1. Tumores Ampulares Dr. Alberto Espino Dpto Gastroenterologia UC Sept 02, 2014

3. Es importante examinar la papila? Es recomendado visualizar la segunda porción duodenal incluyendo la papila mayor en toda EDA estándard Detección precoz de enfermedades periampulares y enfermedades pancreatobiliares. Factores de dificultad: – Características anatomicas de D2 – Angulo tangencial – Divertículo periampular – Formación de loop WJG 2013;19: 2037-2043 GIE 2012; 75: 254-260

4. ¿Cómo es una papila normal?

5. ¿Cuántos de ustedes examinan la papila duodenal durante una EDA ?

7. Examen de ampolla de Vater o papila mayor Completo, incompleto y no visualizada WJG 2013

17. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma.

18. Periampullary Tumours Relatively rare – Annual incidence of 3000 cases in US 1 – prevalence rates estimated to be 0.04 to 0.12 % in autopsy series 95% adenomas (villous and tubulovillous) – 5% neuroendocrine tumours, paragangliomas etc Occur sporadically or more commonly in the setting of FAP (80% lifetime incidence, 4% risk of malignancy) Stepwise progression to adenocarcinoma – 25 - 80% for sporadic adenomas 2 1. Martin Gastro Intest Clin N A 2003 2. Burke GIE 1999

19. Clinical features – Asymptomatic – particularly in FAP undergoing surveillance – Jaundice, fluctuating LFT’s, nonspecific discomfort, anorexia, pancreatitis, GI bleeding/anaemia

20. Management Surveillance FAP patients with small lesions (<1cm) Surgery – Radical resection – Local excision Endoscopic excision Palliative stenting

21. Pancreaticoduodenectomy Historical gold standard (1909) Definitive Eliminates need for surveillance (sporadic) Outcomes – Recurrence rates for adenoma ≈ 0 – Adverse events Operative mortality 0-9% Morbidity 25-65% (anastomotic dehiscence and fistulae) Related to case volume

22. Local surgical excision Entails mobilization of the duodenum and longitudinal duodenotomy - followed by…. (i) Simple excision of the ampullary neoplasm (ii)Extended excision (including adjacent duodenal and ductal tissue) Lower complications rates(1) – Mortality 0-4% – Morbidity14-27% Recurrence rates up to 30%(2) 1.de Castro Surgery 2004 2.Winter J Gastrointest Surg 2010

23. Endoscopic ampullectomy Described in the late 1980’s Developed as a less invasive alternative ASGE guideline 2007 – Outcomes Largely retrospective data – Success rates for removal 46-92%

24. Outcomes Ceppa Annals of Surg 2013

25. Complications El Hajj Gastrointest Endos Clin N Am 2013

26. Patient Selection Endoscopy – Suspicious features – induration and rigidity of papilla, ulceration, submucosal mass effect, friability – Biopsy 1,2 High sensitivity (>90%) for detecting the presence of an adenoma Low sensitivity for confirming adenocarcinoma – missing the diagnosis in 30% The frequency of malignant foci in ampullary adenomas is 26-30% Accuracy improved – Number of biopsies > 6 – Biopsies taken after ERCP 1.Artifon GIE 2009 2.Sauvanet Am J Surg 1997

27. Staging – EUS +/- IDUS Depth of involvement – T stage Intraductal extension Periampullary LN’s – CT/MRI - nodal staging and metastases – ERCP Main role is at the time of resection to assess intraductal extension (PD and CBD)

28. Proposed algorithm