Forward- vs. Oblique-Viewing Endoscope for Duodenal Papillectomy: A Comparative Study on Efficacy and Safety.

Two current documents govern ampullary adenoma: the AGA Clinical Practice Update expert review (Barakat, Maranki, Irani, Chahal; Clin Gastroenterol Hepatol, online 2026-09-09; ungraded Best Practice Advice from literature review plus expert opinion, no systematic review) and the ESGE 2021 graded guideline (Vanbiervliet et al., Endoscopy 2021;53:429-448), which it does not replace. DIAGNOSIS: both use a side-viewing duodenoscope. AGA adds that biopsies should avoid the pancreatic orifice to limit post-procedure pancreatitis. Because 20-40% of ampullary adenomas harbor malignancy, AGA advises AT LEAST 6 biopsies, targeting ulcerated or indurated areas. ESGE requires proven adenoma before papillectomy and recommends against diagnostic papillectomy. STAGING: AGA says to consider EUS for every adenoma potentially amenable to endoscopic resection, EXCEPT lesions <1 cm with no worrisome clinical or endoscopic features. ESGE recommends EUS plus MRCP (IDUS in selected patients) and advises against routine molecular testing of biopsies. SELECTION: AGA describes the lesion most amenable to papillectomy as having well-defined margins, size <4-5 cm, nonfriable tissue, softness to probing, and intraductal extension <=1 cm. AGA sets 3 absolute contraindications: metastatic spread; invasive cancer beyond the mucosa; and >1 cm intraductal extension in a surgically fit patient. Relative contraindications are size >5 cm, early-stage/T1 cancer, and likely poor follow-up adherence. For >1 cm intraductal extension, AGA suggests surgical consultation; <1 cm may be treated endoscopically with close surveillance. This is a stricter intraductal threshold than ESGE's, which suggests surgery only for intraductal involvement >20 mm and adjunct RFA or cystotome ablation with temporary biliary stenting for <=20 mm in expert centers. ESGE also gates en bloc resection at adenomas up to 20-30 mm and lists >4 cm or a periampullary diverticulum as technical reasons to consider surgery. TECHNIQUE: both say to avoid biliary or pancreatic sphincterotomy before papillectomy (AGA's reasons: cautery artifact and bleeding) and to use en bloc snare resection when feasible. Submucosal injection is generally not needed, except for a laterally spreading duodenal-wall component. ESGE also suggests endocut current. PANCREATITIS PROPHYLAXIS: AGA advises using ALL THREE together: prophylactic pancreatic duct stent, rectal NSAID, and high-volume lactated Ringer's. ESGE recommends the PD stent and rectal diclofenac or indomethacin 100 mg, with lactated Ringer's suggested mainly when stenting is not possible. BLEEDING: standard hemostasis methods (epinephrine, electrocoagulation, clips, APC, hemostatic sprays); ESGE says prophylactic hemostasis is individualized. BILIARY DRAINAGE when resection is not feasible: AGA allows drainage with or without sphincterotomy and SEMS for significant jaundice or cholangitis, at the surgeon's discretion. ESGE recommends against routine preoperative drainage, reserving it for cholangitis, severe jaundice, delayed surgery, or neoadjuvant therapy, with SEMS when drainage is needed. ADJUNCT/RESIDUAL: for adenomas >3 cm resected piecemeal or with positive margins, AGA advises considering adjunct thermal ablation plus ductography, repeated every 2-3 months until biopsy confirms eradication. ESGE allows APC and EMR for benign residual or recurrent lesions. SURVEILLANCE: both use the same schedule: side-viewing duodenoscopy with biopsy of the scar and any abnormal area at 3 months, then at 6 and 12 months, then yearly for at least 5 years. AGA says surveillance beyond 5 years should be individualized (recurrence risk, comorbidity, life expectancy) but is required if high-risk features are present. In FAP, AGA individualizes intervals by ampullary, gastric and duodenal disease burden. MALIGNANCY: AGA advises multidisciplinary discussion (GI, surgery, oncology) for high-grade dysplasia, incomplete resection, or suspected malignancy. ESGE recommends pancreaticoduodenectomy with lymphadenectomy for T1 or higher, and accepts local resection for Tis when final pathology shows no residual disease.