Management of Duodenal Adenomas Involving the Ampulla of Vater – A Warning against Limited Resection

Abstract

Duodenal adenomas are uncommon, however, when present a proportion have dysplasia associated with the adenoma and therefore require treatment. The options range from less invasive endoscopic treatments to a pancreaticoduodenectomy. This case report describes two patients with adenomas involving the ampulla of Vater. One patient had familial adenomatous polyposis, the other was a renal transplant patient with a large adenoma. Both patients’ adenomas contained high-grade dysplasia. Both patients underwent a pancreaticoduodenectomy. Histology of both specimens demonstrated that the adenoma had migrated up the bile duct for at least 7 mm, and the pancreatic duct for 8 mm in one patient. Limited resection of ampullary adenomas may leave residual adenomatous tissue in the bile duct with the risk of recurrent adenomatous disease and malignant transformation.

Review of the investigation and surgical management of resectable ampullary adenocarcinoma

“…EP was described in 1987 by van Stolk and with improved endoscopic techniques and pre‐operative investigations this has now become the treatment of choice for most adenomas . Ampullary tumours have been observed to spread along the mucosa of the pancreatic and biliary ducts prior to any muscular invasion . This ductal extension has been noted in both benign and malignant tumours and is a critical factor in the consideration of local treatment options .…”