[Benign tumors of the Vater's papilla]. / Gutartige Tumore der Papilla Vateri.

BACKGROUND AND OBJECTIVE: Villous adenoma is the most common tumour of the papilla of Vater, and transition from adenoma to carcinoma is now generally accepted as proven. It is thus essential for an adenoma to be removed. Methods of removal have ranged from endoscopic sling papillectomy to partial duodenopancreatectomy. It was the aim of this study to determine whether recurrence can be prevented by local resection. PATIENTS AND METHODS: 58 patients with a benign tumour of the papilla (26 men, 32 women; average age 59 [range from 18 to 81] years) were included. Depending on preoperative histology, intraoperative frozen-section diagnosis and macroscopic histopathology, some form of surgical intervention was undertaken, most often resection of the ampulla. The clinical course and findings at postoperative follow-up were recorded and the absence of recurrence checked by endoscopy. RESULTS: Ampullectomy was performed in 49 of the 58 patients, papillectomy in three. Although frozen-section examination had failed to reveal any malignancy, resection of the head of the pancreas with preservation of the pylorus was done in six patients, carcinoma having been suspected macroscopically. There were no operative deaths. An adenoma had been found in 44 patients, one quarter of them showing severe dysplasia: follow-up examinations after a mean interval of 45 months (range of 6-180 months) failed to find any recurrence. CONCLUSION: Ampullectomy provides an adequate surgical treatment of benign adenoma of the ampulla of Vater. Accurate surgical technique and pre-, intra- and final histopathological diagnosis by an experienced pathologist are decisive factors in determining the ultimate outcome. If the histological findings as to benignity are unclear, resection of the head of the pancreas with preservation of the pylorus by an experienced surgeon is indicated.

Local resection of benign periampullary tumors.

Benign tumours of the ampulla of Vater are rare and histologically mostly villous or tubulovillous adenomas. The frequency of malignant lesion in an adenoma of the papilla figures around 26%. Villous adenoma of the ampulla is considered as premalignant lesion. Various techniques have been advocated ranging from simple excision of the ampullary tumour and the contiguous duodenal mucosa to wide resection of the mass including the papilla and adjacent duodenal, ductal, and pancreatic tissue. In this study, 41 patients suffering from a benign tumor of the Ampulla of Vater were examined. Sixty-six percent of all patients exhibited a villous or tubulovillousadenoma with medium or severe degree of dysplasia. Thirty-six patients were treated with local resection of the ampulla, using ampullectomy in 33 patients. In 5 of the 41 patients pylorus-preserving duodenopancreatectomy was applied. The median follow-up of 42 month showed no evidence of recurrent disease. Ampullectomy is an adequate way of treating benign ampullary lesions, but, precise technique is important. The decision-making should be based on histological examination of preoperative biopsy specimens and of operative frozen sections, by an experienced pathologist. If the histology of the ampullary lesion is uncertain, pylorus-preserving partial pancreaticoduodenectomy is justified in patients with low perioperative risks, and if this extended procedure can be done safely by an experienced surgeon.

Tumor of the ampulla of Vater: experience with local or radical resection in 171 consecutively treated patients.

HYPOTHESIS: This study was designed to evaluate prospectively oncological factors determining survival after resection of tumors of the papilla, comparing local and radical oncological resection. We hypothesized that, in malignant lesions of the ampulla, the T and N stages are major determinants of the patient's long-term outcome. BACKGROUND DATA: The frequency of malignant lesions in adenomas of the papilla is about 26%. Villous adenoma of the ampulla is considered a premalignant lesion. Local excision has been recommended for benign adenoma and pancreatoduodenectomy for malignant lesions. PATIENTS AND METHODS: From January 1, 1982, through June 30, 1997, 171 patients with tumors of the ampulla of Vater were surgically treated. Demographics, intraoperative factors, tumor pathological findings, and postoperative short- and long-term follow-up data were documented prospectively. Of the patients, 45 had adenoma of the papilla and 126 had malignant lesions of the ampulla. RESULTS: Local resection was performed in 40 of the 45 patients with adenoma. In 98 of the 126 patients with malignant lesions, a radical Kausch-Whipple resection or pylorus-preserving pancreatoduodenectomy was used. Of the patients with benign adenoma, 40 had local resection and 5 had pylorus-preserving pancreatic head resection, with a hospital mortality of 0%. Thirty of 35 patients had villous adenoma, 9 (30%) of the 30 with severe dysplasia. Of the 126 patients with malignant lesions, 98 had partial pancreatoduodenectomy and 10 had ampullectomy, with an overall hospital mortality of 3.1% for patients who underwent resection. Seventy-eight of the 98 patients had an R0 resection. The 5-year survival probability for all patients who underwent resection was 84% for cancer stage I, 70% for stage II, and 27% for stage III. In 8 patients with villous adenoma and carcinoma in situ and in 10 patients with cancer in the adenoma, ampullectomy with local lymph node dissection was performed. In 4 of the patients who had villous adenoma and a carcinoma in stage pT1 N0, an R0 resection was performed, resulting in cure of cancer. On the basis of a multivariate regression analysis, the prognosis after oncological resection of cancer of the ampulla is determined by the absence of lymph node metastasis (P<.05), the absence of infiltration into the pancreatic head tissue (P<.05), and the application of an R0 resection. CONCLUSIONS: In patients with villous adenoma of the ampulla, ampullectomy was an adequate surgical treatment. In patients with a low-risk cancer in stages pTis and pT1 N0 M0, G1 or G2, a local resection with ampullectomy including local lymph node dissection is justified. An oncological resection of cancer of the ampulla by means of a pylorus-preserving partial pancreatoduodenectomy or the Kausch-Whipple resection is the surgical procedure of choice; the 3- and 5-year survival rates were 72% and 52%, respectively, in patients with R0 resections.

Benign tumour of the ampulla of Vater: surgical treatment and prognosis.

OBJECTIVE: To find out whether wide local resection is adequate treatment for patients with benign tumours of the papilla of Vater. DESIGN: Retrospective study. SETTING: University hospital, Germany. SUBJECTS: 31 patients with benign tumours out of a total of 129 with lesions of the ampulla of Vater treated between May 1978 and February 1995. INTERVENTIONS: Histological examination of specimens before, during, and after the operation. MAIN OUTCOME MEASURES: Sensitivity and positive predictive value of histological examination, and outcome of treatment. RESULTS: Histological examination before and during the operation had a sensitivity of 89% and 97%, respectively. 28 patients were treated by wide excision of the ampulla and 3 by pylorus-preserving partial pancreaticoduodenectomy. At a median follow up of 43 months (range 6-156) there was no evidence of recurrent disease. CONCLUSION: Wide excision of the ampulla with reconstruction and reimplantation of the duct is adequate treatment for benign lesions. If the histological picture is uncertain, partial pancreaticoduodenectomy is justified in patients at low risk.

[Arterial lesions following radiotherapy]. / Arterielle Gefässschäden nach Strahlentherapie.

From 1980 to 1990 twelve patients with vascular lesions attributable to irradiation were treated. The time interval between radiotherapy because of malignancy and onset of symptoms due to radiation-induced atherosclerosis was on an average 7 years (1 month-29 years). A typical morphological finding at angiography was the well-localised vascular lesion in the previous radiation area, its localisation clearly distinguishable from typical atherosclerotic lesions. 10 patients had other radiation damage with involvement of the skin and perivascular tissue frequently necessitating an extra-anatomic reconstruction (n = 6). 4 patients had an anatomical reconstruction, one had a PTA, one was treated conservatively. Due to absence of multifocal arteriosclerotic lesions, long-term results of vascular reconstruction are good and will certainly contribute to further improvement of life quality after curative therapy for malignant disease.