Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Authors: Geoffroy Vanbiervliet, Marin Strijker, Marianna Arvanitakis, Arthur Aelvoet, Urban Arnelo, Torsten Beyna, Olivier Busch, Pierre H. Deprez, Lumir Kunovsky, Alberto Larghi, Gianpiero Manes , AlanMoss, Bertrand Napoleon, Manu Nayar, Enrique Pérez-Cuadrado-Robles, Stefan Seewald, Marc Barthet, Jeanin E. van Hooft

MAIN RECOMMENDATIONS

1 ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.
Strong recommendation, low quality evidence.

2 ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.
Strong recommendation, low quality evidence.

3 ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, be-cause of good results regarding outcome (technical and clinical success, morbidity, and recurrence).
Strong recommendation, moderate quality evidence.

4 ESGE recommends en bloc resection of ampullary adenomas up to 20-30mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.
Strong recommendation, low quality evidence.

5 ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.
Weak recommendation, low quality evidence.

6 ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.
Strong recommendation, moderate quality evidence.

7 ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.
Strong recommendation, moderate quality evidence.

8 ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.
Strong recommendation, low quality evidence.