Surgical ampullectomy: A comprehensive review

Table 1 Indications for surgical ampullectomy

Lesion type	Generally accepted indications	Uncertainties	Generally accepted contra-indications	Ref.
Adenoma	Lesion too large for EP, including those with HGD or Cis	Tumour size thresholds		[6,10,12,13,20-24,26,37-40,42,44,46,49,51,52]
	Failed EP, including recurrence or positive margins			[42,52]
		FAP patients		[53-55]
AAC	T1 or T2, unfit for PD	T1 or T2, fit for PD	T3 or T4, fit for PD	[6,21-24,30,39,41,43-46,49,51,58]
	Well-differentiated	Moderately-differentiated	Poorly-differentiated	[21,23,30,39,43,49,56,57,60]
			Nodal or distant metastases	[21,23,24,30,39,41,49]
		Requirement for lymphadenectomy		[39,57]
		Intraductal extension		[10,12,19,21,26,56]
Others	Sphincterotomy-associated biliary stricture			[70]
		Neuroendocrine tumours		[66,67]

AAC: Ampullary adenocarcinoma; FAP: Familial adenomatous polyposis; EP: Endoscopic papillectomy; HGD: High-grade dysplasia; PD: Pancreatoduodenectomy.

Table 2 Spigelman’s classification of duodenal polyposis

Characteristics		Points
Number of polyps	1 to 4	1
	5 to 20	2
	> 20	3
Size of polyps	1 to 4 mm	1
	5 to 10 mm	2
	> 10 mm	3
Histological type	Tubular polyp, hyperplasia, inflammation	1
	Tubulovillous	2
	Villous	3
Dysplasia	Mild	1
	Moderate	2
	Severe	3

A total of 0 points = stage 0; 1 to 4 points = stage I; 5 to 6 points = stage II; 7 to 8 points = stage III; and 9 to 12 points = stage IV[55].

Table 3 Clinical outcomes of surgical ampullectomy

Indication	Outcome		Estimate	Ref.
Adenoma or AAC	Complete excision (R0)		96.4%	[38]
Adenoma or AAC	Recurrence		9.4%	[38]
Adenoma or AAC	Complications		28.3%	[38]
Adenoma or AAC	Mortality1		0.9%	[6,12,14,20,22,24,25,28,30,32,39,41,43,45,47-52,58,62,64,67,72,74,76-79]
AAC	Survival at 5 yr	T1	40%	[50]
		T1 + T2	64.3%	[41]
		T2	16%	[50]
		T3	0%	[50]
		T3 + T4	18.2%	[41]

¹Pooled mortality of cited studies (5 deaths in 532 surgical ampullectomies across 30 studies).

AAC: Ampullary adenocarcinoma.