Surgical ampullectomy:A comprehensive review

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

Surgical method choice and coincidence rate of pathological diagnoses in transduodenal ampullectomy: A retrospective case series study and review of the literature

BACKGROUND Transduodenal ampullectomy(TDA) is not in wide clinical use due to its low radical effect and a high recurrence rate of tumors. However,TDA is still an effective treatment method; it has great clinical value in cases of duodenal benign tumors,precancerous lesions,and benign and malignant borderline tumors,and can avoid the risks associated with pancreaticoduodenectomy with larger resection range and greater thoroughness than endoscopic papillectomy.AIM To investigate the surgical method choice and the coincidence rate of pathological diagnoses in TDA for ampullary neoplasms.METHODS Ten patients with ampullary neoplasms underwent TDA based on the fact that their endoscopic biopsy results suggested benign lesions,and the endoscopic ultrasound(EUS)-assessed tumors were resectable. All cases underwent duodenal ampullary lesion endoscopic biopsy,intraoperative frozen-section pathological examination,and postoperative pathological examination.RESULTSThis study included seven patients with benign tumors and three with malignant tumors(1 pTis,2 pT1),according to the postoperative pathology results. The coincidence rate of the postoperative pathology results with the intraoperative frozen-section biopsy results was 100%(10/10),and the coincidence rate with the endoscopic biopsy results was 70%(7/10) based on pathological characteristics.The endoscopic biopsy false-negative rate was 30%(3/10). All patients were followed for 6 to 70 mo without tumor recurrence or metastasis.CONCLUSION The coincidence rate of postoperative pathology results,intraoperative frozensection pathology results,and endoscopic biopsy results is the restraining factor of TDA clinical application. Endoscopic biopsy results and EUS have importance relevance to surgical planning. Intraoperative frozen-section pathology results have a significant influence on the choice of surgical procedure.

Management of ampullary neoplasms: A tailored approach between endoscopy and surgery

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

ampullary 腺瘤的诊断和管理: 内视镜检查法的膨胀角色

Ampullary adenoma is a pre-cancerous lesion arising from the duodenal papilla that is often asymptomatic.It is important to distinguish whether the adenoma is sporadic or arises in the setting of familial adenomatous polyposis as this has important implications with respect to management and surveillance.Multiple modalities are available for staging of these lesions to help guide the most appropriate therapy.Those that are used most commonly include computed tomography,endoscopic ultrasound,and endoscopic retrograde cholangiopancreatography.In recent years,endoscopy has become the primary modality for therapeutic management of the majority of ampullary adenomas.Surgery remains the standard curative procedure for confirmed or suspected adenocarcinoma.This review will provide the framework for the diagnosis and management of ampullary adenomas from the perspective of the practicing gastroenterologist.

Endoscopic management of adenomatous ampullary lesions

Lesions of the ampulla of Vater represent an uncommon group of gastrointestinal malignancies. The majority of lesions of the ampulla of Vater are either adenomas or adenocarcinomas. Ampullary lesions are often incidental findings. Accurate preoperative diagnosis and staging of ampullary tumors is imperative for predicting prognosis and determining the most appropriate therapeutic approach. Endoscopic ampullectomy is a safe and efficacious therapeutic procedure that can obviate the need for potentially major surgical intervention. This review will provide the framework for the diagnosis and management of ampullary lesions from the perspective of the practicing gastroenterologist. Strategies for safe and successful endoscopic ampullectomy with a focus on accurate preoperative diagnosis and staging, resection technique, and management of complications are presented.

Endoscopic papillectomy: The limits of the indication, technique and results

In the majority of cases, duodenal papillary tumors are adenomas or adenocarcinomas, but the endoscopy biopsy shows low accuracy to make the correct differentiation. Endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography are important tools for the diagnosis, staging and management of ampullary lesions. Although the endoscopic papillectomy(EP) represent higher risk endoscopic interventions, it has successfully replaced surgical treatment for benign or malignant papillary tumors. The authors review the epidemiology and discuss the current evidence for the use of endoscopic procedures for resection, the selection of the patient and the preventive maneuvers that can minimize the probability of persistent or recurrent lesions and to avoid complications after the procedure. The accurate staging of ampullary tumors is important for selecting patients to EP or surgical treatment. Compared to surgery, EP is associated with lower morbidity and mortality, and seems to be a preferable modality of treatment for small benign ampullary tumors with no intraductal extension. The EP procedure, when performed by an experienced endoscopist, leads to successful eradication in up to 85% of patients with ampullary adenomas. EP is a safe and effective therapy and should be established as the first-line therapy for ampullary adenomas.

Feasibility and safety of endoscopic cryoablation at the duodenal papilla: Porcine model

AIM: To assess the feasibility and safety of liquid nitrogen spray cryoablation at the duodenal papilla in a porcine model. METHODS: This prospective study protocol was approved by the University of Florida Institutional Animal Care and Use Committee. Six pigs underwent liquid nitrogen spray cryotherapy at the duodenal papilla. Freeze time of 20-s was applied per cycle(4 cycles/session). Survival animals(n = 4) were monitored for adverse events. Hemoglobin, white blood count, liver tests, and lipase were obtained at baseline and post-treatment. EGD was performed on day#7 to evaluate the papilla and for histology. All animals were euthanized and necropsy was performed at the end of the one-week survival period. Feasibility was defined as successful placement of the decompression tube in the duodenum, followed by delivery of spray cryotherapy to the duodenal papilla. Safety was determined by monitoring post-treatment blood tests and clinical course. Treatment effect was defined as endoscopic and histologic changes after cryotherapy. This was established by comparing endoscopic and histologic findings from mucosal biopsies prior to cryotherapy and on post-operative day(POD)#7. Full-thickness specimen was obtained post-mortem to assess depth of injury. RESULTS: Spray cryotherapy was feasible and successfully performed in all 6/6(100%) animals. Cryospray with liquid nitrogen(four 20-s freeze-thaw cycles) at the duodenal papilla resulted in white frost formation at and around the target region. The mean proceduraltime was 54.5 min(range 50-58 min). All six animals studied had stable blood pressure, heart rate, and pulse oximetry measurements during the procedure. There were no significant intra-procedural adverse events. There were no significant differences in hemoglobin, white cell count, liver tests or lipase from baseline to post-cryotherapy. Survival animals were monitored daily post-operatively without any clinical ill effects from the cryotherapy. There was no bleeding, infection, or perforation on necropsy. Endoscopic on POD#7 showed edema and ulceration at the duodenal papilla. On histology, there was loss of crypt architecture with moderate to severe necrosis and acute mixed inflammatory infiltration in each specimen following cryotherapy. The extent of cryogen-induced tissue necrosis(depth of injury) was limited to the mucosa on full-thickness specimen evaluation. CONCLUSION: Endoscopic liquid nitrogen spray cryotherapy is feasible and safe for ablation at the duodenal papilla in a porcine model.