Treatment of Ampullary Neoplasm, Diagnosed as Benign on Preoperative Endoscopic Biopsy

ABSTRACT

Adenoma of the ampulla of Vater is a rare disease, and there is no universal consensus on the management of this entity due to its rarity and unpredictable behavior. Because many of these tumors recur after local excision and because it is difficult to obtain a definitive diagnosis or to exclude malignancy before operation, local excision of ampullary tumors still remains controversial despite being a standard operation for nearly a century. Many surgeons resort to more radical resection, such as pancreatoduodenectomy for treatment of this troublesome disease. The author's report on the evaluation and treatment of 10 patients who underwent pancreatoduodenectomy for ampullatry tumors, diagnosed as benign adenoma on preoperative endoscopic biopsy. Endoscopic retrograde cholangiopancreaticography (ERCP) and computed tomography (CT) was performed in all cases. There were 6 men and 4 women, with a median age of 53 years (22-72 years). Postoperative histopathologic examination revealed that five of the ten patients had had cancerous change within adenoma. Four of the five ampullary adenocarninomas were confined to mucosa, but one had invaded the pancreatic parenchyma. No case was accompanied with lymphatic involvement. Reoperative pancreatoduodenectomy was perfomed in one patient with recurrent villotubular adenoma after local excision of ampulla. All patients are still alive and without any evidence of tumor recurrence after pancreatoduodenectomy (median follow up period 35 months, range 17-77 months). There was no postoperative death. Diagnosis of malignancy could not be ruled out based on a preoperative endoscopic biopsy in ampullary tumors. We conclude that pancreatoduodenectomy with regional lymph node dissection should be the standard treatment in circumstances without any contraindication to extensive surgery.