Local resection for ampullary tumors. Is there a place for it?

Surgical ampullectomy: A comprehensive review

Tumours of the ampulla of Vater are relatively uncommon lesions of the digestive system. They are typically diagnosed at an earlier stage than other types of tumours in this region, due to their tendency to invoke symptoms by obstructing the bile duct or pancreatic duct. Consequently, many are potentially curable by excision. Surgical ampullectomy (SA) (or transduodenal ampullectomy) for an ampullary tumour was first described in 1899, but was soon surpassed by pancreatoduodenectomy (PD), which offered a more extensive resection resulting in a lower risk of recurrence. Ongoing innovation in endoscopic techniques over recent decades has led to the popularization of endoscopic papillectomy (EP), particularly for adenomas and even early cancers. The vast majority of resectable ampullary tumours are now treated using either PD or EP. However, SA continues to play a role in specific circumstances. Many authors have suggested specific indications for SA based on their own data, practices, or interpretations of the literature. However, certain issues have attracted controversy, such as its use for early ampullary cancers. Consequently, there has been a lack of clarity regarding indications for SA, and no evidence-based consensus guidelines have been produced. All studies reporting SA have employed observational designs, and have been heterogeneous in their methodologies. Accordingly, characteristics of patients and their tumours have differed substantially across treatment groups. Therefore, meaningful comparisons of clinical outcomes between SA, PD and EP have been elusive. Nevertheless, it appears that suitably selected cases of ampullary tumours subjected to SA may benefit from favourable peri-operative and long-term outcomes with very low mortality and significantly long survival, hence its role in this setting warrants further clarification, while it can also be useful in the management of specific benign entities. Whilst the commissioning of a randomised controlled trial seems unlikely, well-designed observational studies incorporating adjustments for confounding variables may become the best available comparative evidence for SA, potentially informing the eventual development of consensus guidelines. In this comprehensive review, we explore the role of SA in the modern management of ampullary lesions.

Pancreas-preserving duodenectomy for treatment of a duodenal papillary tumor: A case report

BACKGROUND

Duodenal papillary tumor is a rare tumor of the digestive tract, accounting for about 0.2% of gastrointestinal tumors and 7% of periampullary tumors. The clinical manifestations of biliary obstruction are most common. Some benign tumors or small malignant tumors are often not easily found because they have no obvious symptoms in the early stage. Surgical resection is the only treatment for duodenal papillary tumors. At present, the methods of operation for duodenal papillary tumors include pancreatoduodenectomy, duodenectomy, ampullectomy, and endoscopic resection.

CASE SUMMARY

A 47-year-old man was admitted to because of a duodenal mass that had been discovered 2 mo previously. Electronic gastroscopy at another hospital revealed a duodenal papillary mass that had been considered to be a high-grade intraepithelial neoplasia. Therefore, we conducted a multidisciplinary group discussion and decided to perform a pancreas-preserving duodenectomy and a R0 resection was successfully performed. After surgery, the patient underwent a follow-up period of 5 yr. No recurrence or metastasis occurred.

CONCLUSION

According to our experience with a duodenal papillary tumor, compared with pancreaticoduodenectomy, the use of pancreas-preserving duodenectomy can preserve pancreatic function, maintain gastrointestinal structure and function, reduce tissue damage and complications, and render the postoperative recovery faster. Pancreas-preserving duodenectomy for treatment of a duodenal papillary tumor is feasible under strict control of surgical indications.

Endoscopic resection of advanced and laterally spreading duodenal papillary tumors

Historically, neoplasia of the duodenal papilla has been managed surgically, which may be associated with substantial morbidity and mortality. In the absence of invasive cancer, even lesions with extensive lateral duodenal wall involvement, or limited intraductal extension may be cured endoscopically with a superior safety profile. Endoscopic papillectomy is associated with greater risks of adverse events such as bleeding than resection elsewhere in the gastrointestinal tract. Additionally site-specific complications such as pancreatitis exist. A structured approach to lesion assessment, adherence to technical aspects of resection, endoscopic management of complications and post-resection surveillance is required. Advances have been made in all facets of endoscopic papillary resection since its introduction in the 1980s; extending the boundaries of endoscopic cure, optimizing outcomes and enhancing patient safety. These will be the focus of the present review.

Ampullectomy for an unexpected ampullary hamartoma in a heterotaxic patient

INTRODUCTION

Heterotaxy designates rare congenital disorders of organ positioning in the thoracic and abdominal cavities, which can be associated with numerous anomalies, complicating the surgical management because of the loss of conventional anatomic landmarks.

PRESENTATION OF CASE

A 72-year-old man was found to have asymptomatic cholestasis. Further workup included computed tomography and magnetic resonance cholangiopancreatography that revealed anomalies of lateralization of digestive organs associated with intestinal malrotation and polysplenia, and a stone-like element in the main bile duct. Endoscopic retrograde cholangiopancreatography failed to extract the lesion. Laparotomy found no stone, but a polypoid tumor with ampullary implantation. Pancreaticoduodenectomy was judged unreasonable due to the presence of macroscopic cirrhosis and a complete ampullectomy was performed. Histopathological examination revealed a hamartomatous polyp.

DISCUSSION

The unusual angle of the duodenoscope in a left-sided duodenum may have contributed to the improper pre-operative diagnosis. Endosonography could have recognized the tissular origin of the lesion and prompted a more detailed preoperative planning. It was fortunate that the patient ended up receiving the appropriate treatment despite the absence of an adequate pre-operative diagnosis, as the option of performing an extended resection was ruled out due to the presence of cirrhosis.

CONCLUSION

Although heterotaxy leads to increased technical difficulties in performing usual endoscopic and surgical procedures, it can be safely managed by experienced surgeons as illustrated by the present case. Imaging modalities have limited sensitivity in the diagnosis of small ampullary tumors. As false-negatives are likely to occur, this possibility should guide the choice of the best operation.

Endoscopic ultrasound evaluation in the surgical treatment of duodenal and peri-ampullary adenomas

AIM: To investigate endoscopic ultrasound (EUS) for predicting depth of mucosal invasion and to analyze outcomes following endoscopic and transduodenal resection.

METHODS: Records of 111 patients seen at our institution from November 1999 to July 2011 with the post-operative pathological diagnosis of benign ampullary and duodenal adenomas were reviewed. Records of patients who underwent preoperative EUS for diagnostic purposes were identified. The accuracy of EUS in predicting the absence of muscular invasion was assessed by comparing EUS reports to the final surgical pathological results. In addition, the incidence of the post-operative complications over a period of 30 d and the subsequent long-term outcome (recurrence) over a period of 30 mo associated with endoscopic and transduodenal surgical resection was recorded, compared and analyzed.

RESULTS: Among 111 patients with benign ampullary and duodenal adenomas, 47 underwent preoperative EUS for 29 peri-ampullary lesions and 18 duodenal lesions. In addition, computed tomography was performed in 18 patients, endoscopic retrograde cholangio-pancreatography in 10 patients and esophagogastroduodenoscopy in 22 patients. There were 43 patients with sporadic adenomas and 4 patients with familial adenomatous polyposis (FAP)/other polyposis syndromes. In 38 (81%, P < 0.05) patients, EUS reliably identified absence of submucosal and muscularis invasion. In 4 cases, EUS underestimated submucosal invasion that was proven by pathology. In the other 5 patients, EUS predicted muscularis invasion which could not be demonstrated in the resected specimen. EUS predicted tumor muscularis invasion with a specificity of 88% and negative predictive value of 90% (P < 0.05). Types of resection performed included endoscopic resection in 22 cases, partial duodenectomy in 9 cases, transduodenal ampullectomy with sphincteroplasty in 10 cases and pancreaticoduodenectomy in 6 cases. The main post-operative final pathological results included villous adenoma (n = 5), adenoma (n = 8), tubulovillous adenoma (n = 10), tubular adenoma (n = 20) and hyperplastic polyp (n = 2). Among the 47 patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural complications which included retroperitoneal hematoma, intra-abdominal abscess, wound infection, delayed gastric emptying and prolonged ileus. After median follow-up of 20 mo there were 6 local recurrences (13%, median follow-up = 20 mo) 4 of which were in patients with FAP.

CONCLUSION: EUS accurately predicts the depth of mucosal invasion in suspected benign ampullary and duodenal adenomas. These patients can safely undergo endoscopic or local resection.

Cap-assisted EMR of large, sporadic, nonampullary duodenal polyps

BACKGROUND

EMR is an effective alternative to surgery for the removal of nonampullary duodenal polyps (NADPs). Cap-assisted EMR (EMR-C) has been rarely performed in the duodenum because of the risk of perforation.

OBJECTIVE

To evaluate the safety and effectiveness of EMR-C for the removal of large (≥ 15 mm) NADPs.

DESIGN

Retrospective study.

SETTING

Tertiary-care referral center.

PATIENTS

Between 2000 and 2010, 26 consecutive patients with sporadic NADPs underwent EMR-C.

INTERVENTION

EMR with the cap technique.

MAIN OUTCOME MEASUREMENTS

Complete eradication of polyps, complications, and recurrence.

RESULTS

A total of 14 sessile polyps (53.8%), 7 lateral spreading type nongranular tumors (26.9%), and 5 lateral spreading type granular tumors (19.2%) were treated. The median size of lesions was 15 mm. Five lesions involved one-half of the luminal circumference. Post-EMR histologic assessment showed low-grade dysplasia in 5 patients (19.2%) and high-grade dysplasia in 18 patients (69.2%). Three patients (11.5%) had well-differentiated endocrine tumors. Complete eradication was obtained in 25 of 26 (96%) patients. No perforations occurred. Three cases of intraprocedural bleeding were managed endoscopically. Median follow-up was 6 years (range 1-10 years). Residual adenomatous tissue was observed in 3 patients in lesions of 50 mm. In one of these cases, an adenocarcinoma occurred after 8 months, which was managed surgically.

LIMITATIONS

Retrospective design, single center.

CONCLUSION

This study supports the efficacy and safety of EMR-C for removing NADPs. Regular follow-up is mandatory because of the high risk of residual or recurrent adenomatous tissue and even cancer.

Pancreas-sparing duodenectomy with regional lymphadenectomy for pTis and pT1 ampullary carcinoma

BACKGROUND

The role of pancreas-sparing duodenectomy (PSD) in the treatment of ampullary carcinoma (Amp Ca) with local lymph node metastasis remains controversial. The aim of this study was to investigate the feasibility, safety, and long-term prognosis of PSD with regional lymphadenectomy in the treatment of early-stage (pTis/pT1) Amp Ca with or without regional lymph node metastasis.

METHODS

Between May 2005 and November 2009, 31 consecutive patients with Amp Ca were enrolled in this study; 25 underwent PSD. A retrospective control group of 28 patients who underwent pancreatoduodenectomy (PD) for Amp Ca during the same period was established. These 2 groups were matched in terms of demographic data, tumor size, and TNM classification.

RESULTS

In the PSD group, 9 patients (36%) had regional lymph node metastasis, and 23 patients (92%) had R0 resection. Patients who underwent PSD achieved favorable results in intraoperative blood loss, duration of hospital stay, and morbidity rate. The 3-year overall and disease-free survival in PSD group were 72% and 61%, respectively. There were no differences in hospital mortality and long-term survival between the 2 groups, even for patients with lymph node metastasis (N1).

CONCLUSION

PSD with regional lymphadenectomy is feasible and safe in the treatment of pTis/pT1 Amp Ca with or without regional lymph node metastasis. Long-term survival and morbidity rates are also favorable. PSD can be performed as an alternative of PD in selected patients with Amp Ca.

Pedunculated early ampullary carcinoma treated by ampullectomy: report of a case

CASE REPORT

A 30-year-old woman was admitted to our hospital for treatment of an ampullary tumor. Upper gastrointestinal endoscopy revealed a pedunculated tumor in the ampulla of Vater with a diameter of 50 mm, which was biopsied and diagnosed as tubulovillous adenoma with moderate atypia. Endoscopic ultrasonography demonstrated a hypoechoic tumor limited to the mucosa and without evidence of lymph node metastasis. Since endoscopic resection was not indicated because of the large size and pedunculated morphology with a long stalk, the patient underwent ampullectomy and papilloplasty. Histological examination revealed well-differentiated tubular adenocarcinoma in tubular adenoma with severe atypia limited to the mucosa. The patient remains well with no evidence of recurrence 10 months after resection.

DISCUSSION

Ampullectomy is an established method for ampullary tumor, but such a tumor with a long stalk is rare.

Giant laterally spreading tumors of the papilla: endoscopic features, resection technique, and outcome (with videos)

BACKGROUND

Successful endoscopic treatment of conventional papillary adenomas is well described. However, many authors recommend surgical resection for larger lesions with extrapapillary extension.

OBJECTIVE

To describe the classification, technique, and outcome for the endoscopic resection of giant laterally spreading tumors of the papilla (LST-P).

DESIGN

Single-center case series.

SETTINGS

Tertiary referral academic gastroenterology unit.

PATIENTS

Patients referred for endoscopic treatment of LST-P.

INTERVENTION

Pre-resection staging and single-session endoscopic removal of papillary adenomas. For those classified as LST-P (>30 mm, extending beyond the papilla onto the duodenal wall and involving as much as two thirds of the duodenal circumference), a standardized single-session EMR technique was used.

MAIN OUTCOME MEASUREMENTS

Technical success, complications, and adenoma recurrence for single-session removal of LST-P. Outcomes were compared with those of conventional ampullary adenoma resection during the same period.

RESULTS

Twenty-five patients with ampullary adenomas were referred. In 10 patients identified with LST-P (mean age 70.2 years; adenoma size 30-80 mm), combination EMR and papillectomy was performed in a single session. The median admission duration was 1 night (range 0-35). Complications included bleeding (30%) and cholecystitis (10%), with no cases of pancreatitis or perforation. Adenoma recurrence at 3 months was found in 1 patient (10%). Complication and recurrence rates in smaller (<30 mm) ampullary adenoma resections were not significantly different.

LIMITATIONS

A relatively uncommon entity and thus small sample size.

CONCLUSIONS

Endoscopic resection of carefully staged LST-P is a viable therapeutic alternative to surgery. In experienced hands, the outcomes are comparable to those for conventional ampullary adenomas.

Reappraisal of endosonography of ampullary tumors: correlation with transabdominal sonography, CT, and MRI

PURPOSE

To reappraise the accuracy of transabdominal sonography (US), CT, MRI, and endosonography (EUS) in the diagnosis and staging of ampullary tumors.

METHOD

We reviewed the medical records and the images of 41 consecutive patients with ampullary tumors. Tumor detection rate and accuracy of TNM (tumor-node-metastasis) staging of malignant tumors were determined. Imaging findings were correlated with histopathologic findings.

RESULTS

The detection rates for ampullary tumors were 97.6% for EUS, 81.3% for MRI, 28.6% for CT, and 12.2% for US (p < 0.001 for EUS versus CT; p < 0.001 for EUS versus US; p > 0.05 for EUS versus MRI). The accuracy in T staging for ampullary carcinomas was 72.7% for EUS, 53.8% for MRI, and 26.1% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI). The accuracy in N staging for ampullary carcinomas was 66.7% for EUS, 76.9% for MRI, and 43.5% for CT with no statistically significant difference between the 3 modalities. The sensitivity in detecting malignant lymph nodes was 46.7% for EUS, 25.0% for MRI, and 0% for CT (p < 0.01 for EUS versus CT; p > 0.05 for EUS versus MRI; p > 0.05 for MRI versus CT). Transpapillary stenting, advanced tumor extension (>T2), large tumor size (>2 cm), tumor differentiation, and endoscopic appearance of tumor growth did not significantly influence EUS accuracy in T or N staging (p > 0.05).

CONCLUSION

EUS was superior to CT and was equivalent to MRI for tumor detection and T and N staging of ampullary tumors. Neither indwelling stents nor tumor size, differentiation, or endoscopic appearance affected the staging accuracy of EUS.

Prognostic impact of perineural invasion following pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma

The aim of this study was to identify prognostic factors in patients undergoing pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma. The records of 46 consecutive patients with ampullary carcinoma who underwent pancreatoduodenectomy from 1988 through 2006 were retrospectively reviewed. A 98% rate of potentially curative (R0) resection was achieved. There was no 30-day mortality. Overall 5-year survival rate was 64%. Univariate analysis revealed that T3 and T4 tumor (i.e., pancreatic parenchymal invasion) (P < 0.001), lymph node metastasis (P = 0.01), and perineural invasion (P < 0.001) were significant predictors of poor prognosis. Furthermore, perineural invasion was found to be a significant independent predictor of poor prognosis by multivariate analysis (P = 0.024). Pancreatoduodenectomy with lymphadenectomy for ampullary carcinoma is a safe surgical procedure with an acceptable cure rate. The presence of perineural invasion may be useful for predicting poor prognosis in patients with ampullary carcinoma who undergo potentially curative resection.

Transduodenal local resection for low-risk group ampulla of vater carcinoma

BACKGROUND

Carcinoma of the ampulla of Vater has a more favorable prognosis, compared to other malignant tumors of the periampullary region, because it usually presents with symptoms in the early stage. However, treatment by local resection only of the ampullary carcinoma remains controversial. The aim of this study was to evaluate the treatment results of the ampulla of Vater carcinoma according to different types of operation in low-risk-group patients.

METHODS

We retrospectively reviewed the medical records of 17 low-risk-group patients among a total of 102 patients with ampulla of Vater carcinoma who had underwent curative surgery from 1992 to 2002. All specimens were critically reviewed by a single expert pathologist, and the relationship between surgical outcomes and operation type was assessed.

RESULTS

The low-risk group was comprised of 10 men and 7 women with a median age of 57.8 years. Thirteen of 17 patients underwent a pancreaticoduodenectomy (PD) or a pylorus preserving pancreaticoduodenectomy (PPPD), while 4 patients underwent a transduodenal local resection (TDLR). The operation time was significantly shorter in the TDLR group, compared to the PD or PPPD groups. Among the 17 patients, there was only 1 case of recurrence in the inguinal area 33 months after the pancreaticoduodenectomy.

CONCLUSIONS

Transduodenal local resection is a comparable mode of operation for low-risk-group patients with Ampulla of Vater carcinoma. In particular, it is essential to evaluate the invasion depth in preoperative endoscopic ultrasonography, cell differentiation in preoperative biopsy, and positivity of resection margin accurately by using frozen section during the operation.

Local resection of ampullary tumors

Ampullary tumors are rare. Their appropriate treatment is still contraversial. Local resection of ampullary tumors is a relatively simple procedure with a lower operative morbidity and mortality rate than pancreatoduodenectomy. However, the mortality of Whipple procedure has significantly decreased in the past two decades, as reported in many medical centers. Since accurate preoperative histological diagnosis and staging of the tumors are often difficult and inconclusive, local resection should be limited in those with a poor health status, or in those refusing major operations, although it is considered an alternative in patients with a high co-morbidity.

Prospective evaluation of indeterminate ERCP findings by intraductal ultrasound

BACKGROUND AND AIM

Although the role of intraductal ultrasound (IDUS) in the evaluation of specific disease entities is well known, its utility in evaluating indeterminate findings in a heterogeneous group of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) is unknown. This study evaluates the diagnostic accuracy of IDUS in patients with indeterminate findings at ERCP.

METHODS

This was a prospective study of all patients who underwent IDUS for evaluation of an indeterminate biliary stricture or main pancreatic duct (MPD) dilation noted at ERCP over an 8-month period. The accuracy of IDUS was established based on long-term follow-up, surgery, or further investigations.

RESULTS

Twenty-nine (5%) of 600 patients who underwent ERCP had an indeterminate finding that warranted further evaluation by IDUS: this was biliary stricture in 19 patients and MPD dilation in 10. Technical success was 100%. Mean duration of follow-up was 435 days (range 192-614 days). In patients with biliary stricture, IDUS diagnosed 11 as benign and eight as malignant. In patients with MPD dilation, IDUS diagnosed intraductal papillary mucinous tumor in six patients and chronic pancreatitis in four. Findings on IDUS supported the correct diagnosis in 27 of 29 patients (93%). In two patients with dominant hilar stricture in the setting of primary sclerosing cholangitis, IDUS was false positive in one and false negative in the other. One patient died of multiorgan failure due to post-ERCP pancreatitis.

CONCLUSIONS

A technically easy procedure, IDUS offers unique advantages in the evaluation of patients with indeterminate findings at ERCP.

Large periampullary villous tumor of the duodenum

A 67-year-old woman, who had symptoms of epigastric pain and abdominal distension, was found, on endoscopy, to have a large sessile villous adenoma of the periampullary duodenum. Despite the lack of evidence of malignancy, a pancreaticoduodenectomy procedure was performed, mainly because of the tumor size and site, involving the ampulla of Vater. The presence of the carcinoma was diagnosed only in the resected specimen by definitive histology. Because there is no general consensus on the optimal surgical procedure for the treatment of villous tumors of the duodenum, especially for the early stages, the indications for the operative procedure are discussed, based on a review of the literature.

Carcinoma of the ampulla of Vater: factors influencing long-term survival of 127 patients with resection

INTRODUCTION

The prognosis for patients with carcinoma of the ampulla of Vater is improved relative to other periampullary neoplasms. Identification of independent prognostic factors in ampullary carcinomas has been limited by the small number of tumors resected. The aim of the present study was to determine the clinicopathologic factors that influence long-term survival in patients with resected ampullary carcinoma.

METHODS

Clinicopathologic data were retrospectively reviewed for patients with ampullary carcinomas radically resected between March 1987 and September 2002. The correlation between clinicopathologic variables and survival of patients after resection was examined by the Kaplan-Meier method, the log-rank test, and Cox proportional hazards regression. Ampullary carcinomas were radically resected in 127 patients either by pancreaticoduodenectomy (n = 124) or local resection (n = 3).

RESULTS

Hospital mortality was 9.7%. The overall actuarial survival rates (including hospital deaths) at 1, 3, 5, and 10 years were 76.2%, 46.8%, 43.3%, and 35.7%, respectively. Factors that significantly influenced survival were lymph node status (P < 0.001), depth of tumor infiltration (P = 0.029), and TNM stage (P < 0.001) on univariate analysis. On multivariate analysis, both depth of infiltration and lymph node status were the independent determinants of survival after resection (P = 0.003, P = 0.005, respectively).

CONCLUSIONS

Carcinoma of the ampulla of Vater has a higher resectability rate and a much better survival rate than pancreatic cancer. Pancreaticoduodenectomy is the treatment of choice for this tumor. Long-term survival was independently influenced by the depth of tumor infiltration and lymph node metastasis.

Carcinoma arising from villous adenoma of the ampullary bile duct: Report of a case

Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct.

Therapeutic approach to tumors of the ampulla of Vater

BACKGROUND/AIM

Indications for local resection for tumors of the ampulla of Vater have not been established. The present study evaluated suitable treatments for tumors of the papilla of Vater.

PATIENTS AND METHODS

Clinicopathological factors were reviewed for 53 patients with tumors of the ampulla of Vater treated between February 1993 and August 2003.

RESULTS

Of 53 patients, 41 were treated surgically. Local resection was performed in 7 of these 41 patients, with a histologically involved margin evident in 4 patients. Lymph node metastasis was identified in 20 patients who received radical resection, including 1 patient with pT1 cancer.

CONCLUSION

Given the presence of some positive surgical margins, local resection is indicated as a therapeutic approach to tumors of the papilla of Vater only for benign tumors or some malignant tumors that cannot undergo pancreaticoduodenectomy (PD).

Impact of lymph node metastasis on survival in patients with pathological T1 carcinoma of the ampulla of Vater

To determine the prognostic factors for patients with pathological T1 (pT1) carcinoma of the ampulla of Vater, 36 consecutive patients with carcinoma of the ampulla of Vater who underwent surgery were retrospectively analyzed in terms of clinicopathological features. The overall 5-year Kaplan-Meier survival in all patients was 50.2%, and the median survival of all patients was 64.0 months. Factors favorably influencing a long-term outcome were the absence of lymph node metastasis (P < 0.0001), the absence of ulcer formation of the tumor (P = 0.0062), and the absence of tumor invasion into the duodenum (P = 0.0025) and the pancreas (P = 0.0098). In a multivariate analysis, lymph node metastasis was the only predictor of survival (P = 0.0023). In the pT1 stage patients, 20% of the patients had lymph node metastasis, and their survival was statistically poor compared to the pT1 patients without lymph node metastasis (P = 0.017). As for survival after the operation, there was no significant difference between pancreatoduodenectomy and pylorus-preserving pancreatoduodenectomy.

Predictors of failure after pancreaticoduodenectomy for ampullary carcinoma

BACKGROUND

Complete resection offers the only potential cure for ampullary carcinoma. We analyzed factors that contribute to treatment failure and survival in patients who underwent pancreaticoduodenectomy for ampullary carcinoma.

STUDY DESIGN

We retrospectively reviewed all patients who underwent pancreaticoduodenectomy between August 1994 and August 2003 for ampullary carcinoma. Demographic, clinical, and pathologic data were collected. Chi-square analysis was used for categorical data and the t-test was used for continuous variables. Kaplan-Meier analyses were compared using the log-rank test to examine patient survival.

RESULTS

Forty-three patients (24 men) aged 63.7 +/- 11.4 years (standard deviation) were followed for a mean of 23.9 months (median 660 days, range 18 to 2,249 days). Jaundice (n = 33) and weight loss (n = 13) were the most common presenting symptoms. Stage (p < 0.01) and degree of differentiation (p < 0.029) were significant predictors of failure by univariate analysis. But only stage (p < 0.04) was a significant predictor by multivariate analysis. Further analysis revealed that nodal status (p < 0.001), but not tumor grade, was a significant predictor of treatment failure. Neither demographic nor clinical variables were significant predictors. Five-year overall and disease-free survival rates were 67.4% and 51.4%, respectively. Both metastases and disease recurrence had significant impact on patient survival.

CONCLUSIONS

Tumor stage is associated with treatment failure after pancreaticoduodenectomy for ampullary carcinoma and may identify candidates for adjuvant therapy. Because an aggressive surgical approach can be adopted safely with the best chance for cure, we recommend that pancreaticoduodenectomy be offered to all patients with ampullary tumors when malignancy or dysplasia is in question.

Endoscopic resection of benign tumors of the duodenal papilla without and with intraductal growth

BACKGROUND

Endoscopic papillectomy of benign papillary tumor is still not widely practiced. Intraductal growth has been considered a contraindication for endoscopic therapy. This prospective study evaluates endoscopic papillectomy for treatment of benign papillary tumors without and with intraductal growth.

METHODS

Monofilament snare and monopolar electrocoagulation were used for papillectomy. A 7F stent was placed in the pancreatic duct. Patients with distal intraductal growth underwent sphincterotomy and endoscopic resection after exclusion of more proximal growth.

RESULTS

Between February 1985 and April 2004, 106 patients (109 lesions), 68 women, 38 men, median age 68 years (range 29-88 years) were included. Median tumor size was 2 cm (range 0.5-6 cm) with one session (range 1-8) required for removal. Nine patients had invasive carcinoma (8%). Surgery for incomplete removal or recurrence was performed in 12% of 75 patients without and 37% of 31 patients with intraductal growth (p < 0.01), respectively. Fifteen patients had recurrence (15%); but, only 4 required surgery. Endoscopic resection was curative (median follow-up, 43 months) in 83% without and 46% with intraductal growth (p < 0.001).

CONCLUSIONS

Endoscopic papillectomy is safe and effective, and may be feasible in cases of intraductal growth. Surveillance and, if required, re-treatment are mandatory because of the risk of recurrence.

Prospective, randomized, controlled trial of prophylactic pancreatic stent placement for endoscopic snare excision of the duodenal ampulla

BACKGROUND

Tumors that arise in the region of the major duodenal papilla account for 5% of GI neoplasms and 36% of resectable pancreaticoduodenal tumors. There is limited published literature that addresses the safety of endoscopic excision of the papilla. Although there is consensus about prophylactic pancreatic-duct stent placement, there is little supporting prospective data. The aim of this randomized, controlled trial was to compare the rates of postsnare ampullectomy pancreatitis in patients who did/did not receive prophylactic pancreatic-duct stent placement.

METHODS

Consecutive patients who were to undergo en bloc snare ampullectomy were randomized to placement of pancreatic-duct stent after ampullectomy or to no stent placement.

RESULTS

In total, 19 patients were enrolled, and 10 received pancreatic stents. Postprocedure pancreatitis occurred in 3 patients in the 24 hours after endoscopy, all cases occurred in the unstented group, 33% vs. 0% (stented group), p = 0.02. Median peak amylase level was 3692 U/L (range 1819-4700 U/L) and median peak lipase level was 11450 U/L (range 5900-17,000 U/L). All 3 patients were hospitalized for a median of 2 days (range 1-6), and all made a complete recovery.

CONCLUSIONS

Our findings suggest that a protective effect is conferred by pancreatic stent placement in reducing postampullectomy pancreatitis. Future large-scale studies are required to confirm this benefit.

Jaundice at presentation heralds advanced disease and poor prognosis in patients with ampullary carcinoma

Jaundice is a common manifestation of ampullary carcinoma. The aim of this study was to evaluate the correlation between jaundice at initial presentation and the degree of tumor spread and to determine the prognostic significance of jaundice in patients with ampullary carcinoma. Fifty-nine patients who had undergone curative resection for ampullary carcinoma were analyzed retrospectively. Jaundice was defined as a total bilirubin serum concentration of > or = 3 mg/dl. The median follow-up time was 106 months. Jaundice was noted at the time of initial presentation in 43 (73%) patients. Jaundice at presentation correlated with lymph node metastasis (p < 0.0001), lymphatic vessel invasion (p < 0.0001), invasion into the pancreas (p = 0.0007), and vascular invasion (p = 0.0487). Pancreatic invasion was absent in patients without jaundice. Superior mesenteric nodal involvement was more frequent in patients with jaundice (15/43) than in those without (0/16) (p = 0.0062). The survival of patients with jaundice (median survival 48 months; cumulative 10-year survival rate 39%) was worse than for patients without jaundice (median survival time not available; cumulative 10-year survival rate 86%) (p = 0.0014). In conclusion, jaundice at presentation predicts advanced-stage ampullary carcinoma and a poor prognosis. Pancreatic invasion and superior mesenteric nodal involvement were not observed in nonjaundiced patients.

Pancreatoduodenectomy for tumors of Vater's ampulla: report on 94 consecutive patients

Evaluation of prognostic factors of adenocarcinoma of Vater's ampulla is still a matter of debate. The aim of this study was to evaluate retrospectively factors that influence early and long-term outcomes in a 20-year single-institution experience on ampullary carcinoma. A total of 94 consecutive patients with ampullary carcinoma or adenoma with severe dysplasia were managed from 1981 to 2002. Among them, 64 underwent pancreatoduodenectomy, and the remaining 30 submitted to surgical (n = 5) or endoscopic (n = 25) palliative treatment. Demographic, clinical, and pathologic data were collected, and a comparison was made between patients who did or did not undergo resection. Standard statistical analyses were carried out in an attempt to establish a correlation between clinical variables, intraoperative and pathologic factors, and survival in patients with resection. A total of 85 (90.4%) patients had potentially resectable lesions due to the extent of the tumor, but only 64 (68%) underwent curative resection. The surgical morbidity rate was 34.3%. Postoperative mortality was 9.3%, with no deaths among the 38 more recently treated patients. Median survivals were 9 and 54 months for nonresected and resected patients, respectively. The overall 5-year survival was 64.4% for patients undergoing pancreatoduodenectomy. Survival was found to be significantly affected by resection, tumor size, tumor grade, and tumor infiltration. Patients with negative lymph nodes show a trend toward longer survival. In a multivariate analysis, only the depth of tumor infiltration influenced patient survival. Pancreatoduodenectomy is the treatment of choice for ampullary carcinoma and adenomas with high-grade dysplasia, with a good chance of long-term survival. Surgical resection remains the most important factor influencing outcome.

Clinicopathologic analysis of early ampullary cancers with a focus on the feasibility of ampullectomy

OBJECTIVE

The purpose of this study was to evaluate whether ampullectomy can substitute for pancreatoduodenectomy (PD) in early ampullary cancer by clinicopathologic study.

SUMMARY BACKGROUND DATA

Although ampullectomy has been attempted in early ampullary cancer (pTis, pT1), the indication and extent of resection have not been established.

METHODS

Of 201 patients who had undergone PD for ampullary cancer between 1986 and 2002, 67 patients with a histologic diagnosis of pTis (n = 5) or pT1 (n = 62) cancer were analyzed retrospectively. Pathologic PD specimens were reviewed to analyze the cancer spread pattern, and medical records were reviewed for clinical outcomes.

RESULTS

The 5-year survival rate of the 66 patients with early ampullary cancer (excluding one mortality) was 83.7%. Recurrence was confirmed in 12 patients (18.2%) and all died because of the recurrence. Pathologic review showed that 22 patients (32.8%) had at least one risk factor for failure after ampullectomy: lymph node metastasis (n = 6, 9.0%), perineural invasion (n = 1), or mucosal tumor infiltration along the CBD or P-duct (n = 15, 22.4%). Mean lengths of invasion into the CBD or the P-duct beyond the sphincter of Oddi were 7.7 mm (range, 1-25 mm) or 6.3 mm (range, 2-18 mm), respectively. Moreover, these risk factors were not correlated with tumor size, histologic grade, or the gross morphology of the primary tumor, although pTis cancer or pT1 cancer sized 1.0 cm or less was found to be least associated with risk factors.

CONCLUSIONS

Ampullectomy for early ampullary cancer should not be considered an alternative operation to PD because of the high possibility of recurrence. PD should be preferably performed for adequate radical resection, even in early ampullary cancer, and ampullectomy should be reserved for those who have pTis or pT1 cancer sized 1.0 cm or less with high operative risk.

Ampullary tumors: endoscopic versus operative management

Most ampullary adenomas (80%) are common benign ampullary tumors; however, they can range from mild dysplasia to high-grade dysplasia to invasive carcinoma. They are considered premalignant lesions found in the setting of familial polyposis syndromes or found sporadically, usually manifested by vague abdominal pain, liver enzyme elevation, jaundice, recurrent pancreatitis, or with uncommon symptoms such as gastrointestinal bleeding or duodenal obstruction. Endoscopic retrograde cholangiopancreatography with biopsy is a minimally invasive technique used to visualize these tumors directly and to evaluate their histologic characteristics. Definitive treatment primarily depends on these histologic results. Local resection has a high rate of recurrence (5% to 30%) and requires postoperative endoscopic surveillance, which is the reason it is not considered as a first choice in the management of ampullary tumors. The operative mortality is 10% or less for pancreaticoduodenectomy, a procedure of choice at most experienced centers for frank carcinoma, foci papillary adenocarcinoma in pre-excisional biopsies, or high-grade dysplasia ampullary adenomas. Endoscopic interventions for presumed benign ampullary adenomas have resolved symptoms of obstruction, but long-term follow up is necessary to detect early malignant transformation. In summary, the choice of treatment depends on level of surgical skill available, patient tolerance of long-term endoscopic surveillance versus radical surgery, and the presence or absence of coexisting familial adenomatous polyposis.

Carcinoid of the ampulla of Vater

Endocrine neoplasms only rarely occur at the ampulla of Vater, comprising mostly carcinoids and malignant carcinoids, as well as few cases of poorly differentiated endocrine carcinomas (small cell carcinomas). Only 105 cases are reported in the literature, most as single case reports. For many years, the neoplasms of the disseminated neuroendocrine cell system of the gastrointestinal tract have been subsumed as 'carcinoids'. Instead, in the latest World Health Organization (WHO) classification published in 2000, it is recommended to distinguish between (i) well-differentiated endocrine tumors (carcinoids); (ii) well-differentiated endocrine carcinomas (malignant carcinoids); and (iii) poorly differentiated endocrine carcinomas (small cell carcinomas). Patients with carcinoid tumors of the ampulla of Vater are very often free of clinical and laboratory findings that belong to the carcinoid syndrome. Approximately 26% of all patients with carcinoid tumor reported in the literature had neurofibromatosis. Besides endoscopic retrograde cholangiopancreatography, endosonography, computed tomography or magnetic resonance imaging may complete the staging approach of this tumor. The Kausch-Whipple procedure or pylorus-preserving pancreaticoduodenectomy is considered the treatment of choice for ampullary, well-differentiated carcinoids >2.0 cm and for ampullary neuroendocrine carcinomas. However, it should be considered that long-term survival of patients with ampullary carcinoids is also reported after local tumor excision (5-year survival rate of 90%). The dilemma is that the differentiation of neuroendocrine tumors cannot be assessed intraoperatively in most cases. Therefore, considering that the 5-year survival rate in patients with neuroendocrine carcinomas of the ampulla of Vater is very low without radical resection, neuroendocrine tumors of the ampulla of Vater without definite histological differentiation should undergo extended surgery.

Factors predictive of malignancy and endoscopic resectability in ampullary neoplasia

OBJECTIVE

Endoscopic treatment of ampullary lesions has been well described, though it remains uncertain if specific features predict malignancy, and whether identifiable factors are associated with successful endoscopic resection of benign lesions.

METHODS

Fifty-six consecutive patients undergoing endoscopic evaluation of ampullary neoplasia between March 2000 and May 2004 were included in the study. Clinical presentation, underlying medical conditions, endoscopic treatment, endoscopic ultrasound (EUS) to define extent of local involvement, pathology results, and outcome were documented. Data elements for analysis included EUS findings, lesion lifting with submucosal injection, age, gender, tumor size, and endoscopic intervention. Analyses were performed to determine the ability to predict malignancy and the ability to extirpate benign lesions.

RESULTS

Thirty-one males and 25 females were included; mean age was 62 yr. Final diagnoses included 29 adenomas, 20 adenocarcinomas, 4 adenomyomas, 2 paragangliomas, and 1 neuroendocrine tumor. Thirty of 35 patients with benign lesions had extirpation with a mean of two endoscopic procedures. Complications of endoscopic resection included cholangitis (1), bleeding (2), and pancreatitis (4). The presence of malignancy was associated by multivariate analysis with the inability to obtain a cleavage plane with saline injection. Univariate analysis also identified EUS T stage as a predictor of malignancy. In benign lesions, none of the analyzed variables predicted successful endoscopic resection.

CONCLUSION

In ampullary lesions, failure to achieve a cleavage plane with submucosal injection is the strongest predictor of malignancy followed by EUS T stage. Endoscopic treatment of benign ampullary neoplasia is effective; no factor was predictive of successful extirpation.

[Technique of surgical ampullectomy]

We describe the technique of surgical ampullectomy, which consists of complete resection of the papilla of Vater, including the sphincter, the distal part of common bile duct and Wirsung duct, and the duodenal wall around the papilla. Limits of resection are assessed by frozen section, particularly on both biliary and pancreatic ducts which are sutured together and reinserted on the duodenal wall. Surgical ampullectomy, combined with frozen section, is associated with a low morbidity, and represents a valid alternative to pancreaticoduodenectomy and endoscopic ampullectomy for presumed-benign ampullomas.

Ampullary adenoma: clinical manifestations, diagnosis, and treatment

Ampullary adenomas occur sporadically and in the setting of familial polyposis syndromes. In either case, and whether symptomatic at presentation or found asymptomatically in the setting of endoscopic screening programs, they are premalignant lesions with risk for malignant degeneration to carcinoma following the adenoma-to-carcinoma sequence that is well recognized in colonic adenocarcinoma. Accordingly, many experts advocate excision, although others cite the low rate of histologic progression suggested by some recent studies as justification for close endoscopic surveillance rather than excision before demonstration of dysplastic change. This recommendation, however, is complicated by considerable data underscoring the limited accuracy of endoscopic forceps biopsy in detecting occult foci of carcinoma within ampullary adenoma. Thus, the optimal management of these lesions continues to generate considerable controversy. Indications for excision of an ampullary adenoma include treatment of immediate symptoms as well as prevention of malignant degeneration. Although pancreaticoduodenectomy has long been considered the standard procedure for ampullary carcinoma, much controversy exists regarding the procedure of choice for ampullary adenoma. Radical surgery (pancreaticoduodenectomy) possesses the advantage of low recurrence rate but at the expense of higher morbidity (25%-65%) and mortality (0%-10%). Local surgical excision (surgical ampullectomy) possesses the advantages of lower morbidity (0%-25%), essentially nil mortality, and possibly decreased length of hospital stay, but decidedly higher recurrence rates (generally 5%-30%) and the need for postoperative endoscopic surveillance. Snare ampullectomy is a newer endoscopic excisional technique for which limited data are available; advantages compared with radical surgery mirror those of local surgical excision, with apparent lower mortality (0%-1%) and lower morbidity (12%). Presumed advantages compared with local surgical excision include lack of necessity for general anesthesia and laparotomy with comparable morbidity. Disadvantages seem to include limited availability of experienced operators, procedural complexity sometimes requiring adjunctive modalities such as fulguration, the need for multiple procedures (mean, 2.0 procedures) to effect complete excision, and recurrence rates approaching 30%, with a requirement for continued endoscopic surveillance. Ultimately, choice is driven by availability of local expertise, patient tolerance of or expected compliance with long-term endoscopic surveillance programs, presence or absence of coexisting familial polyposis syndromes, medical comorbidities, and overall life expectancy.

Laparoscopic resection of a periampullary villous adenoma

BACKGROUND

Adenomas of the duodenal papilla are rare lesions. Because of their malignant potential, resection is mandatory. Options for resection include endoscopic resection, transduodenal local excision, and pancreaticoduodenectomy. This report details a case of periampullary villous adenoma diagnosed endoscopically and resected laparoscopically via a transduodenal approach.

CASE REPORT

A healthy 75-year-old woman with heartburn underwent an upper endoscopy for vague right upper abdominal pain. A periampullary tumor was diagnosed. Endoscopic biopsy results were consistent with a villous adenoma, and endoscopic ultrasound showed distal bile duct involvement. The patient underwent laparoscopic transduodenal local excision of the tumor with biliary reconstruction.

CONCLUSIONS

Laparoscopic transduodenal resection of periampullary lesions provides advantages similar to those of an endoscopic resection by removal of the tumor using minimally invasive techniques. In addition, laparoscopic surgery maintains the surgical tenents of open transduodenal resection with en bloc tumor resection including the adjacent duodenal wall and ductal structures as necessary. As noted in this case, laparoscopic techniques resect ampullary lesions involving the ductal structures as well. Laparoscopic transduodenal ampullectomy is a valuable treatment option for benign and selected premalignant ampullary lesions.

Safety and outcome of endoscopic snare excision of the major duodenal papilla

BACKGROUND

The optimal management of adenoma of the major duodenal papilla is not established. Options include surgical excision, endoscopic ablative techniques, snare excision, and observation with periodic biopsies. The aims of this retrospective study were to determine the safety and outcome of snare excision of the papilla.

METHODS

Twenty-eight snare excisions of the papilla were performed in 26 patients. Sixteen had familial adenomatous polyposis. In 22 procedures, a minisnare was used, and in 6 cases a prototype snare was designed for excision of the papilla. Pancreatic stents were placed as a prophylactic measure at the discretion of the endoscopist (n = 10).

RESULTS

Histopathologically, resected tissue included 25 adenomas, 1 inflammatory polyp, 1 invasive malignancy, and 1 normal papilla. Immediate complications were minor bleeding (n = 2), mild pancreatitis (n = 4) and a duodenal perforation (n = 1). The presence (n = 10) or absence (n = 18) of a pancreatic stent did not correlate with subsequent pancreatitis (2 in each group, p = NS). Follow-up was available for 21 patients (median, 9 months; range, 2-32 months). Pancreatic duct stenosis at the papillectomy site resulted in pancreatitis in 2 patients (17%) at, respectively, 4 months and 24 months. Follow-up endoscopy revealed recurrent/residual adenomatous tissue in 2 (10%).

CONCLUSIONS

Snare excision of the major duodenal papilla was well tolerated. Most complications were mild except for a small duodenal perforation. Stenosis of the pancreatic duct orifice with pancreatitis may be a late complication.

Impact of grade of dysplasia in villous adenomas of Vater's papilla

Therapeutic strategies for villous adenoma of the papilla of Vater remain controversial. This study evaluates the accuracy of preoperative histopathologic diagnosis and the impact of the grade of dysplasia on recurrence as well as on potential alteration of the surgical approach. A series of 32 patients with an adenoma of Vater's papilla who underwent local resection or pylorus-preserving pancreaticoduodenectomy between January 1990 and August 2000 were reviewed retrospectively. Multiple endoscopic biopsies had been performed preoperatively. The histopathology of the preoperatively obtained biopsy specimens and subsequent surgical specimens were evaluated for grade of dysplasia by two pathologists and correlated with the clinical course after operative treatment. Altogether, 3 of 11 patients (27%) with a low-grade (LG) dysplasia adenoma and 6 of 21 patients (29%) with a high-grade (HG) dysplasia adenoma in the initial endoscopic biopsy specimens exhibited invasive carcinoma at the postoperative histologic examination (NS). Recurrence was not observed in the 6 patients from the LG dysplasia adenoma group following local resection and benign postoperative histology. In contrast, recurrence of villous adenoma was discovered in 2 of 12 patients (17%) and development of invasive carcinoma in 5 of 12 patients (42%) from the preoperative HG dysplasia group (p <0.05). The overall risk of carcinoma after primary diagnosis of an HG dysplasia adenoma was 44% (14/32). Adenoma of the papilla of Vater including HG dysplasia appears to be associated with a high risk of exhibiting invasive carcinoma postoperatively and a high rate of recurrence. Therefore pylorus-preserving pancreaticoduodenectomy should be offered to patients with an HG dysplasia adenoma.

Local resection of ampullary adenocarcinomas of the duodenum

BACKGROUND

Pancreaticoduodenectomy (PD) is considered to be the optimal treatment for ampullary adenocarcinomas. Local resection (LR) is a less invasive and potentially equally effective alternative for cancers with favourable prognostic features. Identification of these prognostic parameters may allow selection of patients suitable for LR.

METHODS

Twenty-five patients were treated for a primary Vater's ampulla adenocarcinoma at the Alfred Hospital, Melbourne, Australia, between January 1989 and January 2000. Risk factors for cancer recurrence were evaluated and the specific role of LR was defined.

RESULTS

Fourteen patients had PD, five had LR and six had bypass procedures (five biliary stents; one operative bypass). Presenting symptoms included jaundice (64%), abdominal pain (54%) and weight loss (32%). Adenocarcinomas that were resected had a median diameter of 2.5 cm, and were limited to the ampulla in 26% (T1), invaded the duodenal wall in 42% (T2) and infiltrated 2 cm or less into the pancreas in 32% (T1) of cases. Locally resected cancers were confined to the ampulla or invaded the duodenum and recurred in one patient following excision. Six recurrences occurred in total, influenced significantly by T staging (P = 0.009). Patient age, preoperative symptoms, laboratory tests, tumour size, differentiation, ulceration, lymphovascular spread and perineural invasion had no effect on recurrence. Patients undergoing LR had lower morbidity and mortality, reduced blood transfusion requirements and shorter hospital stay than those treated by PD.

CONCLUSIONS

T staging predicts the risk of tumour recurrence and can be determined using endoscopic ultrasound. Local resection is a suitable alternative to pancreaticoduodenal resection in patients with T1 and T2 adenocarcinomas with a maximum diameter of 3 cm or less.

Idiopathic acute recurrent pancreatitis

Acute recurrent pancreatitis (ARP) results most commonly from alcohol abuse or gallstone disease. Initial evaluation fails to detect the cause of ARP in 10-30% of patients, and as a result the diagnosis of "idiopathic" ARP is given. In these patients, a more extensive evaluation including specialized labs, ERCP, endoscopic ultrasound, or magnetic resonance cholangiopancreatography typically leads to a diagnosis of microlithiasis, sphincter of Oddi dysfunction, or pancreas divisum. Less commonly, hereditary pancreatitis, cystic fibrosis, a choledochocele, annular pancreas, an anomalous pancreatobiliary junction, pancreatobiliary tumors, or chronic pancreatitis are diagnosed. Determining the etiology is important, as it helps to direct therapy, limits further unnecessary evaluation, and may improve a patient's long term prognosis.

Endoscopic management of tumors of the major duodenal papilla: Refined techniques to improve outcome and avoid complications

BACKGROUND

Adenomas of the major duodenal papilla have malignant potential and are traditionally treated by pancreaticoduodenectomy. This is a report of our experience with endoscopic management and a description of techniques for decreasing complications and enhancing efficacy.

METHODS

Forty-one patients were referred for endoscopic management of papillary tumors. If there was no duct invasion and the appearance suggested a benign lesion, biductal sphincterotomy with pancreatic duct stent placement was performed. If the lesion could be elevated by injection of an epinephrine solution, piecemeal resection was performed. The base of the lesion was thermally ablated as needed. Resection/ablation together with stent removal was performed 1 month later.

RESULTS

Nine patients (22%) had lesions other than papillary adenoma or cancer. Malignant appearance, ductal stricturing, or extension into the ducts was found in 16 of 41 patients (39%) in whom biopsy specimens alone were obtained. Three patients with adenomas (7%) did not undergo endoscopic resection (because of extremely large lesions and/or comorbid illnesses). Thirteen patients with adenomas (32%) had endoscopic resection; 12 (92%) were lesion-free after 32 ERCPs (mean 2.7). Endoscopic management was unsuccessful in 1 patient (8%). Pancreatitis developed in 1 patient.

CONCLUSIONS

Endoscopically treatable papillary neoplasms can be identified on the basis of endoscopic, radiographic, and biopsy features. Preresection sphincterotomy, stent placement, elevation by epinephrine injection, and piecemeal resection may reduce complications and permit more aggressive treatment.

Endoscopic surveillance and ablative therapy for periampullary adenomas

OBJECTIVES

Periampullary adenomas are an increasingly recognized condition, both in those with familial adenomatous polyposis syndromes (FAP) as well as sporadic cases. Endoscopic management has been advocated for these lesions without differentiating between these two patient groups regarding aim of therapy. The aims of this study were to determine the safety and effectiveness of endoscopic surveillance and ablative therapy of periampullary adenomas in patients with both sporadic and FAP-associated lesions.

METHODS

Retrospective analysis of 59 patients with FAP and 32 with sporadic lesions who were all enrolled in a program of endoscopic surveillance and ablative therapy. Median follow-up was 24 months (range, 1-134 months).

RESULTS

Ampullary ablative therapy has resulted in return to normal histology in 44 and 34% of sporadic and FAPassociated lesions, respectively. Complications of endoscopic therapy were mild in 12 patients and severe in 3 patients: the latter category involved one occurrence of asymptomatic duodenal stenosis and one occurrence of postcoagulation syndrome--both after Nd-YAG laser therapy-and necrotizing pancreatitis after ampullary biopsy in one patient. Thirteen patients have been referred for surgical intervention. There has been no mortality and no cases of advanced malignancy missed by endoscopy.

CONCLUSIONS

Endoscopic surveillance and ablative therapy of periampullary lesions is safe and can be effective, although eradication of ampullary tissue requires multiple ablative sessions.

Local ampullary resection with careful intraoperative frozen section evaluation for presumed benign ampullary neoplasms

BACKGROUND

Frozen section evaluation has been reported to be inaccurate in detecting foci of adenocarcinoma within adenomas of the ampulla of Vater, leading many authors to advocate pancreaticoduodenectomy as the method of treatment for these neoplasms. The authors hypothesized that (1) ampullary resection is less morbid than pancreaticoduodenectomy, and (2) frozen section evaluation following ampullary resection is accurate and allows for a selective application of pancreaticoduodenectomy to those with carcinoma or benign lesions too large to be locally resected.

METHODS

A retrospective review of a single-surgeon experience was conducted. Thirty-eight patients who underwent ampullary resection and pancreaticoduodenectomy (39 procedures) for benign and malignant ampullary neoplasms were identified. Our technique of step-frozen section analysis is described.

RESULTS

Twenty-one ampullary resections were performed for preoperative diagnoses of benign (16) and malignant (5) ampullary neoplasms. Frozen section evaluation accurately predicted the final histology in all patients undergoing ampullary resection. Ampullary resection (vs pancreaticoduodenectomy) was associated with a statistically lower operative time (169 minutes vs 268 minutes), estimated blood loss (192 mL vs 727 mL), mean length of stay (10 days vs 25 days), and overall morbidity (29% vs 78%).

CONCLUSIONS

Frozen section evaluation of ampullary neoplasms is accurate. Because ampullary resection is less morbid than pancreaticoduodenectomy and frozen section evaluation is accurate, ampullary resection with frozen section evaluation is our current approach to the treatment of small benign ampullary neoplasms.

Tumors of the papilla of Vater--inadequate diagnostic impact of endoscopic forceps biopsies taken prior to and following sphincterotomy

BACKGROUND

It has been proposed that adenomas of the papilla of Vater are precursors of adenocarcinomas. Duodenoscopy with ERCP and forceps biopsies have substantially improved the morphologic exploration of the major duodenal papilla. Yet there is little and contradictory information as to the diagnostic accuracy of endoscopic biopsies in tumors of the papilla. Moreover, after endoscopic sphincterotomy data on the diagnostic impact of endoscopic biopsies from the papilla are scarce and, in most cases, retrospectively obtained. Thus, the aim of the present prospective and histopathologically controlled study was to assess the diagnostic accuracy of endoscopic biopsies taken from tumors of the papilla before and after sphincterotomy.

PATIENTS AND METHODS

Forty patients with tumors of the papilla of Vater were included in the study. In each case, a comparison was made between endoscopic forceps biopsy diagnoses prior to and following sphincterotomy and the definitive histological diagnosis after surgical tumor resection.

RESULTS

Resected tumors were diagnosed histomorphologically as follows: 19 adenocarcinomas (47%), 6 tubular adenomas (15%), 7 villous adenomas (17%), 7 inflammatory non-neoplastic lesions (pseudotumors) (17%), and one adenomyoma (2%). Overall accuracy for preoperative histopathological diagnosis was 62% (25 of 40, 95% CI: 47%-76%) prior to sphincterotomy while it was 70% (28 of 40, 95% CI: 55%-81%) following the procedure. Regarding adenocarcinomas, sensitivity was found to be 21% (4 of 19, 95% CI: 8%-43%) prior to and 37% (7 of 19, 95% CI: 19%-58%) after sphincterotomy while specificity was 100% at both times.

CONCLUSIONS

Endoscopic forceps biopsies do not allow for reliable preoperative diagnosis of tumors of the papilla of Vater.

Local resection of benign periampullary tumors

Benign tumours of the ampulla of Vater are rare and histologically mostly villous or tubulovillous adenomas. The frequency of malignant lesion in an adenoma of the papilla figures around 26%. Villous adenoma of the ampulla is considered as premalignant lesion. Various techniques have been advocated ranging from simple excision of the ampullary tumour and the contiguous duodenal mucosa to wide resection of the mass including the papilla and adjacent duodenal, ductal, and pancreatic tissue. In this study, 41 patients suffering from a benign tumor of the Ampulla of Vater were examined. Sixty-six percent of all patients exhibited a villous or tubulovillousadenoma with medium or severe degree of dysplasia. Thirty-six patients were treated with local resection of the ampulla, using ampullectomy in 33 patients. In 5 of the 41 patients pylorus-preserving duodenopancreatectomy was applied. The median follow-up of 42 month showed no evidence of recurrent disease. Ampullectomy is an adequate way of treating benign ampullary lesions, but, precise technique is important. The decision-making should be based on histological examination of preoperative biopsy specimens and of operative frozen sections, by an experienced pathologist. If the histology of the ampullary lesion is uncertain, pylorus-preserving partial pancreaticoduodenectomy is justified in patients with low perioperative risks, and if this extended procedure can be done safely by an experienced surgeon.

Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study

BACKGROUND

An adenoma-carcinoma sequence also applies to adenomas of the major duodenal papilla. Therefore accurate preoperative diagnosis and tumor staging are essential to select the appropriate patients for adequate treatment. In a prospective, histopathologically controlled study of tumors of the main duodenal papilla, the preoperative diagnostic value of ultrasound (US) catheter probes applied during endoscopic retrograde cholangiopancreatography (ERCP) was investigated.

METHODS

Intraductal US was compared with conventional endoscopic ultrasonography (EUS) and computed tomography (CT). In 27 consecutive patients with benign polypoid tumors of the major duodenal papilla (n = 12) and carcinomas of the papilla (n = 15), respectively, the value of these imaging procedures in determining tumor visualization, tumor diagnosis and tumor staging according to the TNM classification was assessed. Every patient underwent surgical resection; histopathologic evaluation of resected specimens served as the reference standard.

RESULTS

Intraductal US was significantly superior to EUS and CT in terms of tumor visualization (100% vs 59.3% vs 29.6%, respectively). Sensitivity and specificity rates for intraductal US and EUS were 100% versus 62.5% and 75% versus 50%, respectively. Overall accuracy rate in tumor diagnosis for intraductal US (88.9%; 24 of 27) was significantly (p = 0.05) superior to EUS (56.3%; 9 of 16). The latter did not depict 4 adenomas and 7 carcinomas. Neither intraductal US nor EUS is suitable for detection of distant metastases.

CONCLUSION

Intraductal US appears to be the most effective imaging method in visualizing, diagnosing and staging tumors of the major duodenal papilla. Combining ERCP with catheter probe sonography offers a new diagnostic modality that has some potential advantages for local staging of small tumors of the main duodenal papilla. Consequently, minimally invasive techniques for resection of seemingly benign tumors of the papilla or, even more so, of small carcinomas should preferably be based on intraductal US.

Good outcome from surgery for ampullary tumour

BACKGROUND

Ampulla of Vater tumours are rare but usually resectable. There is debate as to the better surgical approach between the standard radical procedure, which provides adequate resection margins, and local resection, which may carry a lower mortality. This study reports the 16-year experience of a specialist unit with these tumours, and compares our results with that of recently published series.

METHOD

A retrospective review of patients admitted with an ampullary tumour to the Hepatobiliary and Pancreatic Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia, between January 1981 and April 1997.

RESULTS

Twenty-five patients (13 men, 12 women) of median age 65 years were admitted with an ampullary tumour to the unit during this period. The most common presentation was obstructive jaundice. Multiple endoscopic biopsy was found to be very reliable in distinguishing between benign and malignant tumours. Five patients, all male, had benign neoplasms: three adenomas, one carcinoid and one gangliocytic paraganglioma. Transduodenal local excision was performed in four patients. One patient had a Whipple procedure resulting in the only in-hospital death at 3 months. Twenty patients had adenocarcinoma, of which 13 patients had a pancreaticoduodenectomy, two local excisions, two palliative bypasses, two were unfit for surgery and one declined surgery. The resectability rate was 88%, with no operative mortalities. The 5-year actuarial survival of patients who underwent radical resection was 49%.

CONCLUSIONS

Proximal pancreaticoduodenectomy, preferably a pylorus-preserving procedure, is safe and effective in the treatment of ampullary carcinoma, with low operative mortality and good long-term survival. Local resection is only recommended for small benign tumours and for patients who may be unfit for radical surgery.

Local excision of periampullary villous tumours of the duodenum

AIMS

Our goal was to describe our technical approach to transduodenal submucosal resection of periampullary villous tumours of the duodenum.

METHODS

We address technical tips to aid in exposure and reconstruction of pancreaticobiliary continuity with special reference to the indications for adding biliary sphincteroplasty, pancreatic septectomy, and local resection of neoplasms extending past the immediate ampullary mucosa into the bile and/or pancreatic ducts.

CONCLUSIONS

This approach has proven safe, easy and without significant morbidity.

The use of endoscopic ultrasonography to reduce the cost of treating ampullary tumors

BACKGROUND

Local excision of selected ampullary tumors may result in the same benefit as Whipple resection with less morbidity and mortality. The purpose of this study was to determine if endoscopic ultrasonography could aid in the selection of patients for local resection and to determine if there was a significant cost difference between the two surgical procedures.

METHODS

In this retrospective study of 32 patients who underwent surgery for ampullary tumors, endoscopic ultrasonography staging was performed in 18 patients. Resected specimens were used to determine pathologic staging. Local disease was defined as stage T2N0 or less. Cost data were available for 20 patients.

RESULTS

The sensitivity and specificity of endoscopic ultrasonography for differentiating local from advanced ampullary tumors were both 83%. The median total cost for a local resection was $9314 versus $16,017 for a Whipple resection (p < 0.0017).

CONCLUSION

Endoscopic ultrasonography is an effective tool for identifying patients with localized ampullary tumors. The cost of a local resection for ampullary tumors is significantly less than that of a Whipple resection. The use of endoscopic ultrasonography to select patients for local resection may be a cost-effective technique in the management of patients with ampullary tumors.