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Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 14, 2015; 21(26): 7970-7987
Published online Jul 14, 2015. doi: 10.3748/wjg.v21.i26.7970
Management of ampullary neoplasms: A tailored approach between endoscopy and surgery
Francesca Panzeri, Stefano Crippa, Paola Castelli, Francesca Aleotti, Alessandro Pucci, Stefano Partelli, Giuseppe Zamboni, Massimo Falconi
Francesca Panzeri, Department of Surgery, Ospedale “Mater Salutis”, 37045 Legnago, Italy
Stefano Crippa, Paola Castelli, Francesca Aleotti, Stefano Partelli, Massimo Falconi, Division of Pancreatic Surgery, San Raffaele Hospital IRCCS, Vita e Salute University, 20132 Milano, Italy
Alessandro Pucci, Giuseppe Zamboni, Department of Pathology, Ospedale Sacro Cuore-Don Calabria, 37024 Negrar, Italy
Author contributions: Panzeri F and Crippa S reviewed the literature and wrote the paper; Pucci A and Zamboni G extensively contributed to the pathology section; Castelli P, Aleotti F and Partelli S were involved in editing the manuscript; and Falconi M critically reviewed all the work.
Conflict-of-interest statement: The authors have no relationships relevant to the contents of this paper to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Massimo Falconi, MD, Professor, Division of Pancreatic Surgery, San Raffaele Hospital IRCCS, Vita e Salute University, Via Olgettina 60, 20132 Milano, Italy. falconi.massimo@hsr.it
Telephone: +39-2-26436046 Fax: +39-2-26437807
Received: January 30, 2015
Peer-review started: January 30, 2015
First decision: March 10, 2015
Revised: March 27, 2015
Accepted: May 2, 2015
Article in press: May 4, 2015
Published online: July 14, 2015
Processing time: 165 Days and 5.2 Hours
Abstract

Ampullary neoplasms, although rare, present distinctive clinical and pathological features from other neoplastic lesions of the periampullary region. No specific guidelines about their management are available, and they are often assimilated either to biliary tract or to pancreatic carcinomas. Due to their location, they tend to become symptomatic at an earlier stage compared to pancreatic malignancies. This behaviour results in a higher resectability rate at diagnosis. From a pathological point of view they arise in a zone of transition between two different epithelia, and, according to their origin, may be divided into pancreatobiliary or intestinal type. This classification has a substantial impact on prognosis. In most cases, pancreaticoduodenectomy represents the treatment of choice when there is an overt or highly suspicious malignant behaviour. The rate of potentially curative resection is as high as 90% and in high-volume centres an acceptable rate of complications is reported. In selected situations less invasive approaches, such as ampullectomy, have been advocated, although there are some concerns mainly because of a higher recurrence rate associated with limited resections for invasive carcinomas. Importantly, these methods have the drawback of not including an appropriate lymphadenectomy, while nodal involvement has been shown to be frequently present also in apparently low-risk carcinomas. Endoscopic ampullectomy is now the procedure of choice in case of low up to high-grade dysplasia providing a proper assessment of the T status by endoscopic ultrasound. In the present paper the evidence currently available is reviewed, with the aim of offering an updated framework for diagnosis and management of this specific type of disease.

Keywords: Ampulla of Vater; Cancer of the ampulla of Vater; Pancreaticoduodenectomy; Ampullectomy; Prognosis; Ampullary neoplasm; Lymphadenectomy; Recurrence

Core tip: In this paper we review current evidence regarding ampullary neoplasm, with a particular focus on diagnosis and treatment. We are providing a framework for management of these neoplasms that, although rare, display distinctive clinical features. Current evidence about optimal management is reviewed, outlining the role of surgery as compared to newer endoscopic techniques: indeed, while surgery is mandatory for invasive carcinomas due to possible nodal involvement, endoscopy should be considered for non-invasive lesions.