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INTRODUCTION: Precise characterization of benign duodenal and peri-ampullary tumors, offers a diagnostic challenge to reliably distinguish adenomas from malignant lesions and render the possibility of trans-duodenal resection. EUS has emerged as a useful technique in assessing tumor depth of invasion and is often employed at our institution when planning therapeutic approach. We performed a retrospective review of patients with benign duodenal and peri-ampullary adenomas who underwent preoperative EUS to determine the accuracy of this technique in predicting the absence of muscular invasion and also to analyze outcomes associated with endoscopic and trans-duodenal surgical resection.
METHODS: Records of 111 patients seen at our institution over the last 10 years with post-operative pathological diagnosis of benign ampullary and duodenal adenomas were identified and reviewed. We analyzed information on patient gender, age, tumor location and size, EUS results, type of resection performed, final pathology findings and incidence of local tumor recurrence.
RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 periampullary lesions and 18 duodenal lesions. In 38 (81%) patients, EUS reliably identified absence of sub mucosal and muscularis invasion. In 4 cases, EUS underestimated sub mucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. Type of resection performed included endoscopic resection in 25 cases, partial duodenectomy in 6 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. There were 6 local recurrences (13%; median follow-up=20 months) 4 of which were in patients with Familial Adenomatous Polyposis (FAP). The main post-operative final pathological results included villous adenoma (n=5), adenoma (n=6), tubulovillous adenoma (n=10), tubular adenoma (n=20) and hyperplastic polyp (n=2),. Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intraabdominal abscess, wound infection, delayed gastric emptying and prolonged ileus.
CONCLUSION: EUS can accurately predict depth of mucosal invasion in 81% of benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection with acceptable local control rates sparing the need for more extensive operations.