Approach to the endoscopic resection of duodenal lesions

Figure 12 Ampullary evaluation followed by endoscopic papillectomy and endoscopic retrograde cholangiopancreatography. A 2-cm adenoma of the Ampulla of Vater (major papilla) was referred for endoscopic management (A); Endoscopic ultrasonography showed no invasion of the ampullary lesion into the duodenal muscularis propria or pancreas (B); Sterile normal saline was injected to lift the ampullary adenoma (C); after which hot-snare resection was accomplished (D); The adenoma was resected en bloc and the cut distal bile duct was evident following papillectomy (E); A biliary sphincterotomy was performed (F) and a 5-Fr, 4-cm-long, polyethylene, single-pigtail stent was placed into the pancreatic duct of Wirsung (G). Rectal indomethacin was also administered to reduce the risk of post-ERCP pancreatitis. Endoclips were used to provide mucosal closure of the inferior margin of the resection.