Endoscopic management of adenomatous ampullary lesions

Figure 1 Technique of en-bloc ampullectomy. A: Lesion is identified; B: Submucosal (saline + epinephrine) injection; C: With the snare tip anchored above the papillary mound the entire papilla is snared; D: Check mobility and ensure the snare is firmly closed; E: En-bloc ampullary resection. Biliary and pancreatic (guidewire) orifice is identified; F: Biliary and pancreatic stents are placed. Adjuvant APC therapy is applied; G: Tissue retrieval with the snare; H: Ampullectomy specimen; I: Ampullary adenoma: tubulovillous architecture that shows neoplastic epithelial cells with pseudostratified and enlarged hyperchromatic nuclei. Adjacent there is normal duodenal mucosa. (HE: 20 ×). (Courtesy of Mercedes Hernando, MD). APC: Argon plasma coagulation.