The Assessment of Specimens Procured by Endoscopic Ampullectomy

Dept of Pathology, University of Virginia Health System, Charlottesville, VA 22908, USA.
American Journal of Clinical Pathology (Impact Factor: 2.51). 10/2009; 132(4):506-13. DOI: 10.1309/AJCPUZWJ8WA2IHBG
Source: PubMed


Endoscopic ampullectomy (EA) is increasingly used in the management of ampullary neoplasia. Although studies on the safety and efficacy of this procedure exist, no study has specifically addressed the histopathologic features of the specimens. We review our experience with 45 EA specimens assessed for the following: diagnosis, high-grade dysplasia (HGD), submucosal ampullary gland/ductule involvement, specimen integrity, and margin status. Familial adenomatous polyposis (FAP) status and the endoscopist's impression of completeness of removal were also ascertained. Previous biopsy diagnoses were compared with ampullectomy diagnoses, and histologic and clinical features were correlated with disease persistence. The histologic features of the ampullectomy specimens were as follows: diagnosis (no diagnostic abnormality, 3; reactive, 8; adenoma, 26; adenocarcinoma, 7; other, 1); HGD, 1; submucosal ampullary gland/ductule involvement, 20; specimen integrity (intact, 22; fragmented, 23); and margin status (positive, 20; negative, 2; could not be assessed, 12). Five patients had FAP, and EA was deemed complete in 21 (47%). The diagnostic agreement between preampullectomy biopsy and ampullectomy was 64%. Of the patients, 33 (73%) had documented persistent disease. None of the histologic or clinical features had a statistically significant relationship with disease persistence.

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    • "Keypoints for successful outcome are negative resection margins and endoscopic surveillance [23], but primarily clinical suspicion that the presence of painless jaundice in a patient with history of renal cancer and negative CT scanning for pancreatic or other causes of obstruction should alert for prompt investigation for an ampullary metastasis. "
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    ABSTRACT: OBJECTIVE:: The objective of this study was to compare the effectiveness, morbidity, and mortality associated with endoscopic ampullectomy (EA) and surgical ampullectomy (SA). BACKGROUND:: The proposed management of benign ampullary lesions includes local resection (EA or SA) and en bloc resection (pancreaticoduodenectomy). Most agree that en bloc resection entails a significant morbidity and mortality. No study has previously compared EA and SA for the treatment of benign ampullary lesions. METHODS:: Medical records of patients selected for ampullectomy at Duke University Medical Center from 1991 to 2010 were reviewed. RESULTS:: After review, 109 patients were confirmed to have undergone ampullectomy for a suspected benign ampullary lesion. Sixty-eight patients underwent EA, whereas 41 patients underwent SA. Patients in each group were identical in terms of age, sex, race, and comorbid conditions, except that EA had a higher rate of severe obesity (body mass index >35). Endoscopic ampullectomy was found to have a significantly reduced length of stay, lower morbidity, and readmission rates, but it had similar rates of mortality, margin-positive excisions, and reinterventions. CONCLUSIONS:: In patients selected for ampullectomy for benign ampullary lesions, EA was found to have equivalent efficacy when compared with SA. Moreover, EA had lower morbidity and identical mortality. These findings suggest that patients would likely benefit from an aggressive endoscopic approach before consideration for surgery.
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