This 44 year old man was referred for endoscopic ampullectomy after endoscopy done for upper GI bleeding from a Mallory Weiss tear revealed an incidental adenoma of the ampulla. This was confirmed by biopsy to be tubulovillous adenoma. EUS revealed no extension of the lesion into the pancreas. At ERCP, no duct could be cannulated at first. Manipulation of the lesion with the catheter shows it has somewhat of a stalk.Therefore we decided to proceed with ampullectomy en bloc. We decided against saline lift injection. A small polypectomy snare is used to encircle the lesion from below. Using a combination of cautery and cut current, the ampulla is resected. The specimen is retrieved immediately using a Roth net, as delay might allow it to disappear around the corner.
The base of the ampullectomy site appears intact without suggestion of perforation or bleeding. Next task is to access the bile and pancreatic ducts. Using a 5-4-3 catheter, bile duct is cannulated, and an 018 Roadrunner wire (Cook Endoscopy) is passed into bile duct for access. Most importantly, the pancreatic is cannulated with some difficulty, and another 018 wire is knuckled into the duct around two turns. Our goal is to perform dual biliary and pancreatic sphincterotomies to prevent stenosis and obstruction of either duct. Biliary sphincterotomy is done first and the biliary wire removed. While we are passing the sphincterotome (Autotome 39, Boston Scientific) over the pancreatic wire, some bleeding starts from the lower margin. We proceed with protection of pancreatic drainage with the pancreatic sphincterotomy followed by placement of 4F 9cm unflanged soft pancreatic stent (Hobbs Medical), with the pigtail flipped up and out of the way. Next we inject the bleeding area with 1:10,000 epinephrine. A Resolution clip (Boston Scientific) is placed. We pass the clip with the elevator down, then position it with the big wheel but not the elevator to avoid crimping. The clip fires nicely, but release requires reopening and closing the handle, advancing the sheath and shaking but not pulling back on the delivery system. Here it is fluoroscopically. Now with everything under control we pull back a bit on the stent and watch the pancreatic juices flow.
Pathology revealed a 1.8 x 1.5cm tubulovillous adenoma without carcinoma, and with margin free of adenoma. The patient did well with overnight in hospital observation. Follow up X-ray in 2 weeks showed the stent had fallen out. At one year follow up the ampulla appeared healed with no recurrence.
This case illustrates the importance of pancreatic drainage, control of bleeding, and preference for en-bloc rather than piecemeal resection whenever possible, so as to allow best retrieval and histopathologic assessment.
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Harewood GC, Pochron NL, Gostout CJ. Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla. Gastrointest Endosc 2005;62:367-70.
Martin L. Freeman, M.D., University of Minnesota