Endoscopic treatment of ampullary adenomas in familial adenomatous polyposis

Duodenal adenomas, usually considered premalignant, are found in less than or equal to 100% of patients with familial adenomatous polyposis (FAP). Endoscopic screening is accepted, but the optimal treatment is unclear. Our objective was to assess endoscopic treatment of the upper gastrointestinal tract in patients with FAP. We reviewed the clinical records of 393 FAP patients in detail. Six patients had ampullary cancers. Sixty-nine had periampullary adenomas, none of whom developed malignancy during follow-up. Several endoscopic approaches were used, leading to various outcomes. (a) Follow-up with ampullary biopsy was the only method in 18 patients, with macroscopic improvement in one, unchanged condition in 11, and enlargement of adenomas in six. (b) Thermal ablation was used in 19 patients, with resolution in 10, improvement in seven, unchanged condition in one, and one recurrence. (c) Yearly push enteroscopy, duodenoscopy, and ampullary biopsies were conducted in 11 of the 19 patients treated first with thermal ablation. Positive biopsies resulted in endoscopic retrograde cholangiopancreatography (ERCP), prophylactic sphincterotomy, and ablation with reexamination every 2-6 months. Follow-up of the patients treated with this last and favored strategy showed that five experienced resolution of symptoms, five had macroscopic improvement, and one had macroscopic as well as histologic progression. We conclude that patients with FAP should have periampullary surveillance, including duodenoscopy and biopsies from the time of diagnosis. Periampullary adenomas can be eradicated endoscopically. It is not clear whether ablation of adenomas or periodic biopsy is the ideal treatment.