Endoscopy 2018; 50(05): E109-E110
DOI: 10.1055/s-0044-100917
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Long-term result of endoscopic treatment of an ampullary adenoma with extension into the common bile duct

Rodrigo Corsato Scomparin
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Luiza Haendchen Bento
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Clelma Pires Batista
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Marcelo Simas de Lima
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Gustavo Andrade de Paulo
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Bruno Costa Martins
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
,
Fauze Maluf-Filho
Department of Gastroenterology, Division of Endoscopy, Institute of Cancer of São Paulo, University of São Paulo, São Paulo, Brazil
› Author Affiliations
Further Information

Corresponding author

Rodrigo C. Scomparin, MD
Institute of Cancer of São Paulo – Division of Endoscopy
University of São Paulo
251 Dr Arnaldo Avenue
01246-000 São Paulo
Brazil   
Fax: +55-11-38932000   

Publication History

Publication Date:
16 February 2018 (eFirst)

 

A 56-year-old man with chronic hepatic disease due to hepatitis C and esophageal varices was referred to our hospital with an elevated alpha-fetoprotein level and a solid lesion in the distal common bile duct (CBD) seen on computed tomography (CT) scanning. This lesion was protruding into the second part of the duodenum and causing dilatation of the biliary tree. An upper gastrointestinal endoscopy revealed a raised lesion at the major duodenal papilla ([Fig. 1]). Biopsies showed a tubular adenoma with low grade dysplasia. Endoscopic ultrasound (EUS) revealed thickening that was restricted to the mucosal layer and choledocholithiasis.

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Fig. 1 Endoscopic image showing a lesion at the major papilla.

The patient was not suitable for surgical treatment because of his portal hypertension. We therefore performed an endoscopic papillectomy, followed by a sphincterotomy and placement of a plastic pancreatic stent. A follow-up endoscopy 7 days later revealed a residual lesion with a filling defect in the distal CBD ([Fig. 2]). After 30 days, a cholangioscopy was performed using CO2 and a pediatric gastroscope passed over a guidewire ([Fig. 3]). Biopsies were taken and the residual lesion was treated with argon plasma coagulation (APC) at 20 W and 1.5 L/min ([Video 1]).

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Fig. 2 Cholangiogram performed 7 days after the initial therapy showing an irregular filling defect in the distal common bile duct.
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Fig. 3 Radiographic image during cholangioscopy performed with a pediatric gastroscope passed over a guidewire.

Video 1 Cholangioscopy performed after papillectomy with a pediatric slim gastroscope revealed a residual lesion in the distal common bile duct. Biopsies were taken and the residual lesion was treated with argon plasma coagulation (APC).

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The patient remains completely asymptomatic 5 years later, receiving annual follow-up, and having no residual lesions ([Fig. 4]).

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Fig. 4 Appearances 5 years after treatment on: a endoscopy of the ampullary region; b cholangioscopy.

Ampullary adenomas can be found incidentally on endoscopic screening examinations and harbor a malignant potential [1]. In a retrospective study, 180 patients who had been treated for ampullary adenomas were followed up for a mean of 4.4 years [2]. There was no difference in endoscopic and operative resection of the ampullary adenomas in terms of local recurrence. However, intraductal extension of an adenoma is recognized as a limitation to endoscopic treatment [3]. In selected cases, intraductal adenomatous tissue can be endoscopically treated by ablation [1]. In our case, direct cholangioscopy with a slim scope and APC proved to be a valuable strategy for ablation of the intraductal adenomatous tissue.

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Competing interests

None


Corresponding author

Rodrigo C. Scomparin, MD
Institute of Cancer of São Paulo – Division of Endoscopy
University of São Paulo
251 Dr Arnaldo Avenue
01246-000 São Paulo
Brazil   
Fax: +55-11-38932000   


Zoom Image
Fig. 1 Endoscopic image showing a lesion at the major papilla.
Zoom Image
Fig. 2 Cholangiogram performed 7 days after the initial therapy showing an irregular filling defect in the distal common bile duct.
Zoom Image
Fig. 3 Radiographic image during cholangioscopy performed with a pediatric gastroscope passed over a guidewire.
Zoom Image
Fig. 4 Appearances 5 years after treatment on: a endoscopy of the ampullary region; b cholangioscopy.