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Cold snare piecemeal resection of a large ampullary adenoma
We describe the case of a 63-year-old patient with end-stage renal disease who underwent endoscopic ampullectomy of a large ampullary adenoma.
A side-viewing duodenoscope was utilized to evaluate the mass. A large frond-like villous mass, 40 mm in diameter, was seen at the major papilla ([Fig. 1]). The mass was resected using a dedicated thin-wire braided snare (cold snare) in a piecemeal fashion, and retrieved with a retrieval net ([Video 1]). The snare deformed with repeated use and a total of four snares were required to complete the procedure.
Video 1 Cold snare piecemeal resection of a large ampullary adenoma.
Following resection, the ventral pancreatic duct was deeply cannulated with a short-nosed traction sphincterotome and guidewire. There was no extension of the polyp into the pancreatic duct, and a temporary plastic stent was placed ([Fig. 2]). The patient tolerated the procedure without immediate complications. Pathology from the specimen revealed adenoma with high-grade dysplasia.
Endoscopic ampullectomy is a safe and successful alternative to surgery for removal of selected ampullary adenomas. Recent studies have suggested that ampullary adenomas may be endoscopically removed either piecemeal or en bloc using electrocautery . A recent study in Japan evaluated 136 patients with laterally spreading ampullary adenomas . A single treatment session was possible in 104 (83.2 %) of the 125 patients in the en bloc resection group and in 8 (72.7 %) of the 11 in the piecemeal resection group. The total resection rate including additional treatments was 98.4 % in the en bloc group and 100 % in the piecemeal group. This suggests that piecemeal resection using electrocautery is comparable to en bloc resection.
Cold snare resection of colonic polyps is gaining acceptance and there are reports of cold snare removal of large polyps . To our knowledge this is the first case to date of successful cold snare ampullectomy in a patient at high risk for post-procedural bleeding.
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19 May 2020 (online)
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- 2 Yamamoto K, Sofuni A, Tsuchiya T. et al. Clinical impact of piecemeal resection concerning the lateral spread of ampullary adenomas. Intern Med 2019; 58: 901-906
- 3 Tate DJ, Awadie H, Bahin FF. et al. Wide-field piecemeal cold snare polypectomy of large sessile serrated polyps without a submucosal injection is safe. Endoscopy 2018; 50: 248-252