Post written by Kazuki Hama, MD, and Takao Itoi, MD, PhD, FASGE, from the Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan.

Ampullary tumors with intraductal extension are typically treated with pancreaticoduodenectomy, a procedure associated with significant morbidity, especially in elderly patients.

Recently, endoscopic approaches using adjunctive ablative therapies such as intraductal radiofrequency ablation (ID-RFA) and argon plasma coagulation (APC) have shown promise in managing residual or recurrent lesions after endoscopic papillectomy (EP). Yet, treating tumors with extensive intraductal spread remains challenging because of the difficulty of complete resection and high recurrence risk.

In this case, we describe a combined endoscopic approach using EP, ID-RFA, and APC for treatment of a giant ampullary tumor with biliopancreatic duct extension in a 75-year-old woman who declined surgery. This stepwise endoscopic strategy enabled gradual tumor reduction and eventual complete eradication of the lesion over an 18-month follow-up period.

This case highlights the feasibility and effectiveness of a multimodal endoscopic approach—combining EP, ID-RFA, and APC—for treating ampullary tumors with intraductal extension in an elderly patient for whom pancreaticoduodenectomy posed a high surgical risk.

This is particularly important because:

• The tumor had biliopancreatic duct extension, which is usually an indication for pancreaticoduodenectomy, but the patient declined surgery.
• It shows the use of multimodal endoscopic therapy in achieving long-term control and eventual complete eradication of the lesion without major surgery.
• It provides technical insights, such as snare selection, stent placement, RFA settings, and APC use in a complex lesion.

Ultimately, the video emphasizes that for select patients, particularly the elderly or those with comorbidities, endoscopic treatment can be safe and curative. Showcasing this case offers valuable learning points for endoscopists facing similar clinical scenarios.

Even in cases with intraductal extension, a stepwise endoscopic approach combining EP, ID-RFA, and APC can be effective, especially for elderly patients at high surgical risk. Careful technique and appropriate stent placement help minimize adverse events. Ongoing endoscopic follow-up is essential to monitor for residual or recurrent lesions and ensure long-term success.

Thank you for the opportunity to present our case.

Strategy for managing the mass with biliopancreatic extension: First, resect the large mass using endoscopic papillectomy, followed by treatment of the bile duct extension using intraductal radiofrequency ablation. Pancreatic duct radiofrequency ablation carries a high risk of pancreatitis; therefore, treat the pancreatic duct extension using argon plasma coagulation.

Read the full article online.

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