Duodenum - Adenocarcinoma of the Ampulla Treated by Ampullectomy
Comments: This is the case of a seventy-three year old male with a biopsy proven ampullary villous adenoma with carcinoma in-situ. An abdominal CT scan was performed and was unremarkable. The patient now present for endoscopic ultrasound and possible ampullectomy.
The major papilla appeared grossly abnormal. A pale villiform lesion with areas of ulceration is seen. The echoendoscope is positioned in the duodenum directly adjacent to the ampulla. The lesion is examined in detail. It appears exophytic and hypoechoic and there is no clear evidence of local invasion.
An ERCP is then performed for duct identification. Biliary and pancreatic sphincterotomies are often done at this time if they have not already been performed. Wire placement to maintain access in large lesions such as this may not be necessary. Saline may then be injected at the base of the papilla using a sclerotherapy needle. This lifts the lesion off the muscularis propria and provides a cushion. If good lift is not visualized and the saline is being easily injected, the needle may be through the muscularis and should be slightly withdrawn. Epinephrine is often mixed with the saline in an attempt to decrease bleeding, however the evidence for this is purely anecdotal. A snare is then used to perform the ampullectomy. A variety of snares sizes and shapes are available and it’s important to choose one that will provide the highest likelihood of removing the entire papilla and lesion. Removal also can be done in a piecemeal fashion however this makes it very difficult for the pathologist to assess resection margins. The snare is then slowly closed and electrocautery is applied. Following removal the biliary and pancreatic ducts are easily visualized. A pancreatic duct stent is usually placed at this time.
The product of the ampullectomy measured 1.9 x 1.8 x 0.5 cm. It demonstrated a large ulceration of the mucosal surface. A low-power view of the specimen shows a wide and superficial invasive adenocarcinoma with pushing borders. Note that the tumor is limited to the sphincter of Oddi with uninvolved deep ampullary channels and negative lateral and deep margins. The high magnification view confirmed moderately differentiated adenocarcinoma.
Three months following the procedure, there is no evidence of residual tumor and bile drainage is visualized. The patient remains well at a 3 year follow-up visit and no repeat interventions have been required.
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Peter B. Kelsey, M.D. Assistant Professor of Medicine Harvard Medical School Massachusetts General Hospital |
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Citation: Kelsey, PB (May 04 2004). Duodenum - Adenocarcinoma of the Ampulla Treated by Ampullectomy. The DAVE Project. Retrieved Sep, 4, 2010, from http://daveproject.org/viewfilms.cfm?film_id=120 Times viewed since Feb 2006: 11757 |
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