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Qiu Y, Yang Y, Qiao X, Li H, Li P, Wu J, Zhang S. A Pathological Prediction Model and Scoring System Including Endoscopic Signs for Duodenal Papilla Neoplasms: A Retrospective Study. Br J Hosp Med (Lond) 2025; 86:1-18. [PMID: 40265554 DOI: 10.12968/hmed.2024.0585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/24/2025]
Abstract
Aims/Background The application value of endoscopic ultrasound (EUS) in diagnosing duodenal papilla neoplasms (DPNs) remains underexplored. This study aims to evaluate the role of EUS and other clinical indicators in differentiating between benign and malignant DPNs and to establish a pathological prediction model for DPNs. Methods Clinical and imaging data of DPNs patients were collected. Least absolute shrinkage and selection operator (LASSO) regression was employed to screen independent predictors. Patients were divided into training and test cohorts. Univariate and multivariate logistic regression analyses were performed. A nomogram was developed alongside a scoring system, both of which were validated using the test cohort. Results A total of 56 benign and 95 malignant DPNs cases were included. Logistic regression analysis identified age, magnetic resonance imaging (MRI), EUS-measured size, echo intensity and papilla appearance as independent predictors of pathological diagnosis. The nomogram demonstrated a C-index of 0.876, with area under the curve (AUC) values of 0.88 and 0.82 in the training and test cohorts, respectively. The scoring system performed well, with an optimal cutoff value of 14 points. Conclusion Age, MRI, EUS size and papilla appearance are independent risk factors for malignant DPNs. EUS may have extraordinary effects in DPNs differential diagnosis.
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Affiliation(s)
- Yuting Qiu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Yang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xinwei Qiao
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Haobo Li
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Jing Wu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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2
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Fouad M, James MW, Zaitoun AM, Hanks M, Lobo DN. Recurrent ascending cholangitis secondary to food reflux following transduodenal resection of an ampullary adenoma. Ann R Coll Surg Engl 2025. [PMID: 40131729 DOI: 10.1308/rcsann.2024.0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2025] Open
Abstract
Ampullary lesions, including adenomas and early-stage carcinomas, pose a diagnostic and therapeutic challenge because of their location and proximity to the pancreatic and bile ducts. Transduodenal ampullectomy offers a targeted approach for the resection of these lesions while preserving the integrity of the pancreaticobiliary system. Moreover, transduodenal ampullectomy is associated with favourable postoperative outcomes, including low rates of morbidity and mortality, as well as preservation of pancreatic and biliary function. However, potential complications such as ascending cholangitis pancreatic leakage, bleeding and duodenal stenosis can occur, which would impact the postoperative quality of life. Addressing these outcomes might require either endoscopic procedures or surgical interventions. We present an exceedingly uncommon case of recurrent ascending cholangitis resulting from reflux of food particles into the common bile duct that was treated successfully with a Roux-en-Y hepaticojejunostomy and gastroenterostomy.
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Affiliation(s)
- M Fouad
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, UK
| | - M W James
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, UK
| | - A M Zaitoun
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, UK
| | - M Hanks
- Nottingham University Hospitals NHS Trust, UK
| | - D N Lobo
- University of Nottingham, UK
- Nottingham University Hospitals NHS Trust, UK
- University of Pennsylvania, Philadelphia, USA
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3
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Choi JH, Kim WC, Park JK, Lee JK, Lee KT, Lee KH. Bleeding after endoscopic papillectomy and its risk factors: A single center experience of 196 cases. Hepatobiliary Pancreat Dis Int 2024; 23:613-619. [PMID: 38433066 DOI: 10.1016/j.hbpd.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 01/31/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Endoscopic papillectomy (EP) is an effective method to remove an ampulla of Vater (AoV) adenoma with minimal invasiveness. We reviewed the clinical outcomes and prognosis of patients undergoing EP, including tumor recurrence and adverse events. METHODS A total of 196 patients who underwent EP from January 2004 to December 2017 were included. Clinical information was collected through electronic medical records, and risk factors to predict post-procedural bleeding were analyzed using a multivariate logistic regression model. RESULTS A total of 93.9% patients (184/196) underwent complete resection. During the follow-up period, 14.7% patients (27/184) experienced tumor recurrence, and two of seven surgically resected tumors were malignant. A total of 45.4% patients (89/196) experienced adverse events related to EP. Delayed bleeding occurred in 16.3% of the patients (32/196), and they were all successfully treated with endoscopic hemostasis and conservative management. The most frequent site of delayed bleeding was the distal end of the papillary orifice, and 56.3% (18/32) patients of delayed bleeding were classified as having mild severity, the others had moderate severity. Familial adenomatous polyposis (FAP) [odds ratio (OR) = 3.80, 95% confidence interval (CI): 1.01-14.29; P < 0.05] and male sex (OR = 2.82, 95% CI: 1.04-7.63; P = 0.04) showed statistical significance in predicting delayed post-EP bleeding. CONCLUSIONS EP for AoV adenoma was a highly effective and safe procedure. The risk of post-EP delayed bleeding was increased in patients with FAP syndrome and male patients, and post-EP bleeding occurred most commonly in the distal part of the AoV.
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Affiliation(s)
- Jin Ho Choi
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Won Chul Kim
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Joo Kyung Park
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Jong Kyun Lee
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kyu Taek Lee
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea
| | - Kwang Hyuck Lee
- Department of Medicine, Division of Gastroenterology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06351, Korea.
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Sorribas M, Carnaval T, Secanella L, Peláez N, Salord S, Gornals JB, Leiva D, Serrano T, Fabregat J, Busquets J. Pushing the Boundaries of Ampullectomy for Benign Ampullary Tumors: 25-Year Outcomes of Surgical Ampullary Resection Associated with Duodenectomy or Biliary Resection. J Clin Med 2024; 13:7220. [PMID: 39685678 DOI: 10.3390/jcm13237220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2024] [Revised: 11/18/2024] [Accepted: 11/19/2024] [Indexed: 12/18/2024] Open
Abstract
Background: Surgical resection for ampullary lesions lacks clear guidelines. Pancreaticoduodenectomy (PD) is the standard treatment for malignant ampullary tumors but is often excessive for ampullary adenomas (AAs) due to its high morbidity and mortality. Transduodenal ampullectomy (TDA) is generally reserved for small benign lesions where endoscopic treatment fails, but its role in early ampullary cancers is debatable. This study presents our 25-year outcomes with TDA for benign ampullary tumors. Methods: We conducted a retrospective cohort study with prospectively collected data from patients with benign ampullary lesions who underwent TDA between January 1996 and November 2023. Primary outcomes were the 30-day overall and severe (Clavien-Dindo ≥ IIIa) morbidity rates and the 90-day mortality rate. Categoric variables were presented as absolute and relative frequencies, and quantitative variables were presented as means (standard deviation, SD) or medians (range or interquartile range, IQR). Results: Fifty-three patients (29 male; mean [SD] age 62.5 [14.6] years) underwent TDA. The 30-day morbidity rate was 32.1% (17/53 patients), with five (9.4%) cases being severe. The 90-day mortality rate was 1.9%. Definitive histopathology identified 38 (71.7%) AAs and five (9.4%) infiltrating ampullary adenocarcinomas, two (40.0%) of which required subsequent PD. Six (11.3%) patients experienced recurrence. Overall, nine (16.9%) patients died. Conclusions: TDA is a safe and effective technique with acceptable morbidity for non-infiltrating lesions, especially in patients with poor clinical status. Choosing between TDA and PD depends on tumor size, dysplasia grade, and institutional expertise. Lifelong endoscopic surveillance post-TDA is essential for timely recurrence detection.
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Affiliation(s)
- Maria Sorribas
- Digestive and General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Thiago Carnaval
- Oncology Data Analytics Program (ODAP), Catalan Institute of Oncology (ICO), L'Hospitalet de Llobregat, 08908 Barcelona, Spain
| | - Luis Secanella
- Digestive and General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Núria Peláez
- Digestive and General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Silvia Salord
- Gastroenterology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Joan B Gornals
- Gastroenterology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - David Leiva
- Radiology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Teresa Serrano
- Pathology Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
| | - Joan Fabregat
- Digestive and General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), C. Casanova, 143, 08036 Barcelona, Spain
| | - Juli Busquets
- Digestive and General Surgery Department, Bellvitge University Hospital, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Group of Hepato-Biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge-IDIBELL, University of Barcelona, L'Hospitalet de Llobregat, 08907 Barcelona, Spain
- Departament de Ciències Clíniques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona (UB), C. Casanova, 143, 08036 Barcelona, Spain
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Wang W, Wang J, Yang C, Wang X, Zhang S, Wang J. Transduodenal ampullectomy is an effective surgical exploration procedure for unexplained dilation of the cholangiopancreatic duct. Eur J Med Res 2024; 29:560. [PMID: 39587662 PMCID: PMC11590497 DOI: 10.1186/s40001-024-02144-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/05/2024] [Indexed: 11/27/2024] Open
Abstract
BACKGROUND The clinical diagnosis and treatment of dilation of the cholangiopancreatic duct in patients with ambiguous ampullary disease, termed unexplained dilation of the cholangiopancreatic duct (UDCD), is commonly difficult. This study aimed to evaluate the applicability of transduodenal ampullectomy (TDA) for the diagnosis and treatment of UDCD. METHODS We first proposed a surgical exploration procedure based on the TDA and applied it in a representative UDCD patient. We retrospectively analyzed the pathological diagnosis and prognosis of 14 patients at our hospital and 189 patients reported in existing studies who were treated with TDA between January 2010 and December 2022. RESULTS TDA can be used to radically explore the ampullary region and harvest adequate pathological tissue, which is helpful for identifying the cause of UDCD. The diagnostic rate of intraoperative frozen pathology was greater than that of preoperative endoscopic biopsy (78.41% vs. 65.94%, P = 0.044). The postoperative complication rate was 27.07%, with a mortality rate of 0.00%. The 5-year survival rate was 68.31% in patients with adenocarcinoma, 85.99% in patients with adenoma with HGD/pTis, and 100% in patients with benign lesions, and these had a statistically significant difference (P = 0.021). CONCLUSIONS TDA-based surgical exploration can be used as a safe and effective transitional procedure in the treatment of UDCD.
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Affiliation(s)
- Wei Wang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 S. Yishan Road, Shanghai, 200233, China.
- Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
| | - Jie Wang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 S. Yishan Road, Shanghai, 200233, China
| | - Chuanxin Yang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 S. Yishan Road, Shanghai, 200233, China
| | - Xiangjun Wang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 S. Yishan Road, Shanghai, 200233, China
| | - Shilei Zhang
- Department of Pathology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China
| | - Jian Wang
- Department of Hepatobiliary and Pancreatic Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 600 S. Yishan Road, Shanghai, 200233, China.
- Department of Biliary-Pancreatic Surgery, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200127, China.
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6
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Ielpo B, Vellalta G, Jaume-Boettcher SM, d'Addetta MV, Sanchez-Velazquez P, Burdio F. Transduodenal robotic ampullectomy: tips and tricks and strategies for postoperative duodenal fistula management (with video). Updates Surg 2024; 76:1535-1541. [PMID: 38507177 DOI: 10.1007/s13304-024-01808-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 02/25/2024] [Indexed: 03/22/2024]
Abstract
Transduodenal Ampullectomy (TA) is a procedure for resecting low-malignancy ampullary tumors, with postoperative fistula as a notable complication. This study aims to clarify the indications for TA, outline the surgical robotic technique, and emphasize the importance of comprehensive complication management alongside the surgical approach. This multimedia article provides a detailed exposition of the robotic TA surgical technique, including the most important steps involved in exposing and reimplanting biliary and pancreatic ducts. The procedure encompasses the mobilization of the hepatic flexure of the colon, an extensive Kocher maneuver for duodenal mobilization, and ampulla exposure through a duodenal incision. Employing retraction loop sutures enhances surgical field visibility. Reconstruction involves securing pancreatic and biliary ducts to the duodenal mucosa, each tutored with a silicon catheter, and suturing for ampullectomy completion. The total operative time was 380 min. Final histopathology disclosed high-grade dysplasia with an isolated focus of adenocarcinoma (pT1), accompanied by clear resection margins. A postoperative duodenal fistula occurred, managed successfully through conservative treatment, utilizing subcutaneous drainage. Despite accurate robotic TA execution, complications may arise. This study underscores the importance of a comprehensive approach, incorporating meticulous surgical technique and effective complication management, to optimize patient outcomes.
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Affiliation(s)
- Benedetto Ielpo
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain.
| | - Gemma Vellalta
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain
| | - Sofia-Maria Jaume-Boettcher
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain
| | - Maria Vittoria d'Addetta
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain
| | - Patricia Sanchez-Velazquez
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain
| | - Fernando Burdio
- HPB Unit, Pompeu Fabra University, Parc Salut Mar University Hospital, Passeig Maritim, 25, 08003, Barcelona, Spain
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7
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Baroni LM, Funari MP, So Taa Kum A, Bestetti AM, de Oliveira LB, de Carvalho MF, Franzini TAP, de Moura DTH, Bernardo WM, de Moura EGH. Endoscopic Versus Surgical Treatment for Ampullary Lesions: A Systematic Review With Meta-Analysis. Cureus 2024; 16:e65076. [PMID: 39170988 PMCID: PMC11337076 DOI: 10.7759/cureus.65076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2024] [Indexed: 08/23/2024] Open
Abstract
Ampullary lesions (ALs) can be treated through either an endoscopic approach (EA) or a surgical approach (SA). However, it is important to note that EAs carry a significant risk of incomplete resection, while opting for surgical interventions can result in substantial morbidity. We performed a systematic review and meta-analysis for R0 resection, recurrence, adverse events in general, major adverse events, mortality, and length of hospital stay between SAs and EAs. Electronic databases were searched from inception to 2023. We identified nine independent studies. The risk difference was -0.32 (95% CI: -0.50, -0.15; p <0.001) for R0, 0.12 (95% CI: 0.06, 0.19; p < 0.001) for recurrence, -0.22 (95% CI: -0.43, 0.00; p 0.05) for overall adverse events, -0.11 (95% CI: -0.32, 0.10; p = 0.31) for major complications, -0.01 (95% CI: -0.02, 0.01; p = 0.43) for mortality, and -14.69 (95% CI: -19.91, -9.47; p < 0.001) for length of hospital stay. As expected, our data suggest a higher complete resection rate and lower recurrence from surgical interventions, but this is associated with an elevated risk of adverse events and a longer hospital stay.
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Affiliation(s)
| | | | - Angelo So Taa Kum
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Alexandre Moraes Bestetti
- Gastroenterology, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | | | | | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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8
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Demirci NS, Cavdar E, Ozdemir NY, Yuksel S, Iriagac Y, Erdem GU, Odabas H, Hacibekiroglu I, Karaagac M, Ucar M, Ozturk B, Bozkaya Y. Clinicopathologic Analysis and Prognostic Factors for Survival in Patients with Operable Ampullary Carcinoma: A Multi-Institutional Retrospective Experience. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:818. [PMID: 38793001 PMCID: PMC11122928 DOI: 10.3390/medicina60050818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 05/10/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024]
Abstract
Background and Objectives: In ampullary cancer, 5-year survival rates are 30-50%, even with optimal resection and perioperative systemic therapies. We sought to determine the important clinicopathological features and adjuvant treatments in terms of the prognosis of patients with operable-stage ampullary carcinomas. Materials and Methods: We included 197 patients who underwent pancreaticoduodenectomy to treat ampullary carcinomas between December 2003 and May 2019. Demographics, clinical features, treatments, and outcomes/survival were analyzed. Results: The median disease-free survival (mDFS) and median overall survival (mOS) were 40.9 vs. 63.4 months, respectively. The mDFS was significantly lower in patients with lymphovascular invasion (p < 0.001) and lymph node involvement (p = 0.027). Potential predictors of decreased OS on univariate analysis included age ≥ 50 years (p = 0.045), poor performance status (p = 0.048), weight loss (p = 0.045), T3-T4 tumors (p = 0.018), surgical margin positivity (p = 0.01), lymph node involvement (p = 0.001), lymphovascular invasion (p < 0.001), perineural invasion (p = 0.007), and poor histological grade (p = 0.042). For the multivariate analysis, only nodal status (hazard ratio [HR]1.98; 95% confidence interval [CI], 1.08-3.65; p = 0.027) and surgical margin status (HR 2.61; 95% CI, 1.09-6.24; p = 0.03) were associated with OS. Conclusions: Nodal status and a positive surgical margin were independent predictors of a poor mOS for patients with ampullary carcinomas. Additional studies are required to explore the role of adjuvant therapy in patients with ampullary carcinomas.
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Affiliation(s)
- Nebi Serkan Demirci
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Eyyup Cavdar
- Department of Medical Oncology, Adiyaman Training and Research Hospital, Adiyaman University, 02000 Adiyaman, Türkiye
| | - Nuriye Yildirim Ozdemir
- Department of Medical Oncology, Faculty of Medicine, Yıldırım Beyazıt University, 06010 Ankara, Türkiye
| | - Sinemis Yuksel
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Yakup Iriagac
- Department of Medical Oncology, Balikesir Ataturk City Hospital, 10100 Balikesir, Türkiye
| | - Gokmen Umut Erdem
- Department of Medical Oncology, Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, 34098 Istanbul, Türkiye
| | - Hatice Odabas
- Department of Medical Oncology, Dr. Lutfi Kirdar Kartal Education and Research Hospital, 34865 Istanbul, Türkiye
| | - Ilhan Hacibekiroglu
- Department of Medical Oncology, Faculty of Medicine, Sakarya University, 54050 Sakarya, Türkiye
| | - Mustafa Karaagac
- Department of Medical Oncology, Meram Medical Faculty, Necmettin Erbakan University, 42090 Konya, Türkiye;
| | - Mahmut Ucar
- Department of Medical Oncology, Faculty of Medicine, Erciyes University, 38039 Kayseri, Türkiye
| | - Banu Ozturk
- Department of Medical Oncology, Akdeniz University, 07058 Antalya, Türkiye;
| | - Yakup Bozkaya
- Department of Medical Oncology, Yeniyuzyil University-Gaziosmanpasa Hospital, 34098 Istanbul, Türkiye;
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9
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Paik KY. Clinical implementation of simplification of biliopancreatic duct re-implantation method when performing transduodenal ampullectomy. Minerva Surg 2024; 79:230-231. [PMID: 37817479 DOI: 10.23736/s2724-5691.23.10061-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Affiliation(s)
- Kwang Y Paik
- Department of Surgery, Yeouido St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, South Korea -
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10
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Shin DW. [Treatment of Ampullary Adenocarcinoma]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 82:159-170. [PMID: 37876255 DOI: 10.4166/kjg.2023.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 09/28/2023] [Accepted: 10/03/2023] [Indexed: 10/26/2023]
Abstract
The ampulla of Vater is a small projection formed by the confluence of the main pancreatic duct and common bile duct in the second part of the duodenum. Primary ampullary adenocarcinoma is a rare malignancy, accounting for only 0.2% of gastrointestinal cancers and approximately 7% of all periampullary cancers. Jaundice from a biliary obstruction is the most common symptom of ampullary adenocarcinoma. In the early stages, radical pancreatoduodenectomy is the standard surgical approach. On the other hand, no randomized controlled trial has provided evidence to guide physicians on the choice of adjuvant/palliative chemotherapy because of the rarity of the disease and the paucity of related research. This paper reports the biology, histology, current therapeutic strategies, and potential future therapies of ampullary adenocarcinoma.
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Affiliation(s)
- Dong Woo Shin
- Division of Gastroenterology, Department of Internal Medicine, Hallym University College of Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
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11
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Maselli R, de Sire R, Fugazza A, Spadaccini M, Colombo M, Capogreco A, Beyna T, Repici A. Updates on the Management of Ampullary Neoplastic Lesions. Diagnostics (Basel) 2023; 13:3138. [PMID: 37835881 PMCID: PMC10572979 DOI: 10.3390/diagnostics13193138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023] Open
Abstract
Ampullary neoplastic lesions (ANLs) represent a rare cancer, accounting for about 0.6-0.8% of all gastrointestinal malignancies, and about 6-17% of periampullary tumors. They can be sporadic or occur in the setting of a hereditary predisposition syndrome, mainly familial adenomatous polyposis (FAP). Usually, noninvasive ANLs are asymptomatic and detected accidentally during esophagogastroduodenoscopy (EGD). When symptomatic, ANLs can manifest differently with jaundice, pain, pancreatitis, cholangitis, and melaena. Endoscopy with a side-viewing duodenoscopy, endoscopic ultrasound (EUS), and magnetic resonance cholangiopancreatography (MRCP) play a crucial role in the ANL evaluation, providing an accurate assessment of the size, location, and characteristics of the lesions, including the staging of the depth of tumor invasion into the surrounding tissues and the involvement of local lymph nodes. Endoscopic papillectomy (EP) has been recognized as an effective treatment for ANLs in selected patients, providing an alternative to traditional surgical methods. Originally, EP was recommended for benign lesions and patients unfit for surgery. However, advancements in endoscopic techniques have broadened its indications to comprise early ampullary carcinoma, giant laterally spreading lesions, and ANLs with intraductal extension. In this paper, we review the existing evidence on endoscopic diagnosis and treatment of ampullary neoplastic lesions.
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Affiliation(s)
- Roberta Maselli
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Roberto de Sire
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Gastroenterology Unit, Department of Clinical Medicine and Surgery, University Federico II of Naples, 80126 Naples, Italy
| | - Alessandro Fugazza
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Marco Spadaccini
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
| | - Matteo Colombo
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Antonio Capogreco
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
| | - Torsten Beyna
- Department of General Internal Medicine and Gastroenterology, Evangelisches Krankenhaus, 40217 Düsseldorf, Germany;
| | - Alessandro Repici
- Gastroenterology, Endoscopy Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (R.M.); (A.F.); (M.S.); (M.C.); (A.C.); (A.R.)
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy
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Tan M. National Cancer Database Analysis of Ampullary Cancer: Caution Advised. J Am Coll Surg 2023; 237:583. [PMID: 37171092 DOI: 10.1097/xcs.0000000000000756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
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Cai H, Gao P, Lu F, Cai Y, Peng B. Laparoscopic Transduodenal Ampullectomy: How We Have Standardized the Technique (with Video). Ann Surg Oncol 2023; 30:1156-1157. [PMID: 36509879 DOI: 10.1245/s10434-022-12867-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 11/12/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The procedure of choice for the resection of ampullary tumors comprises transduodenal ampullectomy (TDA), endoscopic papillectomy (EP), and pancreaticoduodenectomy (PD).1 For neoplasms with low-grade dysplasia, TDA and EP have equivalent efficacies and lower morbidities than PD1. Compared with EP, also as an organ-preserving procedure, TDA could be applicable for tumors involving the pancreatic ducts or common bile ducts.2 Because TDA has a lower incidence of postoperative gastrointestinal bleeding and a higher R0 resection rate, its use could avoid the need to use multiple endoscopic procedures for larger lesions.3 Furthermore, during TDA, surgeons could convert to PD as necessary. However, TDA has rarely been performed using a minimally invasive approach that addresses the shortcomings of both the endoscopic and open surgical techniques without adding significant morbidity or compromising outcomes.2,4 Conventional laparoscopic TDA (LTDA) remains limited due to the complexity of the surgical anatomy of the ampulla and the reconstruction required compared with robot-assisted procedures.2-5 However, robot-assisted surgery is less popular and much more expensive than laparoscopic surgery. This report with a video describes the LTDA approach to standardize and simplify the surgical processes. METHODS A 48-year-old man was admitted to the hospital with epigastric pain. He had a history of cholecystolithiasis with chronic cholecystitis. A tumor approximately 2.2 cm in diameter located in the duodenal papilla was diagnosed by an enhanced computed tomography (CT) scan. The endoscopic biopsy result indicated a villous adenoma with moderate dysplasia. Laparoscopic TDA and cholecystectomy were planned. However, if the frozen sample analysis showed adenocarcinoma, laparoscopic PD (LPD) would be applied. The patient was placed in the supine position with both legs apart. Trocars were distributed in the same manner as in the authors' previous study to facilitate conversion to LPD.6 The procedure began with kocherization and dissection of the gastrocolic ligament to explore the second and third portions of the duodenum. A figure-eight suture was made using 4-0 prolene in the seromuscular layer, and then the duodenum was retracted to the left side of the patient. A longitudinal duodenotomy was made, and the ampulla of Vater was identified. A transfixing suture was placed through the tumor. Submucosal injection of norepinephrine (1:500) was performed to divide the mucosa from the muscular planes. Ampullectomy was performed by first dissecting in the submucosal plane with a harmonic scalpel at the 6 o'clock position until the pancreatic duct was reached. A 6-Fr plastic catheter was inserted into the pancreatic duct for subsequent reconstruction. Continued dissection around the tumor identified the bile duct. Another 6-Fr plastic catheter was inserted into the bile duct. The dissection was completed in the submucosal plane, and the specimen was retrieved for frozen sectioning. After confirmation of villous adenoma with moderate dysplasia and the proximal margin without residual tumor on frozen biopsy, reconstruction was performed. The septum between the ducts was plastered, and the bile and pancreatic ducts were reconstructed on the duodenal wall with 5-0 PDS-II interrupted sutures to ensure that these ducts remained patent and connected. After reconstruction, the plastic catheter was kept in the pancreatic duct but removed from the bile duct. Then, cholecystectomy was applied. Finally, the duodenum was closed obliquely in two layers, and two drains were routinely placed. RESULTS The operation time was 139 min, and the estimated blood loss was 50 ml. Final pathology confirmed villous adenoma with mild to moderate dysplasia. The postoperative course was uneventful, with a hospital stay of 9 days. There was no evidence of recurrence or patency of the reimplanted ducts 5 months after surgery. From February 2022 to May 2022, four cases of LTDA with the same surgical processes were managed by the authors, and all the patients recovered quickly without any postoperative complications. CONCLUSION After standardization of the surgical processes, laparoscopic TDA was safe for highly selected patients. However, long-term follow-up is required to observe the quality of life and survival of patients.
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Affiliation(s)
- He Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Pan Gao
- Department of Minimal Invasive Surgery, Shangjin Nanfu Hosptial, Chengdu, China
| | - Fei Lu
- The Health Management Center of West China Hospital, Sichuan University, Chengdu, China
| | - Yunqiang Cai
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.
| | - Bing Peng
- Department of Pancreatic Surgery, West China Hospital, Sichuan University, Chengdu, China.
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Klaiber U, Stättner S. Current standards in the surgical treatment of pancreatic and small intestinal neuroendocrine tumors. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2022. [DOI: 10.1007/s12254-022-00840-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Opciones en el tratamiento quirúrgico de la neoplasia neuroendocrina de la ampolla de Váter: experiencia en un centro de referencia. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Tur-Martínez J, Sorribas M, Secanella L, Peláez N, Gornals J, Serrano T, Busquets J, Fabregat J. Surgical options for the treatment of neuroendocrine neoplasms of the ampulla of Vater: a reference centre experience. Cir Esp 2022:S2173-5077(22)00419-7. [PMID: 36436802 DOI: 10.1016/j.cireng.2022.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/03/2022] [Accepted: 10/13/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The main objective of this study was to analyse the results of the surgical treatment of ampullary neuroendocrine tumours (NET) based on transduodenal ampullectomy and pancreatoduodenectomy, in a reference centre in hepatobiliopancreatic pathology. METHOD Retrospective, observational study, including all patients operated on for pancreatic and/or duodenal NET in a reference unit of hepatobiliopancreatic pathology and prospectively registered between January 1st, 1993 and September 30th, 2021. For those parameters not present, retrospective research was performed. Demographic, clinical, analytical and pathological data were analysed. A descriptive study was carried out. Overall and disease-free survival was calculated using Kaplan-Meier curves and the Log-Rank test. RESULTS Of 181 patients operated on for pancreatic and/or duodenal NET, only 9 were located in the ampulla of Vater, which represents 4.9% of all pancreatic and/or duodenal NET. Pancreatoduodenectomy (PD) was performed in 6 patients, while 3 patients underwent transduodenal ampullectomy (TDA). Longer surgical time and more postoperative complications were observed in the PD group. There were no differences in hospital stay. Overall and disease-free survival at 5 years in the PD group compared to ATD was 83.3% vs. 100% and 50% vs. 100%, respectively. CONCLUSIONS Ampullary NET without locoregional involvement or risk factors, can be treated by conservative surgeries such as transduodenal ampullectomy.
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Affiliation(s)
- Jaume Tur-Martínez
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitari d'Igualada, Igualada, Spain
| | - Maria Sorribas
- Servicio de Cirugia General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari de Bellvitge, Spain
| | - Lluís Secanella
- Servicio de Cirugia General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari de Bellvitge, Spain; Departamento de Enfermería Fundamental y Médicoquirúrgica, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Spain; Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Spain
| | - Núria Peláez
- Servicio de Cirugia General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari de Bellvitge, Spain; Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Spain
| | - Joan Gornals
- Servicio de Digestología, Hospital Universitari de Bellvitge, Spain
| | - Teresa Serrano
- Servicio de Anatomía Patológica, Hospital Universitari de Bellvitge, Spain
| | - Juli Busquets
- Servicio de Cirugia General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari de Bellvitge, Spain; Departamento de Ciencias Clínicas, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Spain; Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Spain.
| | - Joan Fabregat
- Servicio de Cirugia General y del Aparato Digestivo, Unidad de Cirugía Hepatobiliopancreática y Trasplante Hepático, Hospital Universitari de Bellvitge, Spain; Departamento de Ciencias Clínicas, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Spain; Research Group of Hepato-biliary and Pancreatic Diseases, Institut d'Investigació Biomèdica de Bellvitge - IDIBELL, Spain
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Haraldsson E, Halimi A, Rangelova E, Valente R, Löhr JM, Arnelo U. Adenomatous neoplasia in the papilla of Vater endoscopic and/or surgical resection? Surg Endosc 2022; 36:2401-2411. [PMID: 33942182 DOI: 10.1007/s00464-021-08521-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/17/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adenomatous neoplasia in the papilla of Vater needs to be resected in order not to progress. It can be challenging to distinguish between early ampullary malignant lesions and non-invasive adenomas, due to the overlap in symptoms and radiological findings. This retrospective study describes the different findings and treatment decisions taken prior to endoscopic and/or surgical resection of ampullary adenomatous lesions. MATERIALS AND METHODS Patients treated with endoscopic and/or surgical resection for suspected or verified ampullary adenomatous neoplasia, between January 2006 and July 2018, where pre-interventional cross-sectional imaging could not discern an obvious invasive, malignant tumor, were included. Findings were compared against the final diagnosis of the histopathological analysis on the resected specimen. RESULTS In total, 172 met the inclusion criteria. Patients were treated with either surgical resection (n = 96), endoscopic papillectomy (EP) (n = 55) or both (n = 21). The final diagnosis was in 48% ampullary adenocarcinoma, and the remaining had either ampullary adenoma (38%) or non-neoplastic lesions (14%). In patients where symptoms and cross-sectional imaging were suspicious for malignancy, but with no tissue samples that confirmed neoplasia prior to surgical resection, only 47% had adenocarcinoma. The remaining had either adenoma (9%) or non-neoplastic lesions (44%). Adenocarcinoma was revealed in 27% of the patients where endoscopic biopsies had shown adenoma. Patients with adenoma, treated with EP, were cured in 59%. However, 28% were after EP sent for further surgery due to ductal invasion or a finding of adenocarcinoma. CONCLUSIONS In patients with a suspicion of ampullary neoplasia on imaging, attempts should be made to get endoscopic tissue samples before deciding on a treatment strategy. If biopsies show ampullary adenoma, patients should be considered for EP, unless there are clear radiologic or endoscopic signs of malignancy. Patients with adenocarcinoma on endoscopic biopsies should undergo surgical resection.
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Affiliation(s)
- Erik Haraldsson
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden.
- Department of Surgery, Skaraborg Hospital, Skövde, Sweden.
| | - Asif Halimi
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - Elena Rangelova
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Section for Upper Abdominal Surgery at the Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roberto Valente
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
| | - J Matthias Löhr
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Upper Abdominal Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical and Perioperative Sciences, Surgery, Umeå University, Umeå, Sweden
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Giehl-Brown E, Weitz J, Distler M. Das Ampullenkarzinom – prognostische und therapeutische Unterschiede zum duktalen Adenokarzinom des Pankreas. Zentralbl Chir 2022; 147:160-167. [DOI: 10.1055/a-1775-9024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
ZusammenfassungDas Ampullenkarzinom stellt eine seltene, jedoch in seiner Inzidenz steigende Entität gastrointestinaler Tumoren dar. Aufgrund der anatomischen Lokalisation führt es vergleichsweise früh im
Erkrankungsprozess zu einer biliären Gangobstruktion, wodurch eine schnellere Diagnosestellung erleichtert und eine bessere Prognose bedingt werden. Adenome der Ampulla hepatopancreatica und
der Papilla duodeni major stellen Vorläuferläsionen des Ampullenkarzinoms dar und besitzen ein 30–40%iges Risiko zur malignen Transformation. Diese Entartungstendenz begründet die
Notwendigkeit zur vollständigen/kompletten Abtragung im Rahmen der endoskopischen Therapie. Der Erfolg der endoskopischen Papillektomie wird durch eine Ausdehnung des Befundes in den
Pankreashauptgang oder Ductus choledochus erschwert. Endoskopisch nicht sanierbare Adenome und Ampullenkarzinome stellen Indikationen für chirurgische Therapieverfahren dar. Grundsätzlich
sollte für benigne Befunde die transduodenale Papillenresektion bervorzugt werden, für maligne Befunde stellt die Pankreaskopfresektion mit systematischer Lymphadenektomie und
Level-II-Dissektion des Mesopankreas die onkologisch korrekte Operation dar. Prognostische Faktoren beim Ampullenkarzinom sind: der pankreatobiliäre Subtyp, eine Lymphknoteninfiltration und
eine Perineuralscheideninvasion. Die Differenzierung in histopathologische Subtypen gewinnt zunehmend in der Indikationsstellung zur Systemtherapie an Bedeutung. Der Einsatz der
neoadjuvanten und adjuvanten Therapie für das Ampullenkarzinom konnte bisher nicht klar definiert werden. Jedoch scheinen Patienten mit dem pankreatobiliären Subtyp oder anderen
prognoselimitierenden Faktoren von einer adjuvanten Therapie zu profitieren. Zukünftige Studien werden zur zielgerichteten Therapiefestlegung benötigt.
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Affiliation(s)
- Esther Giehl-Brown
- Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Jürgen Weitz
- Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Marius Distler
- Klinik und Poliklinik für Viszeral-, Thorax- u. Gefäßchirurgie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
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Dbouk S, Bazzi N, Daou L, Shaalan Z, Choukr A. Our Experience With Transduodenal Surgical Ampullectomy. Cureus 2022; 14:e21467. [PMID: 35223251 PMCID: PMC8860684 DOI: 10.7759/cureus.21467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 11/24/2022] Open
Abstract
Tumors of the ampulla of Vater are uncommon lesions accounting for only 0.5% of the gastrointestinal tumors. A total of three techniques for ampullary tumors (AT) exist: endoscopic papillectomy (EP), surgical transduodenal ampullectomy (TDA), and partial pancreatoduodenectomy (PD). Scarce articles report the outcomes of TDA. Two Arabic men presented to the hospital with epigastric pain and were subsequently diagnosed with AT. The TDA was performed a few days after the diagnosis. The first patient underwent a partial gastrectomy on the eleventh postoperative day. The second patient underwent endoscopic pyloric re-opening on the eleventh postoperative day to relieve gastric obstruction. Both patients started tolerating food and were discharged home. Further randomized controlled studies assessing long-term complications, efficacy, and efficiency of TDA are now warranted.
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Scroggie DL, Mavroeidis VK. Surgical ampullectomy: A comprehensive review. World J Gastrointest Surg 2021; 13:1338-1350. [PMID: 34950424 PMCID: PMC8649570 DOI: 10.4240/wjgs.v13.i11.1338] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 05/29/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Darren L Scroggie
- Department of Population Health Sciences, Bristol Centre for Surgical Research, Bristol Medical School, Bristol BS8 2PS, United Kingdom
| | - Vasileios K Mavroeidis
- Department of HPB Surgery, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol Royal Infirmary, Bristol BS2 8HW, United Kingdom
- Department of Surgery, The Royal Marsden NHS Foundation Trust, London SW3 6JJ, United Kingdom
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Abstract
BACKGROUND Endoscopically unresectable adenomas and carcinomas of the greater duodenal papilla and ampulla of the bile duct necessitate surgical resection. The surgical techniques need to be adapted to local tumor expansion and patterns of infiltrative growth. OBJECTIVE Based on the current scientific data and developments this article provides an overview of indications for surgical resection, surgical strategies and dissection techniques for ampullary tumors. MATERIAL AND METHODS A review of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. RESULTS AND CONCLUSION Ampullary neoplasms can originate from intestinal or pancreatobiliary epithelial cells. Differentiating these histopathological subtypes is of crucial relevance concerning therapeutic strategy and prognosis in ampullary adenocarcinoma. All ampullary adenomas carry a risk of malignant transformation and therefore justify resection. Endoscopic papillectomy, surgical transduodenal ampullectomy and partial pancreatoduodenectomy are suitable resection techniques for ampullary adenoma. The selection of the procedure depends on intraductal tumor extension, tumor size and degree of dysplasia. Ampullary carcinoma is managed by upfront pancreatoduodenectomy comprising systematic lymph node dissection and level II dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.
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Affiliation(s)
- Martin Schneider
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
| | - Markus W Büchler
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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22
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Ampullary Carcinoma: An Overview of a Rare Entity and Discussion of Current and Future Therapeutic Challenges. Curr Oncol 2021; 28:3393-3402. [PMID: 34590592 PMCID: PMC8482111 DOI: 10.3390/curroncol28050293] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 08/27/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022] Open
Abstract
Ampullary carcinomas (ACs) represent a rare entity, accounting for approximately 0.2% of all gastrointestinal solid tumors and 20% of all periampullary cancers (PACs). Unfortunately, few data are available regarding the optimal therapeutic strategy for ACs due to their rarity, and physicians frequently encounter significant difficulties in the management of these malignancies. In this review, we will provide an overview of current evidence on AC, especially focusing on biological features, histological characteristics, and available data guiding present and future therapeutic strategies for these rare, and still barely known, tumors.
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Teterin YS, Tigiev LR, Yartsev PA, Stepan EV, Rogal ML, Kulikov YD. [Management of obstructive jaundice in patients with neoplasms of the major duodenal papilla]. Khirurgiia (Mosk) 2021:49-56. [PMID: 34270194 DOI: 10.17116/hirurgia202107149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To develop the indications and assess an effectiveness of treatment of patients with ampullary tumors followed by mechanical jaundice. MATERIAL AND METHODS There were 26 patients with major duodenal papilla neoplasms for the period 2015-2020 at the Sklifosovsky Research Institute for Emergency Care. RESULTS Twenty patients underwent transpapillary interventions: papillosphincterotomy followed by lithoextraction and bilio-duodenal stenting in 4 (15.3%) patients, bilio-duodenal stenting in 12 (46.1%) patients, nasobiliary drainage in 2 (7.6%) patients, pancreaticoduodenal stenting in 2 (7.6%) patients. Percutaneous transhepatic microcholecystostomy was performed in 6 (23.4%) patients. In all cases, laboratory values decreased in 5-7 days after drainage. Eight (30.7%) patients refused further surgical treatment and were discharged in satisfactory condition. Another 8 (44.5%) patients underwent endoscopic submucosal papillectomy. There were no postoperative complications. Patients were discharged after 5-7 days. Four (22.2%) patients underwent tumor resection via laparotomy. One of these patients required redo laparotomy in postoperative period due to acute perforated duodenal ulcer. Six (33.3%) patients underwent palliative bilio-duodenal stenting. CONCLUSION Invasion of muscle layer or distal parts of the common bile duct, as well as abnormal vascularization are indications for open surgery or palliative endoscopic treatment. Tumor location within mucous and muscle layers without invasion of distal third of the common bile duct and no abnormal vascularization of tumor justify endoscopic papillectomy. Endoscopic approach can be considered as a final minimally invasive method with minimal risk of postoperative complications in case of benign ampullary tumor.
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Affiliation(s)
- Yu S Teterin
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - L R Tigiev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - P A Yartsev
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - E V Stepan
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - M L Rogal
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
| | - Yu D Kulikov
- Sklifosovsky Research Institute for Emergency Care, Moscow, Russia
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Zheng X, Sun QJ, Zhou B, Jin M, Yan S. Microscopic transduodenal excision of an ampullary adenoma: A case report and review of the literature. World J Clin Cases 2021; 9:4844-4851. [PMID: 34222457 PMCID: PMC8223850 DOI: 10.12998/wjcc.v9.i18.4844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/27/2021] [Accepted: 04/09/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Transduodenal local excision is an alternative treatment approach for benign ampullary tumors. However, this procedure has technical difficulties, especially during reconstruction of the pancreaticobiliary ducts. An operating microscope has been widely used by surgeons for delicate surgery due to its major advantages of magnification, illumination, and stereoscopic view. The application of an operating microscope in transduodenal excision of ampullary tumors has not been reported.
CASE SUMMARY A 55-year-old woman was admitted for investigation of recurrent upper abdominal pain. Physical examination and laboratory tests found no abnormalities. Imaging identified a large mass in the descending part of the duodenum. Esophagogastroduodenoscopy revealed a 3.5-cm-sized villous growth over the major duodenal papilla. Pathology of the endoscopic biopsy indicated a villous adenoma with low-grade dysplasia. Microscopic transduodenal excision of the ampullary tumor was performed. The final pathological diagnosis was villous-tubular adenoma with low-grade dysplasia. The patient was discharged on postoperative day 12 after an uneventful recovery. Endoscopic retrograde cholangiopancreatography was performed 3 mo postoperatively and showed no bile duct or pancreatic duct strictures and no tumor recurrence. The patient is continuing follow-up at our clinic and remains well.
CONCLUSION Operating microscope-assisted transduodenal local excision is a feasible and effective option for benign ampullary tumors.
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Affiliation(s)
- Xiang Zheng
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Qing-Jing Sun
- The Affiliated Hospital of Stomatology, School of Stomatology, Zhejiang University School of Medicine, and Key Laboratory of Oral Biomedical Research of Zhejiang Province, Hangzhou 310006, Zhejiang Province, China
| | - Bo Zhou
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Ming Jin
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Sheng Yan
- Department of General Surgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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25
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Ampullary carcinoma of the duodenum: current clinical issues and genomic overview. Surg Today 2021; 52:189-197. [PMID: 33797636 DOI: 10.1007/s00595-021-02270-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/17/2021] [Indexed: 02/07/2023]
Abstract
Ampullary carcinomas of the duodenum are uncommon. Moreover, the diversity in the clinical outcomes of these patients makes it difficult to interpret previous studies and clinical trial results. The difficulty in proper staging of ampullary carcinomas, especially with regard to the T category of the tumor in the TNM system, reflects the anatomic complexity and non-uniform histopathologic subtypes. One major reason for this difficulty in interpretation is that the tumors may arise from any of the three epithelia (duodenal, biliary, or pancreatic) that converge at this location. Generally, ampullary carcinomas are classified into intestinal and pancreaticobiliary types based on morphology and immunohistochemical features. While many studies have described their specific characteristics and clinical impact, the prognostic value of these subtypes is controversial. In recent years, whole-exome sequencing analyses have advanced our understanding of the genomic overview of ampullary carcinoma. Gene mutations serve as prognostic and predictive biomarkers for this disease. Therefore, basic knowledge of the genomic profile of ampullary carcinomas is required for surgeons to understand how best to apply precision medicine as well as surgery and adjuvant therapies. This review provides an overview of the current basic and clinical issues of ampullary carcinoma.
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26
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Marchese U, Tzedakis S, Abou Ali E, Turrini O, Delpero JR, Coriat R, Fuks D. Parenchymal Sparing Resection: Options in Duodenal and Pancreatic Surgery. J Clin Med 2021; 10:1479. [PMID: 33918376 PMCID: PMC8038287 DOI: 10.3390/jcm10071479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 12/13/2022] Open
Abstract
Parenchymal sparing duodenal and pancreatic resection are safe procedures in selected patients with the aim to reduce endocrine and exocrine long-term dysfunction. When the tumor is benign or borderline malignant, this appears to be a good option for the surgeon, associated with low rates of severe surgery-related early postoperative complications and low in-hospital mortality. This mini review offers comments, tips and tricks, and a review of literature concerning those different options with specific illustrations in order to clarify their indication.
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Affiliation(s)
- Ugo Marchese
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; (S.T.); (D.F.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (E.A.A.); (R.C.)
| | - Stylianos Tzedakis
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; (S.T.); (D.F.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (E.A.A.); (R.C.)
| | - Einas Abou Ali
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (E.A.A.); (R.C.)
- Gastroenterology and Digestive Oncology Unit, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - Olivier Turrini
- Faculté de Médecine, Université d’Aix Marseille, 13005 Marseille, France; (O.T.); (J.-R.D.)
- Department of Surgical Oncology, Paoli Calmettes Institute, 232 Boulevard de Sainte Marguerite, 13009 Marseille, France
| | - Jean-Robert Delpero
- Faculté de Médecine, Université d’Aix Marseille, 13005 Marseille, France; (O.T.); (J.-R.D.)
- Department of Surgical Oncology, Paoli Calmettes Institute, 232 Boulevard de Sainte Marguerite, 13009 Marseille, France
| | - Romain Coriat
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (E.A.A.); (R.C.)
- Gastroenterology and Digestive Oncology Unit, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France
| | - David Fuks
- Department of Digestive, Hepatobiliary and Pancreatic Surgery, Cochin Hospital, AP-HP Centre, 27 rue du Faubourg Saint-Jacques, 75014 Paris, France; (S.T.); (D.F.)
- Faculté de Médecine, Université de Paris, 75006 Paris, France; (E.A.A.); (R.C.)
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27
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Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez PH, Kunovsky L, Larghi A, Manes G, Moss A, Napoleon B, Nayar M, Pérez-Cuadrado-Robles E, Seewald S, Barthet M, van Hooft JE. Endoscopic management of ampullary tumors: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:429-448. [PMID: 33728632 DOI: 10.1055/a-1397-3198] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
1: ESGE recommends against diagnostic/therapeutic papillectomy when adenoma is not proven.Strong recommendation, low quality evidence. 2: ESGE recommends endoscopic ultrasound and abdominal magnetic resonance cholangiopancreatography (MRCP) for staging of ampullary tumors.Strong recommendation, low quality evidence. 3: ESGE recommends endoscopic papillectomy in patients with ampullary adenoma without intraductal extension, because of good results regarding outcome (technical and clinical success, morbidity, and recurrence).Strong recommendation, moderate quality evidence. 4: ESGE recommends en bloc resection of ampullary adenomas up to 20-30 mm in diameter to achieve R0 resection, for optimizing the complete resection rate, providing optimal histopathology, and reduction of the recurrence rate after endoscopic papillectomy.Strong recommendation, low quality evidence. 5: ESGE suggests considering surgical treatment of ampullary adenomas when endoscopic resection is not feasible for technical reasons (e. g. diverticulum, size > 4 cm), and in the case of intraductal involvement (of > 20 mm). Surveillance thereafter is still mandatory.Weak recommendation, low quality evidence. 6: ESGE recommends direct snare resection without submucosal injection for endoscopic papillectomy.Strong recommendation, moderate quality evidence. 7: ESGE recommends prophylactic pancreatic duct stenting to reduce the risk of pancreatitis after endoscopic papillectomy.Strong recommendation, moderate quality evidence. 8: ESGE recommends long-term monitoring of patients after endoscopic papillectomy or surgical ampullectomy, based on duodenoscopy with biopsies of the scar and of any abnormal area, within the first 3 months, at 6 and 12 months, and thereafter yearly for at least 5 years.Strong recommendation, low quality evidence.
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Affiliation(s)
- Geoffroy Vanbiervliet
- Department of Digestive Endoscopy, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Marin Strijker
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Arthur Aelvoet
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Urban Arnelo
- Department of Surgery, Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Torsten Beyna
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Dusseldorf, Nordrhein-Westfalen, Germany
| | - Olivier Busch
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pierre H Deprez
- Gastroenterology and Hepatology Department, Cliniques universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Lumir Kunovsky
- Department of Gastroenterology and Internal Medicine, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Surgery, University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alberto Larghi
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gianpiero Manes
- Aziende Socio Sanitaria Territoriale Rhodense, Gastroenterology, Garbagnate Milanese, Italy
| | - Alan Moss
- Department of Endoscopic Services, Western Health, Melbourne, Australia
- Department of Medicine, Western Health, Melbourne Medical School, University of Melbourne, Victoria, Australia
| | - Bertrand Napoleon
- Service de Gastroentérologie, Hôpital Privé Jean Mermoz, Ramsay Générale de Santé, Lyon, France
| | - Manu Nayar
- Department of Gastroenterology, Freeman Hospital, Newcastle upon Tyne, UK
| | - Enrique Pérez-Cuadrado-Robles
- Department of Gastroenterology, Georges-Pompidou European Hospital, AP-HP Centre - Université de Paris, Paris, France
| | - Stefan Seewald
- Gastroenterology Center, Klinik Hirslanden, Zurich, Switzerland
| | - Marc Barthet
- Department of Gastroenterology, Hôpital Nord, Assistance publique des hôpitaux de Marseille, Marseille, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Linn YL, Wang Z, Goh BKP. Robotic transduodenal ampullectomy: Case report and review of the literature. Ann Hepatobiliary Pancreat Surg 2021; 25:150-154. [PMID: 33649269 PMCID: PMC7952669 DOI: 10.14701/ahbps.2021.25.1.150] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/16/2020] [Accepted: 07/24/2020] [Indexed: 01/10/2023] Open
Abstract
Ampullary neoplasms are relatively uncommon lesions with a risk of progression to malignancy. Depending on its nature, size and location, it may be best treated with endoscopic papillotomy, pancreaticoduodenectomy or transduodenal ampullectomy. Transduodenal ampullectomy offers a higher chance of complete resection compared to endoscopic papillotomy, and carries lower morbidity than a pancreaticoduodenectomy, making it the ideal choice for localised ampullary tumour not involving the ducts but not amenable to complete endoscopic resection. While traditionally performed via open surgery, it has been attempted via laparoscopic approach and more recently robotic approach. We present a case of a 63-year-old man who underwent a robotic transduodenal ampullectomy for ampullary adenoma with high grade dysplasia, and review the literature surrounding robotic transduodenal ampullectomy.
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Affiliation(s)
- Yun Le Linn
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Zhongkai Wang
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
| | - Brian K. P. Goh
- Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore
- Duke-National University of Singapore Medical School, Singapore
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29
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Transduodenal surgical ampullectomy: a procedure that requires a multidisciplinary approach. Updates Surg 2021; 73:2215-2223. [PMID: 33387169 DOI: 10.1007/s13304-020-00951-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/12/2020] [Indexed: 02/07/2023]
Abstract
Trans-duodenal surgical ampullectomy (TSA) was first described in 1899. Nowadays its role in ampullary tumor surgery is still a matter of debate and requires a multidisciplinary approach. The aim of this study is to evaluate the results of TSA as a curative treatment for benign and selected malignant tumors arising from the ampulla in a single-institution experience. Sixteen patients with periampullary tumors that underwent TSA in our surgical units between January 2012 and January 2017 were included in the study. Patient demographic characteristics, pre or postoperative endoscopic interventions, operative procedures, postoperative morbidity and mortality, hospitalization, follow-up time, and quality of life questionnaire were analyzed. Mean operative time was 238.5 min (range 180-390), mean tumor size was 2.3 cm (range 1.5-3.9). The microscopic surgical outcome was R0 for 14 patients. The most frequent findings in terms of histological type were high-grade dysplasia/pTis (43.7%), low-grade dysplasia in 37.5% patients, invasive adenocarcinoma in 2 cases (12.5%), chronic inflammation in 1 case (6.3%). The readmission rate was 18.8% (3/16) and in 2 cases (12.5%) relaparotomy was required. The cumulative median duration of follow-up was 50 months (range 1-96). 90-days mortality was 6.2%. Mean hospital stay was 12 days (range 8-60). Our results confirm that TSA offers good results in terms of morbidity and mortality; still, it remains a challenging procedure that requires particular surgical experience and operative skills. A pre-operative planning in a multidisciplinary board should be carried out prior to the procedure.
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30
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Palmeri M, Funel N, Franco GD, Furbetta N, Gianardi D, Guadagni S, Bianchini M, Pollina LE, Ricci C, Chiaro MD, Candio GD, Morelli L. Tissue microarray-chip featuring computerized immunophenotypical characterization more accurately subtypes ampullary adenocarcinoma than routine histology. World J Gastroenterol 2020; 26:6822-6836. [PMID: 33268964 PMCID: PMC7684454 DOI: 10.3748/wjg.v26.i43.6822] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/24/2020] [Accepted: 08/27/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Ampullary adenocarcinomas (AACs) are heterogeneous tumors currently classified into three important sub-classes (SC): Intestinal (INT), Pancreato-Biliary (PB) and Mixed-Type (MT). The different subgroups have similar clinical presentation and are treated by pancreatoduodenectomy with curative intent. However, they respond differently to chemotherapy and have different prognostic outcomes. The SC are often difficult to identify with conventional histology alone. The clinical outcome of all three remains unclear, particularly for MT. AIM To identify two main subtypes of AACs, using an immunohistochemical (IHC) score based on CDX2, CK7 and CK20. METHODS Tissue samples from 21 patients who had undergone resection of AAC were classified by HE histology and IHC expression of CDX2, CK7 and CK 20. An IHC score was obtained for each marker by counting the number of positive cells (0 = no stained cells; 1 < 25%; 2 < 50% and 3 > 50%) and their intensity (1 = weak; 2 = moderate and 3 = strong). A global score (GS) was then obtained by summation of the IHC scores of each marker. The MT tumors were grouped either with the INT or PB group based on the predominant immuno-molecular phenotype, obtaining only two AACs subtypes. The overall survival in INT and PB patients was obtained by Kaplan-Meier methods. RESULTS Histological parameters defined the AACs subtypes as follows: 15% INT, 45% PB and 40% MT. Using IHC expression and the GS, 75% and 25% of MT samples were assigned to either the INT or the PB group. The mean value of the GS was 9.5 (range 4-16). All INT samples had a GS above the average, distinct from the PB samples which had a GS score significantly below the average (P = 0.0011). The INT samples were identified by high expression of CDX2 and CK20, whereas PB samples exhibited high expression of CK7 and no expression of CK20 (P = 0.0008). The INT group had a statistically significant higher overall survival than in the PB group (85.7 mo vs 20.3 mo, HR: 8.39; 95%CI: 1.38 to 18.90; P = 0.0152). CONCLUSION The combination of histopathological and molecular criteria enables the classification of AACs into two clinically relevant histo-molecular phenotypes, which appear to represent distinct disorders with potentially significant changes to the current therapeutic strategies.
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Affiliation(s)
- Matteo Palmeri
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Niccola Funel
- Division of Surgical Pathology, University-Hospital of Pisa, Pisa 56124, Italy
| | - Gregorio Di Franco
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Niccolò Furbetta
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Desirée Gianardi
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Simone Guadagni
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Matteo Bianchini
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Luca E Pollina
- Division of Surgical Pathology, University-Hospital of Pisa, Pisa 56124, Italy
| | - Claudio Ricci
- Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa 56124, Italy
| | - Marco Del Chiaro
- Department of Surgery, University of Colorado, Denver, CO 80045, United States
| | - Giulio Di Candio
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
| | - Luca Morelli
- General Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa 56124, Italy
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31
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Total Pancreatectomy for Ampullary Adenocarcinoma in a 74-Year-Old Patient: Case Report and Literature Review. Case Rep Surg 2020; 2020:8879609. [PMID: 33062367 PMCID: PMC7545421 DOI: 10.1155/2020/8879609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 11/17/2022] Open
Abstract
Primary ampullary neoplasms have origin in the ampulla of Vater, an anatomical structure where the common bile duct and the pancreatic duct join together as a common channel. It represents <0.5% of all gastrointestinal cancers and approximately 7% of all periampullary cancers. The adenocarcinomas arising in this region originate from different epithelial cellular constituents present at the site, the histopathological classification encompass: intestinal type, pancreaticobiliary type, and mixed type. Pancreaticoduodenectomy is the treatment of choice when there is an overt or highly suspicious malignant behaviour. We present here the case of a 74-year-old male patient who presented to our department for further investigation of obstructive jaundice and a pancreatic mass associated with a six-month history of significant weight loss and mild epigastric pain. Eventually, a total splenopancreatectomy was performed given the extension of structural anomalies of the organ secondary to an ampullary adenocarcinoma.
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Abstract
PURPOSE OF REVIEW Endoscopic ampullectomy has proven its safety and efficacy in multiple studies, making it the favorable option for the management of endoscopic ampullectomy. In this review, we plan to review the basic steps every endoscopist should be familiar with before undertaking endoscopic ampullectomy. RECENT FINDINGS In this review, we plan to discuss the indications, preresection evaluation process including endoscopic ultrasound, endoscopic ampullectomy techniques with side-viewing endoscope and endoscopist experience/comfort with the management of the endoscopic ampullectomy complications. SUMMARY Things of utmost interest include reviewing all the ampullary biopsy specimens by an expert gastrointestinal pathologist, careful preresection staging, en bloc resection, familiarity with tools and techniques of endoscopic ampullectomy, postresection adverse events & management and postprocedure surveillance.
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Affiliation(s)
- Jagpal S Klair
- Digestive Disease Institute at Virginia Mason Medical Center, Seattle, Washington, USA
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