Transduodenal Resection Research Articles

Definitive partial sleeve duodenectomy after previous trans-duodenal resection of duodenal adenoma

Background: To illustrate the importance of definitive partial sleeve duodenectomy as a treatment for a biopsy proven nonmalignant recurrent lesion in infra-ampullary portion of the duodenum instead of repeated trans-duodenal resection or whipple.

Transduodenal resection for duodenal adenomas may be an underutilized tool – A single institution experience

BackgroundDuodenal adenomas are pre-malignant lesions. Transduodenal resection and pancreaticoduodenectomy remain the only two surgical options. The optimal surgical management remains controversial between these two strategies. MethodsA retrospective review was conducted to identify patients who underwent intervention for duodenal adenomas. Patient were stratified by type of procedure, pancreaticoduodenectomy or transduodenal resection, and their demographic data as well as perioperative outcomes were compared. Results26 patients underwent surgery for duodenal adenomas. 11 underwent a pancreaticoduodenectomy (PD) (42.3%) and 15 underwent a transduodenal resection (TDR) (57.7%). Median operative time, median estimated blood loss, and mean length of stay were longer in the PD vs TDR group. Two patients (13.3%) in the TDR group developed recurrent adenomas. ConclusionTransduodenal resection should be considered in patients who are suspected to harbor benign duodenal tumors. Duodenal tumors with high grade dysplasia or invasive cancer should undergo an oncologic procedure. Endoscopic surveillance appears to be indicated after transduodenal resection.

内視鏡的・外科的乳頭部切除後に主膵管内再発・癌化をきたした十二指腸乳頭部腺腫の1例

内視鏡的・外科的乳頭部切除後に主膵管内再発・癌化をきたした十二指腸乳頭部腺腫の1例

Robotic Surgery for Benign and Low-Grade Malignant Diseases of the Duodenum

Robotic duodenal surgery (RDS) is a treatment option for many benign and low-grade malignant duodenal conditions that are not amenable to endoscopic intervention and can avoid morbidity related to open surgery. A retrospective review of all patients undergoing RDS (non-Whipple) at a tertiary care center from 2010-2017 was carried out. Indications, procedural details, and outcomes were reviewed. Twenty-four patients underwent RDS during the study period: transduodenal resection in 6 patients (25%), wedge resection in 6 patients (25%), transduodenal ampullectomy in 5 patients (21%), sleeve (segmental) resection in 5 patients (21%), duodenojejunostomy bypass in 1 patient (4%), and duodenal diverticulectomy in 1 patient (4%). Median age was 68 years, 54 per cent were male, and median BMI was 27. Adenoma was the most common diagnosis (68%) followed by neuroendocrine tumor (25%), duodenal diverticulum (4%), and refractory superior mesenteric artery syndrome (4%). Seventy-one per cent were symptomatic with gastroinstestinal bleed being the most common presentation. Median tumor size was 27 mm, and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median operating time was 205 minutes and estimated blood loss was 50cc with no patient requiring intraoperative transfusion. Median length of stay was five days (3-21 days). Overall complication rate was 41 per cent (10/24): minor biliopancreatic leak in three patients; ileus in three patients; bleeding, arrhythmia, hypoxia, and headache in one patient each. Three (12%) patients had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation, but all three were discharged on or before POD 6 with resolution of complication. Ninety-day readmission rate was 8 per cent and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median follow-up of 16 months. It has been concluded that RDS is a safe alternative to open or laparoscopic duodenal resection for benign and low-grade malignant conditions not amenable to endoscopic intervention.

Minimally invasive resection of duodenal tumors

Duodenal tumors represent fewer than 1% of all gastrointestinal neoplasms and are seldom truly benign. Current treatment options include open surgical resection and endoscopic techniques at opposite ends of the risk: benefit spectrum in regard to morbidity and oncological efficacy. Laparotomy has considerable associated morbidity and is in wider practice than laparoscopic resection due to the technical demands of duodenal reconstruction. Endoscopic strategies have proven useful for treating small, superficial lesions but carry a significant risk of bleeding, perforation and incomplete lesion retrieval for larger tumors. Robotic-assisted surgery may bridge the gap between these limitations of open and endoscopic resection: expedited recovery after minimally-invasive resection while minimizing morbidity associated with optimal tumor clearance. This overview of robotic-assisted resection of duodenal tumors presents operative techniques tailored to the anatomical location of the lesion, likely ampullary involvement, and the challenge of effective reconstruction. Techniques include transduodenal resection, transduodenal ampullectomy, segmental duodenal (sleeve) resection, and near-circumferential duodenectomy with Roux-en-Y duodenojejunostomy. At our institution, sixteen patients have undergone robot-assisted transduodenal resections between June 2013 and November 2017. Surgical indications included tubulovillous adenomas [13], neuroendocrine tumors [2] and leiomyomas [1]. The tumors were located in the ampulla [7], duodenum [8] and the minor papilla [1] with a median tumor diameter of 2.85 cm (1.5–5.0 cm). Operative time ranged from 214 to 393 mins with an estimated average blood loss of 50mL. There were no conversions to open surgery or intra-operative blood transfusions. There were no re-operations on index hospitalization, pancreatic fistulas, disease recurrences, or death.

Robotic duodenal surgery is a safe alternate to laparoscopic and open resection for benign and low grade malignant conditions not amenable to endoscopic intervention

Background: Robotic duodenal surgery is a new treatment option for many benign and low grade malignant conditions of the duodenum that are not amenable to endoscopic intervention. Methods: Retrospective review of all patients undergoing robotic duodenal surgery (non-Whipple) at a tertiary care center from 2010 to 2017. Indications, procedural details and short and long term outcomes were reviewed. Results: 24 patients underwent robotic duodenal surgery during the study period: transduodenal resection in 6 (25%), wedge resection in 6 (25%), transduodenal ampullectomy in 5 (21%), sleeve (segmental) resection in 5 (21%), duodenojejunostomy bypass in 1 (4%) & duodenal diverticulectomy in 1 (4%). Median age was 68 yrs, 54% were male & median BMI was 27. 58% were ASA III. Adenoma was the most common diagnosis (68%) followed by low grade neuroendocrine tumor (25%), duodenal diverticulum (4%) and refractory SMA syndrome (4%). 71% were symptomatic with GI bleed being the most common presentation. Median tumor size was 27 mm and the most common location was D2 (58%) followed by D3/D4 (25%) and D1 (17%). Median op-time was 205 min and EBL was 50 cc with no patient requiring intra-op transfusion. Median postop length of stay was 5 days (3–21d). 41% (10/24) had complications: Leak in 3, ileus in 3, bleeding, arrhythmia, hypoxia and headache in 1 each. 3(12%) patient had significant complications (Clavien-Dindo grade ≥ 3) requiring laparoscopic or robotic reoperation but all three were discharged on or before 6th post-op day with resolution of complication. 90-day readmission rate was 8% and 90-day mortality was 0. Recurrent disease or strictures were not seen in any patient after a median followup of 16 months. Conclusion: Robotic duodenal surgery is a safe alternate to open or laparoscopic resection for many benign and low grade malignant conditions not amenable to endoscopic intervention.

Duodenal Schwannoma: An Incidental Finding on PET Scan

Introduction: Gastrointestinal schwannomas (GS) are benign nerve sheath tumors arising from Auerbach's plexus. They are rare, accounting for 0.4-1% of all submucosal tumors. GS are most common in the stomach followed by small bowel, then colon and rectum. They may be associated with neurofibromatosis or present as isolated lesions. We present an incidental finding of duodenal schwannoma (DS). Case report: A 58 year old male with history of HTN presented as an outpatient for evaluation of an FDG-avid incidental duodenal mass discovered on PET scan. He was initially found to have nontender cervical lymphadenopathy on routine dental exam. He was otherwise asymptomatic and physical exam was unremarkable. He had no significant past surgical, family, or social history. A lymph node biopsy revealed poorly differentiated squamous cell carcinoma (SCC) of unclear origin. He then underwent PET scan, which identified an oral and duodenal lesion. Primary site of cancer was later confirmed as oropharyngeal SCC, for which he underwent modified radical neck dissection and adjuvant chemoradiation. The duodenal lesion was further evaluated with EGD/EUS with FNA. Endoscopically, an 18x12 mm pedunculated, subepithelial lesion with a long, broad-based stalk was seen in the second portion of the duodenum. Sonographically, it appeared mostly hypoechoic with internal hyperechoic, non-shadowing regions. The exact wall layer of origin could not be delineated. FNA revealed a spindle and epithelioid cell neoplasm, which stained positive for S-100 and SOX10, but negative for CD117, DOG-1 and desmin, supporting the diagnosis of DS. Laparoscopic-assisted, minimally-invasive transduodenal resection is currently scheduled.Figure: Endoscopic view of 18x12mm pedunculated duodenal lesion.Discussion: GS is a mesenchymal tumor of the GI tract. Endoscopic and radiologic exams can identify submucosal lesions but cannot differentiate between the types of mesencyhmal tumors. The diagnosis is made histologically, with immunohistochemical staining for S-100 indicating GS. Although benign, schwannomas can demonstrate avid FDG uptake on PET imaging, and may be mistaken for malignant lesions.GS are typically asymptomatic but can present with nonspecific symptoms. Surgical excision or endoscopic submucosal dissection is recommended for large tumors to avoid complications, such as bleeding or bowel obstruction. Endoscopic surveillance is an option for smaller tumors with asymptomatic presentation due to the benign nature of GS.Figure: Sonographic image of the duodenal lesion taken during EUS.Figure: Fine needle aspiration of subepithelial duodenal lesion showing spindle and epithelioid cell neoplasm, favoring schwannoma (A). Tumor cells positive for schwannoma markers S100 (B) and SOX10 (C).

Is transduodenal resection for duodenal adenomas adequate?

Objective: Duodenal adenomas (DAs) are uncommon occurrences with malignant potential. The optimal surgical management of DAs remain controversial. Methods: We performed a retrospective review of 27 patients at a single institution who received either a Whipple procedure (40.7%) or a transduodenal resection (TDR) (59.3%) for ampullary and nonampullary duodenal adenomas. Perioperative and postoperative outcomes were compared between the two groups. Results: Both groups had similar demographics. Median operative time and median estimated blood loss (EBL) were longer in the Whipples group than the TDR group. Mean length of stay was longer in the Whipple group vs TDR group (12 vs 7 days). 3 patients (18.7%) who received TDRs developed recurrent adenomas. Two of these patients subsequently received a Whipple procedure. This is summarized in Table 1. Conclusion: Although TDR has the perioperative advantages of less operative time, less EBL and less hospital length of stay, our experience demonstrates that TDR may be inferior to the Whipple procedure for duodenal adenomas due to high recurrence rates.Table 1Whipple (n=11)Transduodenal resection (n=16)Median duration of surgery (min)248120Median estimated blood loss (mL)300100Mean length of stay (Days)137RecurrencesN/A18.7% Open table in a new tab

Endoscopic assessment and management of sporadic duodenal adenomas: The results of single centre multidisciplinary management.

AIMTo review the role of multidisciplinary management in treating sporadic duodenal adenomas (SDA).METHODSSDA managed at North Shore Hospital between 2009-2014 were entered into a prospective database. Pathology, endoscopic and surgical management as well as follow up were reviewed.RESULTSTwenty-eight patients (14 male: Median age 68 years) presented with SDA [18 were classified as non ampullary location (NA), 10 as ampullary location (A)]. All SDA were diagnosed on upper gastrointestinal endoscopy and were imaged with a contrast enhanced CT scan of the chest, abdomen and pelvis. Of the NA adenomas 14 were located in the second part, 2 in the first part and 2 in the third part of the duodenum. Two patients declined treatment, 3 patients underwent surgical resection (2 transduodenal resections and 1 pancreaticoduodenectomy), and 23 patients were treated with endoscopic mucosal resection (EMR). The only complication with endoscopic resection was mild pancreatitis post procedure. Patients were followed with gastroduodenoscopy for a median of 22 mo (range: 2-69 mo). There were 8 recurrences treated with EMR with one patient proceeding to pancreaticodeuodenectomy because of high grade dysplasia in the resected specimen and 2 NA recurrences were managed with surgical resection (distal gastrectomy for a lesion in the first part of the duodenum and a transduodenal resection of a lesion in the third part of the duodenum).CONCLUSIONSDA can be treated endoscopically with minimal morbidity and piecemeal resection results in eradication in nearly three quarters of patients. Recurrent SDA can be treated with endoscopic reresection with surgical resection indicated when the lesions are large (> 4 cm in diameter) or demonstrate severe dysplasia or invasive cancer.

Transduodenal resection of a choledochocele (type III choledochal cyst) with sphincteroplasty: A case report

Choledochal cysts are rare congenital anomalies of the biliary tree which may progress to obstruction or malignancy. Of the five Todani variants, choledochocele, or type III choledochal cyst is the rarest. In this case report, we describe a previously healthy 10-year old female who presented with a choledochocele and was treated by near-total excision with transposition of the common channel, resulting in an extended sphincteroplasty.

A Rare Duodenal Mass, Brunneroma: Case Report

A 65 years old female patient referred to our clinic was diagnosed with ileus following laparoscopic cholecystectomy. Contrast-enhanced abdominal tomography (CT) had earlier been applied to determine the underlying cause of ileus. A hypodense 52 × 32 mm sized mass was incidentally detected in the first and second sections of duodenum. In upper gastric endoscopy, submucosal located mass was observed in the first section of the duodenum at the posterior wall, which was not blocking the passage of endoscope. Positron emission tomography (PET) CT examination with a standardized uptake value (SUVmax) of 6 showed a potential malignancy. As the patient’s clinical condition worsened, exploratory surgery was planned. Small bowel adhesions and strangulation were detected. Transduodenal biopsy was taken. Pathological examination revealed hyperplastic Brunner’s glands, which was considered to be Brunner’s Gland Adenoma. Patient was discharged at postoperative day 12 with cure. For diagnosis of BGA, endoscopic ultrasonography and contrasted tomography can be used. In symptomatic cases, transduodenal resection can be performed. In the case of non-symptomatic and incidentally detected duodenal masses, however, PET-CT would be useful. A SUVmax lower than 2.3 suggests a benign mass and a higher value over 5 in PET-CT have a high risk of malignancy. As in this case, gastrointestinal system tumors with a SUVmax greater than 5 is not always related with malignancy. In conclusion, for regular bordered mass images, which are detected at this localization, BGA should be kept in mind for differential diagnosis. Patients with BGA should be followed-up for malignancy and recurrence.

Robotic Surgery for Benign Duodenal Tumors

IntroductionBenign duodenal and periampullary tumors are uncommon lesions requiring careful attention to their complex anatomic relationships with the major and minor papillae as well as the gastric outlet during surgical intervention. While endoscopy is less morbid than open resection, many lesions are not amenable to endoscopic removal. Robotic surgery offers technical advantages above traditional laparoscopy, and we demonstrate the safety and feasibility of this approach for a variety of duodenal lesions. MethodsWe performed a retrospective review of all robotic duodenal resections between April 2010 and December 2013 from two institutions. Demographic, clinicopathologic, and operative details were recorded with special attention to the post-operative course. ResultsTwenty-six patients underwent robotic duodenal resection for a variety of diagnoses. The majority (88 %) were symptomatic at presentation. Nine patients underwent transduodenal ampullectomy, seven patients underwent duodenal resection, six patients underwent transduodenal resection of a mass, and four patients underwent segmental duodenal resection. Median operative time was 4 h with a median estimated blood loss of 50 cm3 and no conversions to an open operation. The rate of major Clavien-Dindo grades 3–4 complications was 15 % at post-operative days 30 and 90 without mortality. Final pathology demonstrated a median tumor size of 2.9 cm with a final histologic diagnoses of adenoma (n = 13), neuroendocrine tumor (n = 6), gastrointestinal stromal tumor (GIST) (n = 2), lipoma (n = 2), Brunner’s gland hamartoma (n = 1), leiomyoma (n = 1), and gangliocytic paraganglioma (n = 1). ConclusionRobotic duodenal resection is safe and feasible for benign and premalignant duodenal tumors not amenable to endoscopic resection.

Adenomas of the Ampulla of Vater: A comparison of Outcomes of Operative and Endoscopic Resections

BackgroundData comparing operative and endoscopic resection of adenomas of the ampulla of Vater are limited. Our aims were to evaluate and compare the long-term results and outcomes of endoscopic and operative resections of benign tumors of the ampulla of Vater as well as to determine which features of benign periampullary neoplasms would predict recurrence or failure of endoscopic therapy and therefore need for operative treatment. MethodsRetrospective review of all patients treated for adenomas of ampulla of Vater at our institution from 1994 to 2009. ResultsOver a 15-year span, 180 patients (mean age 59 years) were treated for benign adenomas of the ampulla of Vater with a mean follow-up of 4.4 years. Obstructive jaundice was more common in the operative resection group (p = 0.006). The adenomas were tubular in 83 patients (44 %), tubulovillous in 77 (45 %) and villous in 20 (11 %). Endoscopic resection alone was performed in 130 patients (78 %). Operative resection was performed in 50 patients (28 %), with pancreatoduodenectomy in 40, transduodenal local resection in 9, and pancreas-sparing total duodenectomy in 1. Nine patients who underwent endoscopic resection initially were endoscopic treatment failures. Fifty-eight percent of endoscopically treated patients required one endoscopic resection, while 58 (42 %) required two or more endoscopic resections (range 2–8). Patients who underwent operative resection had larger tumors with a mean size of 3.7±2.8 versus 1.8±1.5 cm in those treated by endoscopic resection (p < 0.001) or intraductal extension (p = 0.02). Intraductal extension and ulceration had no effect on recurrence if completely resected endoscopically (p = 0.41 and p = 0.98, respectively). Postoperative complications occurred in 58 % of patients, and post-endoscopic complications in 29 % (p < 0.001). Endoscopic resection was associated with a greater than fivefold risk of recurrence than operative resection (p = 0.006); 4 % of recurrences had invasive carcinomas. When comparing patients who underwent local resections only (endoscopic and operative), there was no difference in the recurrence rate between endoscopic resection and operative transduodenal resection (32 versus 33 %; p = 0.49). The need for two or more endoscopic resections for complete tumor removal was associated with 13-fold greater risk of recurrence (p < 0.001). ConclusionThere is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.

Comparison between two types of local resection in the treatment of ampullary cancer

This study aims to compare the effects of two different local resection procedures on the prognosis of ampullary cancer. We carried out a retrospective study using clinical and pathological data from patients with ampullary cancer who underwent local resection between February 1996 and February 2009 in the PLA General Hospital. In these participants, we carried out a comparative analysis between the transduodenal (the transduodenal group) and the extraduodenal (extraduodenal group) surgical approaches. No significant differences in gender, age, preoperative bilirubin levels, CA19-9 values, biopsy results, tumour size, differentiation status, degree of invasion, surgical margins, recurrence, metastasis and complication rates, and intraoperative blood loss were found. As compared to the transduodenal group, the extraduodenal group showed a longer duration of surgery and higher survival rates. Even though the operation time for the extraduodenal resection of ampullary cancer was longer, the survival rate was higher than in patients who underwent transduodenal resection. For certain patients, the extraduodenal approach may be more appropriate when technical conditions allow it.

Carcinoma Arising from Villous Adenoma of the Ampullary Bile Duct: Report of a Case

Adenocarcinoma arising from the villous adenoma of the ampullary biliary epithelium is an extremely rare disorder. The preoperative diagnosis and treatment of the disease represent a major difficulty. A 67-year-old woman was admitted to the hospital with a chief complaint of jaundice. Preoperative investigations revealed obstructive type jaundice due to a 2-cm mass at the end of common bile duct. She was operated on and after undergoing a sphincterotomy, small, yellowish, grape-like particles fell down from the ampullar orifice. A frozen-section examination of these particles revealed villous adenoma. Next, a transduodenal resection of ampulla and reconstruction were performed. The frozen-section examination of the resected material also revealed a villous adenoma. The patient was discharged uneventfully. The histological examination revealed a villous adenoma arising from the biliary epithelium and some adenocarcinoma foci. The surgical margins were tumor free. Nevertheless, she developed hepatic metastases 15 months after surgery. This case shows the importance of surgeons to keep in mind the fact that frozen examinations may sometimes miss a malignancy and they therefore cannot be relied upon to rule out malignancy in villous adenoma of the ampullary bile duct.

Choledochocele, Diverticular Subtype

2 37-year-old woman was transferred to our hospital with suspected biliary tract stones with acute ancreatitis and a periampullary tumor. She had been uffering from epigastric pain intermittently for the ast 3 years. No icteric sclera or abdominal mass was oted on physical examination. Blood chemistry reults all were within normal limits. The patient’s seum amylase level was 183 U/L and her lipase level as 238 U/L (normal range for both, 190 U/L). An bdominal computed tomography scan showed galltones, a soft-tissue nodule in the common bile duct CBD), and a juxtapapillary cystic lesion (Figure A). uodenoscopy revealed a bulge of the papilla of Vater esembling a submucosal tumor about 3 cm in size. An ndoscopic retrograde cholangiogram showed multile gallstones, CBD, and intrahepatic duct stones. In ddition, a contrast-filled cystic lesion about 4 cm in ize was noted in the papilla with multiple small filling efects within it (Figure B, arrow). A magnetic resoance cholangiogram showed the same findings. The atient underwent surgical intervention with a proviional diagnosis of large choledochocele of the diverticular ubtype. A cholecystectomy was performed first. After dentifying the CBD and pancreatic duct, a small orifice was ound near the ampulla of Vater and bile material was jected while palpating the cyst. Several yellowish stones ere noted within the cyst. Transduodenal resection of the yst and sphincteroplasty were performed. Histopathology howed the cystic space was lined partially by bile duct pithelium. The patient was symptom-free at the 2-year ollow-up evaluation. Choledochoceles or type III choledochal cysts are xtremely rare. Choledochoceles consist of cystic (type ) or diverticular (type B) dilatation of the terminal ntramural portion of the CBD protruding into the duoenum. Type B is less common and constitutes 21% of holedochoceles. The common clinical presentations of holedochoceles are intermittent upper-abdominal pain nd jaundice. Stones in the choledochocele or CBD may nduce acute pancreatitis and cholangitis.

Das Hamartom des Duodenums

A 61-year-old man had been suffering from repeated episodes of postprandial vomiting and a feeling of fullness as well as a weight loss of 8 kg for two months. Three years prior to this, a laparoscopic cholecystectomy had been carried out at a different institution after a pancreatitis on the assumption of a biliary genesis. There were no sings of jaundice or gastro-intestinal bleeding. The physical examination was -- apart from epigastric pain -- unremarkable. The routine laboratory parameters and tumor markers were within normal range. Endoscopy revealed a thickened duodenal wall with a stenosis at the level of the papilla, and a tumorous mass in the duodenal bulb. The biopsy specimens gave no evidence of malignancy. The barium upper GI series revealed an excentric stenosis of the duodenal pars II. Computerized tomography showed no evidence for tumor growth extending beyond the wall or a pathologic enlargement of the adjacent lymph nodes. A pylorus-preserving partial duodenopancreatectomy was performed and the postoperative course was without any complications. The histological examination of the resectate showed -- besides a chronically fibrosing pancreatitis -- a hamartoma of the duodenal wall. Besides the endoscopic removal of a hamartoma of the duodenum a surgical transduodenal resection represents the most frequently applied procedure. The partial duodenopancreatectomy is a rather rare therapeutic option. It was chosen in our patient on account of the atypical presentation of the tumor, unclear histology and an adequate operative risk.

Transduodenal Resection of Peri‐Ampullary Lesions

Transduodenal resection (TDR) of lesions near the ampulla of Vater is an alternative to the Whipple pancreaticoduodenectomy. A retrospective analysis was performed to determine the long-term outcome and the utility of intraoperative frozen section examinations in aiding operative decision making in patients undergoing TDR. From 1992 to 2002, 19 patients with an average age of 64.2 years (range: 33-84 years) underwent a transduodenal resection of a peri-ampullary lesion; median follow-up was 47 months (range: 2-100 months). Pathology of the lesions was as follows: 11 with benign ampullary adenomas, including 4 with familial adenomatous polyposis (FAP); 7 with peri-ampullary adenocarcinomas; and 1 with a benign stricture. Survival for the entire cohort is 100%. In 12 cases an intraoperative frozen section was performed. The specificity and positive predictive value of the intraoperative histology were both 100%, and the sensitivity and negative predictive value were 57% and 38%, respectively. Three of the 4 patients with FAP have recurrent adenomatous change; 2 of the 7 with carcinoma have metastatic adenocarcinoma. Transduodenal resection of peri-ampullary lesions appears to be a safe alternative to radical resection for benign adenomas and selected carcinoma. Intraoperative frozen section assessment is recommended in cases of potential adenocarcinoma.

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

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.

Melena due to adenoma of the ampulla of Vater

A patient with gastrointestinal bleeding was found to have a benign adenoma of the ampulla of Vater. The condition was treated by local transduodenal resection of the duodenal papilla, which is considered the treatment of choice. The roentgenographic epsilon sign of tumors of the major duodenal papilla is illustrated and its significance emphasized.