Endoscopic Papillectomy for Ampullary Tumors in Older Patients: Balancing Oncologic Benefit and Geriatric Risk.

ESGE 2021 gates everything on proven adenoma. ESGE recommends AGAINST diagnostic/therapeutic papillectomy when adenoma has not been proven (strong, low), and recommends histological confirmation by endoscopic biopsies in the case of low-grade-dysplasia adenoma before initiating any treatment (strong, low). Assessment uses a side-viewing endoscope when an ampullary tumor is suspected (strong, moderate); the cap-assisted method is suggested only when the papilla is not seen on forward-viewing endoscopy (weak, moderate); high-resolution virtual chromoendoscopy is suggested for diagnosis and staging (weak, low). Staging is EUS plus abdominal MRCP (strong, low); IDUS is suggested only in selected patients, with routine use balanced against training, cost and pancreatitis risk (weak, low). ESGE suggests that IHC, K-ras and p53 evaluation, PCR, and microsatellite instability testing should NOT routinely be applied to ampullary tumor biopsies to inform prognosis or potential treatment response (weak, low). TREATMENT: ESGE recommends endoscopic papillectomy for ampullary adenoma without intraductal extension (strong, moderate), and en bloc resection of adenomas up to 20-30 mm to achieve R0 (strong, low). Technique is direct snare resection WITHOUT submucosal injection (strong, moderate) - but submucosal injection IS recommended before EMR of the extrapapillary duodenal-wall component of a laterally spreading ampullary tumor (strong, moderate); LST-p can be managed endoscopically, accepting higher intraprocedural and delayed bleeding risk (strong, low). ESGE suggests avoiding any biliary, pancreatic or biductal sphincterotomy prior to papillectomy (weak, very low) and suggests endocut current (weak, low). PROPHYLAXIS: prophylactic pancreatic duct stenting is recommended to reduce post-papillectomy pancreatitis (strong, moderate); ESGE suggests routine rectal administration of 100 mg diclofenac or indomethacin immediately before papillectomy in all patients without NSAID contraindication (weak, low); if PD stenting is not possible, high-volume lactated Ringer's hydration is suggested (weak, low). Prophylactic hemostasis is individualized (strong, very low). SURGERY: ESGE only SUGGESTS considering surgical treatment when endoscopic resection is not feasible for technical reasons (e.g. periampullary diverticulum, size >4 cm) and in the case of intraductal involvement of >20 mm - and surveillance thereafter is still mandatory (weak, low). For adenoma with intraductal extension of 20 mm or less, ESGE suggests complementary techniques in expert centers (thermal ablation by cystotome, or RFA) with temporary biliary stenting (weak, low). For malignancy, ESGE recommends pancreaticoduodenectomy including lymphadenectomy for ampullary lesions of stage T1 or higher, including when pathology after endoscopic papillectomy or surgical ampullectomy reveals T1 adenocarcinoma (strong, low); for Tis ampullary cancer, transduodenal ampullectomy or endoscopic papillectomy may be considered sufficient when final pathology shows no residual disease (strong, low). BILIARY DRAINAGE: ESGE recommends against routine preoperative biliary drainage in surgically eligible ampullary cancer, reserving it for cholangitis, severe symptomatic jaundice (e.g. intense pruritus), delayed surgery, or before neoadjuvant chemotherapy in jaundiced patients (strong, moderate); when required, endoscopic SEMS insertion (strong, moderate); ERCP with SEMS in palliative settings (strong, high). FOLLOW-UP: long-term monitoring after endoscopic papillectomy or surgical ampullectomy by duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and yearly thereafter for at least 5 years (strong, low). On recurrence, assess local extent with endoscopy plus biopsies, EUS and MRCP before any treatment (strong, low); benign residual or recurrent lesions may be managed endoscopically including APC and EMR (weak, low).