Management and outcomes for duodenal adenomas may vary based on etiology, familial versus sporadic. We reviewed the records of patients managed at our institution for duodenal adenomatous polyps for the 20-year period ending July 2006. Methods of polyp resection (endoscopic, local surgical resection, or definitive surgical resection) within both sporadic and familial patient groups were compared. Patients with known cancer were excluded. Two hundred seventy-eight patients with duodenal polyps were followed during this time period: 110 patients (39.6%) with sporadic polyps and 168 (60.4%) with FAP. Sporadic patients presented at a mean age of 66.5 years. Endoscopic resection was attempted in 44 patients (40%) with morbidity in 9% and local recurrence rate of 52% with a mean follow-up of 43 months. Surgical resection was performed in 46 patients (42%): 27 by definitive resection and local resection in 19. At a mean follow-up of 41 months there were no local recurrences in the patients treated by definitive resection and 6 recurrences (32%) after local resection. Morbidity was 16.2%. There was a significant difference in local recurrence when comparing definitive resection to both endoscopic and local resection (p< 0.001, p = 0.002 respectively), but no significant difference between endoscopic and local excision (p= 0.13). Cancer was discovered in the surgical specimens of 11 patients (24%) with benign preoperative biopsies. FAP patients began surveillance at a mean age of 39.5 years and mean surveillance duration was 100 months. Endoscopic resection/ablation was attempted in 40 patients (24%) with a morbidity of 7.5%. With a mean follow-up of 77.5 months the local recurrence rate was 72.5%. Surgical resection was performed in 50 patients (30%) with a mean follow-up of 44 months. Definitive resection was performed in 47 and local excision in 3 with local recurrence rates of 9% and 100%, respectively. Surgical morbidity was 48%. Local recurrence was significantly lower following definitive resection compared to endoscopic or local resection (p< 0.001) but there was no difference in local recurrence between the latter 2 groups (p= 0.29). Four patients (8%) undergoing surgery were discovered to have invasive cancer despite benign endoscopic biopsies. In summary, endoscopic and local surgical management for both sporadic and familial duodenal polyps are associated with a high rate of local recurrence. Definitive resection in the form of pancreaticoduodenectomy, pancreas-sparing duodenectomy, or segmental duodenectomy offers the best chance for polyp eradication and prevention of carcinoma, regardless of polyp etiology.