Ampullary neoplasia accounts for well under one per cent of gastrointestinal cancers, and the incidence in young adults has risen over the past twenty years. Because it is rare, guidance has been thin relative to other pancreaticobiliary disease. This American Gastroenterological Association clinical practice update sets out fifteen best-practice statements, drawn from literature review and expert opinion rather than systematic review — so they carry no formal evidence grading.
The assessment advice is the part most likely to change what happens. A side-viewing duodenoscope, not a forward-viewing gastroscope, because the ampulla cannot be properly seen or biopsied otherwise, and because it allows biopsy away from the pancreatic orifice. At least six biopsies, from ulcerated or indurated areas, because 20% to 40% of ampullary adenomas harbour malignancy. Endoscopic ultrasound for staging and to define intraductal extension in any lesion being considered for endoscopic resection, except lesions under 1 cm with no worrying features.
The resection statements are equally specific. Lesions amenable to endoscopic papillectomy have well-defined margins, are under 4 to 5 cm, are non-friable and soft to probing, with intraductal extension of 1 cm or less. Avoid pre-papillectomy sphincterotomy, because electrocautery artefact and bleeding compromise the histology you resected the lesion to obtain. Use en bloc snare resection where feasible. Prevent post-papillectomy pancreatitis with prophylactic pancreatic duct stenting, rectal non-steroidal anti-inflammatories and high-volume lactated Ringer's. Surveillance starts at three months and runs annually to at least five years.
- Use a side-viewing duodenoscope for any suspected ampullary lesion
- Take at least six biopsies, targeting ulcerated or indurated areas
- Do not perform biliary or pancreatic sphincterotomy before papillectomy
- Refer for surgical consideration when intraductal extension exceeds 1 cm
- Book the three-month surveillance duodenoscopy at the time of resection, not afterwards
Why it matters
Up to two in five of these adenomas already contain cancer, and a forward-viewing scope will not tell you which.
Don't overread it
These are best-practice advice statements from expert opinion, without formal evidence grading — they are not a graded guideline.
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