Defining the criteria for local resection of ampullary neoplasms
D. W. Rattner, C. Fernandez-del Castillo, W. R. Brugge and A. L. Warshaw
Department of Surgery, Massachusetts General Hospital, Boston, Mass., USA.
OBJECTIVES: To delineate factors determined preoperatively, which predict
successful local resection of ampullary neoplasms. DESIGN: Retrospective
review of case series of the author's experience from 1988 through 1995.
The median follow-up of patients with malignancies was 29 months. SETTING:
Tertiary care university teaching hospital. PATIENTS: Twenty-seven patients
underwent surgery. The decision to perform either an ampullectomy or
pancreaticoduodenectomy (PD) was based on the size of the lesion, the
presence of a "field defect" (ie, familial polyposis), depth of invasion
determined by preoperative endoscopic ultrasound, and extent of pancreatic
and bile duct involvement seen on endoscopic retrograde
cholangiopancreatography. INTERVENTIONS: Fourteen patients underwent
ampullectomy, 12 patients underwent PD, and one patient had a
retroperitoneal node biopsy performed without resection of the primary
tumor. MAIN OUTCOME MEASURES: Resectability, morbidity, and mortality.
RESULTS: Depth of invasion was accurately determined in nine of 12 patients
studied by preoperative endoscopic ultrasound. Preoperative endoscopic
biopsy specimens were obtained in 21 patients and were inaccurate in seven
of 21 cases. The length of stay following local resection was 10.5 +/- 3.7
days vs 15.4 +/- 5.8 days following PD (P=.02). One patient died following
PD, and there were no deaths following ampullectomy. Six of 12 patients
undergoing PD had postoperative complications vs two of 14 patients
undergoing local resection. CONCLUSIONS: Ampullectomy is the procedure of
choice for resecting benign lesions smaller than 3 cm, small neuroendocrine
tumors, and T1 carcinomas of the ampulla. While endoscopic ultrasonography
is helpful in identifying stage T1 lesions suitable for local resection, no
preoperative test proved accurate enough to substitute for clinical
judgment and intraoperative pathological confirmation.
