Surgical ampullectomy: A comprehensive review

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.

Keywords: Ampulla of Vater; Ampullary tumours; Endoscopic papillectomy; Pancreatoduodenectomy; Surgical ampullectomy; Transduodenal ampullectomy.

Figure 1

A 7-cm polypoid tubulovillous adenoma extending from the ampulla of Vater down to D3, removed by means of open surgical ampullectomy-excision of adenoma en block, following cholecystectomy and catheterization of the ampulla for identification. Preoperative biopsies showed low-grade dysplasia (LGD) and this 74-year old patient with severe comorbidities was initially counselled for pancreatoduodenectomy. Meticulous preoperative endoscopic evaluation revealed its polypoid configuration, possibly emanating from a mucosal stalk, which was confirmed intraoperatively. A: The ampulla is encircled by a fine catheter. Final histology confirmed the presence of a tubulovillous adenoma with extensive LGD and focal high-grade dysplasia. All margins were clear of tumour or dysplasia. (V. Mavroeidis’ archive). B: Inferior aspect of the specimen, depicting the duodenal margin along the tumour, and the insertion point of the catheter into the ampulla. (V. Mavroeidis’ archive).