Ampullary neoplasms: surgical management

Abstract

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. 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. Areview of the literature addressing surgical management of ampullary neoplasms was performed. Current evidence and recommendations were summarized. 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 arisk 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 levelII dissection of the mesopancreas. Lymph node status and perineural sheath invasion are key prognostic factors concerning overall survival.