Results of endoscopic versus operative management of benign tumors of the ampulla of vater

Abstract

Introduction: Since adenomas of the ampulla of Vater are regarded as premalignant lesions, complete removal of these tumors is recommended. The different therapeutic options of ampullary tumors include endoscopic excision (EE) and transduodenal resection of the papilla (TRP). The application of both is discussed controversially. The objective of this study was the evaluation of EE and TRP regarding postinterventional morbidity and recurrences. Patients and Methods: From 1993 until 1998, 36 patients with ampullary tumors were analysed retrospectively. Nineteen patients (12 female! 7 male, mean age 61:±: 11,8 [38-82)) were treated by EE (group A), 17 patients (9 female! 8 male; mean age 55:±: 13,3 [30-73)) underwent TRP (group B). In group B, prior to the transduodenal excision of the papilla, endoscopic biopsy revealed mild to moderate dysplasia (n= 10), severe dysplasia (n=3) and chronic papillitis (n=4). The patients were followed for a mean of 15,8:±:20 and 14:±:11,3 months (pO.05), respectively. Results: The histology of specimens from group A showed mild to moderate dysplasia (n= 12), severe dysplasia (n=5), adenomyoma (n=2) and carcinoma of the papilla (n= 1). Besides post-papillectomy bleeding in two patients, no other complications occurred. The resulting morbidity was 10,5 %. Nine patients (47,4 %) had recurrences, in one patient histology showed incomplete resection of the adenoma. Further management of the recurrences included repeated EE (n=3), TRP (n= 1), Whipple s procedure (n=2) and endoscopic controls including biopsy (n=3). Histologic examination in group B revealed mild to moderate dysplasia (n=7), papillitis (n=5), adenomyoma (n=2) and fibrosis of the papilla (n=3). One patient developed incisional hernia one and stenosis of the neo-papilla. The morbidity was 11,7 %. Recurrences did not occur after TRP, thus the recurrence rate in group B was significantly lower than in group A (p<0,05). Conclusion: The results indicate that tumors of the ampulla of Vater should preferably be treated by TRP, since morbidity of the procedure is comparable to that of EE, while recurrences and consecutive reinterventions are significantly less after operative treatment of the premalignant lesions. Thus TRP is more effective regarding cure of ampullary tumors than EE.