Carcinoma of the ampulla of Vater

Abstract

The records of fifteen patients proved to have had carcinoma of the ampulla of Vater are reviewed. Jaundice, progressive or fluctuating, weight loss, absent or minimal pain, and nausea and vomiting were the important symptoms. Icterus, evidence of weight loss, palpable liver, and a palpable gallbladder were the significant physical findings. Laboratory data reveal the serum bilirubin levels to be high, the alkaline phosphatase elevated, the serum proteins depressed, the prothrombin time prolonged, the urinary urobilinogen absent, and the stool to be guaiac positive. Duodenal drainage not infrequently reveals the presence of occult blood. Radiologic studies are likely to demonstrate pressure defects in the duodenum due to a dilated gallbladder or common bile duct. The usual finding on cholecystography is nonvisualization. Distortion or a filling defect in the second portion of the duodenum may be observed. Enlargement of the duodenal loop may be seen whenever a large mass is present. T tube cholangiography may reveal a high degree of obstruction at the distal end of the common duct. Palliative operations have been disappointing, resulting in an average survival of five months in three patients. The two stage operation is reserved for elderly patients with concomitant disease and a high degree of biliary tract obstruction. The average survival time in three patients with two stage pancreaticoduodenal resection was sixteen months. The most impressive results are obtained whenever a one stage Whipple procedure is possible. The average survival in eight patients was fifty-nine months. Two patients died of other causes. Two others are living thirteen and seven years, respectively, without evidence of recurrent tumor. The historic evolution of the Whipple procedure is reviewed for better understanding of its rationale. We have presented our reasons for selecting the sequence of end to end pancreaticojejunostomy, end to side choledochojejunostomy, and gastrojejunostomy as the preferred method of reconstruction of the gastrointestinal tract.