Post written by Dario Ligresti, MD, from the Endoscopy Service, Department of Diagnostic and Therapeutic Services, Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione – Istituto di Ricovero e Cura a Carattere Scientifico, and Giacomo Emanuele Maria Rizzo, MD, from the Department of Surgical and the Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy.

We describe a case of a 66-year-old man with a history of pulmonary cancer who was admitted at the emergency department of a secondary center for persistent abdominal pain and hyperlipasemia.

Initially, a CT scan and gastroscopy identified a pedunculated duodenal polyp of about 26 mm in diameter, but major papilla was unrecognizable. The patient was then referred to our institute and underwent an EUS evaluation showing a mild dilation of the common bile and main pancreatic ducts, both extending all the way through the stalk of the lesion to the polyp head.

Therefore, we planned ERCP with hot snare en-bloc endoscopic resection and subsequent biliary and pancreatic stenting. Moreover, an intraprocedural mild oozing bleeding was successfully treated with monopolar coagulating forceps (Coagasper; Olympus, Tokyo, Japan) and application of hemostatic matrix (Purastat; 3D-Matrix Europe SAS, Caluire et Cuire, France).

At the end, histology showed an R0 resection of a tubulo-villous adenoma with high-grade dysplasia.

This is an extremely rare case of well-managed endoscopic resection of pedunculated ampulloma involving the biliary and pancreatic ducts. We consider it an outstanding technical and didactic view of this procedure, and we showed management of an intraprocedural adverse event (bleeding from the edge of the resected area).

Moreover, few similar cases of ampullary or periampullary polyps have been described in the literature, and only 2 of them have been endoscopically resected, even if none involved the biliary and pancreatic ducts.

We think it is extremely important to prepare your initial strategy as best as you can before starting this type of interventional endoscopic procedure, know what you will resect, and be ready to manage adverse events.

In our case, the patient was under anticoagulant therapy (warfarin) because of mechanical aortic valve replacement, so we stopped anticoagulation 1 week before the procedure, switching to low-molecular-weight heparin, which was administered up to 12 hours before the procedure.

Nonetheless, intraprocedural bleeding from the resected area occurred even if the international normalized ratio was in the normal range at the time of resection. Yet, our case will surely encourage other endoscopists to always consider EUS examination before resection of a pedunculated duodenal polyp in order to first evaluate the involvement of major papilla with the biliary and pancreatic ducts and prepare the best resection strategy.

Postresection view of the specimen clearly showing the common bile duct and main pancreatic duct in the stalk of the lesion (guidewires were placed postresection to highlight both ducts).

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.