Ampullary adenomas greater than 20 mm in size have higher risk of recurrence compared to smaller lesions

Lesions of ampulla of Vater are uncommon and often discovered incidentally. Most adenomatous lesions can be treated by endoscopic papillectomy which can obviate the need for surgery. Data regarding effectiveness for endoscopic papillectomy especially for larger lesions is lacking. We aimed to assess the impact of polyp size on recurrence on subsequent ERCP procedures following initial papillectomy.

After approval of the study from local IRB, patients with diagnosis of ampullary lesion who were treated with endoscopic papillectomy at our quaternary care referral center were included in the study from January 2017 to December 2024. Charts were obtained using the relevant billing and ICD10 codes from electronic medical records and were then individually reviewed by a group of researchers to extract relevant information. Patients were divided into two groups based on polyp size; ≤ 20 mm and > 20 mm for comparison.

A total of 71 patients underwent endoscopic papillectomy at our institute during this time period. 37 had polyps less than 20 mm (smaller polyp group), and 34 had polyps ≥ 20 mm (larger polyp group). Patients with larger polyps were older with a mean age of 67.5 ± 10.2 compared to 57.8 ± 16.0 in the smaller polyp group (p = 0.019). There was no significant difference between race and sex of the two groups. Hot snare was the most employed tool in both groups, with occasional use of cold snare in conjunction (44.1% vs 29.7%, p = 0.219). A lifting solution was used in 91.2% of larger polyp cases and 83.8% of smaller polyp cases (p = 0.266). Pancreatic duct stenting was performed in most cases in both groups (88.2% vs 89.2%, p = 1.0), while bile duct stenting was more common in the larger polyp group (94.1% vs 70.3%, p = 0.013). Complication rates were similar across groups, including pancreatitis (14.7% vs 8.1%) and bleeding (14.7% vs 8.1%, p = 0.248), with no cases of perforation or cholangitis. Pathology confirmed adenoma in 87.9% of larger polyp cases and 81.1% of smaller ones (p = 0.732). Recurrence on subsequent surveillance ERCPs occurred in 38.2% of larger polyp patients and 13.5% of smaller polyp patients (p = 0.028). Mean time to recurrence was similar (2.9 ± 10.3 vs 2.8 ± 14.6 months, p = 0.018), and patients underwent an average of 2.3 ± 1.6 vs 1.9 ± 1.9 follow-up ERCPs respectively (p = 0.208). Total follow-up time was also similar between groups (21.5 ± 17.9 vs 23.4 ± 25.4 months, p = 0.767).

Polyp size greater than 20 mm appears to have a higher rate of recurrence or residual polyp on subsequent ERCP procedures following initial papillectomy. Close follow up and detailed examination of the resection site must be pursued on subsequent surveillance procedures following resection of these lesions.