A closing window ...

Here is a circumferential duodenal polyp situated in the second part of the duodenum. The patient is somewhat uncomfortable and your 'window of opportunity' is closing. 
WHERE SHOULD YOU TARGET YOUR BIOPSY?

■ 12 O'clock

Looks amourphous and worrying but not the right answer

■ 3 O'clock

Wouldn't be my priority site

■ 6 O'clock

This is the least worrying spot!

■ 9 O'clock

Absolutely - for two reasons!

explanation

In general ampullary or peri-ampullary adenomas are far more likely to turn malignant than adenomas situated elsewhere in the duodenum. This is the first reason, why you should target your biopsy at 9 O'clock.  There is a second reason and that is that the most 'chunky' polyp is at 9 O'clock. In my experience, the larger the 'polyp volume', the greater is the risk of malignant conversion. 

So should we offer an ampullectomy?  I would offer this to anyone with a life-expectancy of 10 years or more, I would consider (no promises) anyone with a life-expectancy of 5 years or more IF there is HGD on biopsies and there is no evidence of ductal obstruction (pt never had jaundice and there is no ductal dilatation or MRI or on EUS). 

Of course, an ampullectomy (probably better called a 'papillectomy') is dangerous but less dangerous than surgery.  In Leeds we quote the following risks of a papillectomy: 1:10 risk of acute pancreatitis for up to a few months after the procedure, 1:10 risk of late bleeding for up to 2 weeks after the procedure, 1:50 risk of a perforation, a 1:10 risk of late papillary stenosis, 1:20 risk of acute cholangitis and a 1:200 risk of death

Tiger country!!!