Endoscopic treatment of ampullary adenomas.

Tumors of the papilla of Vater are rare, with a prevalence of 0.04%±0.12% reported in autopsy studies. They may occur as sporadic lesions or in patients with familial adenomatous polyposis. Histologically, the malignant transformation of benign adenomas to carcinomas has been documented. The reported frequency of malignancy in an adenoma of the papillae ranges from 26 to 65%. Adenomatous residual foci, as well as areas of moderate to severe dysplasia, have also been found in up to 90% of resection specimens of carcinoma of the major papilla. Based on these observations, adenomas of the major or the minor papilla are thought to exhibit the same adenoma-carcinoma sequence as adenomas of the colon [1]. For these reasons, complete removal of these lesions is mandatory, but the treatment of choice remains controversial. Surgery represents the traditional option, including pancreaticoduodenectomy which has a peri-operative mortality rate ranging from 2 to 9% and a very significant postoperative complication rate (up to 41% in a large series) [2] and duodenotomy with local excision; the latter is certainly less invasive, but it is associated with local recurrence. Thus, because of low morbidity and mortality, endoscopic treatment has gained increasing consensus as a treatment of first choice, even if the difficult anatomic location of these lesions makes resection a much more complex procedure as compared to a polypectomy in the colon [3]; furthermore, subsequent surgery in operable patients is not precluded by previous endoscopic resection [4].