Endoscopic ampullectomy: to inject or not to inject? The underwater technique

A 70-year-old man with a history of abdominal pain underwent esophagogastroduodenoscopy, which showed an abnormal major papilla of about 2 cm in diameter with a villous surface ([Fig. 1]). Histology revealed a tubulovillous adenoma with focal high grade dysplasia. On endoscopic ultrasound, the lesion was confined to the mucosal layer.

Fig. 1 Abnormal major papilla (underwater view).

Inspired by the work of Binmoeller et al. on their new approach, termed “The Underwater Technique,” for resection of nonampullary duodenal adenomas [1], we planned an endoscopic underwater ampullectomy.

The duodenoscope was equipped with an auxiliary water jet injection cap (BioShield irrigator; US Endoscopy, Mentor, Ohio, United States), to allow irrigation while leaving the operative channel free. Carbon dioxide insufflation was off during resection.

En bloc ampullectomy was performed with a standard polypectomy snare, using blended current (VIO 300 D, DRY CUT, effect 5, 60 watts; ERBE Elektromedizin GmbH, Tübingen, Germany) ([Fig. 2] and [Fig. 3]). The procedure was uneventful, and the patient was discharged 36 hours later.

Fig. 2 Ensnared papilla during underwater ampullectomy.

Fig. 3 Endoscopic view following underwater ampullectomy.

Pathology confirmed the diagnosis of tubulovillous adenoma with high grade dysplasia. Resection margins were free of dysplasia, and the muscularis mucosae was entirely removed, as confirmed by smooth muscle actin immunohistochemical stain ([Fig. 4]). At 3-month follow-up, endoscopy showed complete duodenal healing, with no histologic recurrence.

Fig. 4 Histological pictures. a Hematoxylin and eosin (H&E) low-power magnification microphotography showing the entire thickness of the resection (black ink on the deeper margin). b Smooth muscle actin stain confirms the muscularis mucosa layer. c Normal colonic mucosa on the right and dysplastic mucosa on the left (focal cribriform glandular architecture, high grade dysplasia) (H&E × 4).

Ampullary adenomas can occur sporadically or manifest as syndromes of genetic conditions, and can transform into malignant ampullary cancer [2]. Several authors advocate submucosal injection immediately before endoscopic ampullectomy, as done for resection of colorectal polyps. Others opt not to use submucosal injection. There are insufficient data to conclude that this is a necessary step in the procedure [2] [3] [4] [5].

On the basis of Binmoeller’s results, we applied the underwater technique for endoscopic ampullectomy. Although the efficacy of this technique cannot be fully demonstrated with a single report, this application appeared to be feasible and safe, and we believe it may represent a potential alternative endoscopic approach to resection of ampullary adenomas.

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^* Both authors contributed equally to this work.

• References

• 1 Binmoeller KF, Shah JN, Bhat YM et al. “Underwater” EMR of sporadic laterally spreading nonampullary duodenal adenomas (with video). Gastrointest Endosc 2013; 78: 496-502
• 2 Hirota WK, Zuckerman MJ, Adler DG et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 2006; 63: 570-580
• 3 Baille J. Endoscopic ampullectomy. Am J Gastroenterol 2005; 100: 2379-2381
• 4 Norton ID, Gostout CJ, Baron TH et al. Safety and outcome of endoscopic snare excision of the major duodenal papilla. Gastrointest Endosc 2002; 56: 239-243
• 5 Catalano MF, Linder JD, Chak A et al. Endoscopic management of adenoma of the major duodenal papilla. Gastrointest Endosc 2004; 59: 225-232