Familial Adenomatous Polyposis: Should Routine Ampulla Biopsies Be Performed?
Vanessa M. Shami, MD, FASGE, reviewing Mehta NA, et al. Clin Gastroenterol Hepatol 2020 May 31.
Duodenal and ampullary cancers are the most common causes of death in patients with familial adenomatous polyposis (FAP) who have undergone colectomy. Current guidelines recommend inspection of the ampulla; however, a recommendation about the practice of routine biopsy is variable due to the risk of pancreatitis. This single-center, retrospective cohort study evaluates the risk of pancreatitis in patients with FAP who have undergone routine ampullary biopsies during surveillance examinations and the impact of biopsy results on the Spigelman stage (SS).
This study included 273 patients with FAP who had biopsies collected from the ampulla during 792 EGDs completed between January 2011 and December 2018. Initially, a gastroscope was used, and if the ampulla was not fully visualized, a cap was placed and/or a duodenoscopy was performed. Of the 546 examinations in which the ampulla appeared normal, 7.9% were at least adenomatous. Of the 226 with an abnormal-appearing ampulla, only 13 (5.8%) were normal; the rest were at least adenomatous, with one case of adenocarcinoma. Two of 273 patients (0.73%) developed postprocedure pancreatitis, defined by having any two of the following: abdominal discomfort, lipase more than 3 times the upper limits of normal, and/or radiologic evidence of pancreatitis. One of these patients developed two separate episodes of pancreatitis; both patients with postprocedure pancreatitis recovered promptly. The biopsy data increased SS in 36 patients (13.2%), which prompted consideration of prophylactic duodenectomy for 3.3% of these patients.
COMMENTCareful inspection of the ampulla is an established recommendation in patients with FAP. While current guidelines vary on recommendations for performing routine ampullary biopsies, this study demonstrates that the risk of pancreatitis is quite low. Nonetheless, detection of adenomatous tissue in a normal-appearing ampulla (<1 cm) oftentimes does not prompt the need for resection or management changes. While performing biopsies seems reasonable in FAP patients who have an abnormal-appearing or enlarged ampulla, the jury is still out on performing routine biopsies in all patients.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Mehta NA, Shah RS, Yoon JY, et al. Risks, benefits, and effects on management for biopsy of the papilla in patients with familial adenomatous polyposis. Clin Gastroenterol Hepatol 2020 May 31. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2020.05.054)
