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Introduction: The increased application of screening and diagnostic upper endoscopy has increased the frequency of identifying premalignant ampullary lesions. These premalignant lesions need extirpation to derail the adenoma→carcinoma sequence. Extirpative ampullectomy, whether endoscopic or operative, should be definitive treatment. However, the recurrence rates after polypectomy and the number of interventions to rid the polyp are not established. We undertook this study to determine the utility of and long-term outcomes after endoscopic vs. operative ampullectomy.
Methods: From 2002 to 2011, 35 patients underwent operative transduodenal ampullectomy and 38 patients underwent endoscopic ampullectomy per American Society for Gastrointestinal Endoscopy (ASGE) guidelines. Median data are presented.
Results: Patients undergoing operative vs. endoscopic therapy were similar in gender, age, BMI, and pretreatment evaluation. Transduodenal ampullectomy was undertaken for larger polyps than endoscopic polypectomy (2.1 cm vs. 1.5 cm respectively, p<0.001). 97% of transduodenal ampullectomies had microscopically negative (R0) margins whereas 50% of endoscopic ampullectomies had R0 margins. 16/38 (42%) patients treated endoscopically were without disease at last follow-up, though 5 patients were lost to follow-up, 1 patient underwent a pancreaticoduodenectomy for cancer, and one patient died; 15/38 (39%) had residual or recurrent disease despite numerous endoscopic reinterventions. 29/35 (82%) of patients treated with transduodenal ampullectomy were without disease at last follow-up, though despite R0 margins at resection, 5/35 (14%) patients had recurrent or persistent disease; 1 patient underwent a pancreaticoduodenectomy for cancer and 1 patient died.
Conclusions: After endoscopic ampullectomy, residual disease is common and recurrence is frequent and much higher than after transduodenal ampullectomy. The endoscopic approach is further encumbered by patients lost to follow-up. Despite vigilant endoscopic follow-up, whatever the approach for the ampullectomy, cancer will be encountered. This is not an "apples to oranges" comparison, but rather a "big apples to small apples" comparison that does not justify endoscopic ampullectomy rather than transduodenal ampullectomy, except under circumstances more stringent than proposed by the ASGE (e.g., smaller tumors more amenable to complete extirpation). Further data is needed to justify application of endoscopic ampullectomy using ASGE guidelines.