    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.CrossRefPubMedGoogle Scholar
  71. 71.
    Lienert A, Bagshaw PF. Treatment of duodenal adenomas with endoscopic argon plasma coagulation. ANZ J Surg. 2007;77(5):371–3.CrossRefPubMedGoogle Scholar
  72. 72.
    Ghilain JM, Dive C. Endoscopic laser therapy for small villous adenomas of the duodenum. Endoscopy. 1994;26(3):308–10.CrossRefPubMedGoogle Scholar
  73. 73.
    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.CrossRefPubMedGoogle Scholar
  74. 74.
    Zádorová Z, Dvofák M, Hajer J. Endoscopic therapy of benign tumors of the papilla of Vater. Endoscopy. 2001;33(4):345–7.CrossRefPubMedGoogle Scholar
  75. 75.
    Chacko A, Dutta AK. Endoscopic resection of ampullary adenomas: novel technique to reduce post procedure pancreatitis. J Gastroenterol Hepatol. 2010;25(8):1338–9.CrossRefPubMedGoogle Scholar
  76. 76.
    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.CrossRefPubMedGoogle Scholar
  77. 77.
    Tarnasky PR, Palesch YY, Cunningham JT, Mauldin PD, Cotton PB, Hawes RH. Pancreatic stenting prevents pancreatitis after biliary sphincterotomy in patients with sphincter of Oddi dysfunction. Gastroenterology. 1998;115(6):1518–24.CrossRefPubMedGoogle Scholar
  78. 78.
    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.CrossRefPubMedGoogle Scholar
  79. 79.
    Moon JH, Cha SW, Cho YD, Ryu CB, Cheon YK, Kwon KW, et al. Wire-guided endoscopic snare papillectomy for tumors of the major duodenal papilla. Gastrointest Endosc. 2005;61(3):461–6.CrossRefPubMedGoogle Scholar
  80. 80.
    Kubiliun NM, Adams MA, Akshintala VS, Conte ML, Cote GA, Cotton PB, et al. Evaluation of pharmacologic prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a systematic review. Clin Gastroenterol Hepatol. 2015;13(7):1231–9.CrossRefPubMedGoogle Scholar
  81. 81.
    Heinzow HS, Lenz P, Lenze F, Domagk D, Domschke W, Meister T. Feasibility of snare papillectomy in ampulla of Vater tumors: meta-analysis and study results from a tertiary referral center. Hepatogastroenterology. 2012;59(114):332–5.CrossRefPubMedGoogle Scholar
  82. 82.
    De Palma GD. Endoscopic papillectomy: indications, techniques, and results. World J Gastroenterol. 2014;20(6):1537–43.CrossRefPubMedPubMedCentralGoogle Scholar
  83. 83.
    Charton JP, Deinert K, Schumacher B, Neuhaus H. Endoscopic resection for neoplastic diseases of the papilla of Vater. J Hepatobiliary Pancreat Surg. 2004;11(4):245–51.CrossRefPubMedGoogle Scholar
  84. 84.
    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.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  • Matthew E. Feurer
    • 1
  • Eric G. Hilgenfeldt
    • 1
  • Peter V. Draganov
    • 1
    Email author
  1. 1.Division of Gastroenterology, Hepatology, and NutritionUniversity of Florida College of MedicineGainesvilleUSA

Personalised recommendations