eMedicine Specialties > Oncology > Carcinomas of the Gastrointestinal Tract

Carcinoma of the Ampulla of Vater: Follow-up

Author: Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Coauthor(s): Pankaj Chaturvedi, MBBS, MS, Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India; Ronald S Chamberlain, MD, Chairman, Chief, Department of Surgery, Saint Barnabas Medical Center; Venkata Subramanian Kanthimathinathan, MD, Staff Physician, Department of General Surgery, Loma Linda University Medical Center; Uma Chaturvedi, MD, MBBS, DPB, Lecturer, Department of Pathology, KJ Somaiya Hospital and Research Center, India; Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital
Contributor Information and Disclosures

Updated: Apr 8, 2009

Follow-up

Further Inpatient Care

  • Employ broad-spectrum antibiotic coverage for 24 hours.
  • Continuous nasogastric aspiration usually is maintained for the first 24 hours.
  • Oral feeding usually is started on the second postoperative day.
  • Subcutaneous heparin and pneumatic compression stockings are used to prevent deep vein thrombosis (DVT).
  • Adequate blood replacement is necessary in cases of intraoperative blood loss.
  • Early ambulation and chest physiotherapy reduce morbidity.
  • Serum electrolytes, renal function, and liver function should be monitored.
  • Abdominal drains can be removed after 3-5 days if no evidence of pancreatic fistulas exists.
  • Tachycardia and tachypnea may at times be the earliest signs of a leak.

Further Outpatient Care

  • Recurrent disease usually is not curable; therefore, follow-up is limited principally to detection and treatment of secondary consequences, such as reducing pain and managing evident or latent exocrine or endocrine pancreatic insufficiency.
  • Sonography, CT scan of the upper abdomen, and liver function tests may be used to detect recurrence and manage complications. These examinations should not be carried out on a general basis, however, as early diagnosis of recurrent disease apparently offers no therapeutic benefit.

Deterrence/Prevention

  • Those with FAP and their family members should be counseled about the possibility of acquiring ampullary carcinoma. As many as 50-90% of patients with FAP develop duodenal adenomas, concentrated predominantly on or around the major papilla.2 Such patients should receive close endoscopic surveillance.

Complications

  • Most complications that arise after conventional Whipple procedures are caused by dehiscence of the pancreatic anastomosis. Disruption of pancreatic anastomosis is at times a lethal complication.
  • More than 40 reconstruction procedures are described in the literature to reduce the risk of pancreatic leak, including occlusion of the residual pancreas with Ethibloc or fibrin (as a means to avoid complications secondary to anastomosis) or temporary occlusion with a fibrin adhesive and subsequent anastomosis (in order to avoid 4-6 days of secretion and the risk of damage to the anastomosis).
  • A dramatic reduction has been seen over the last decade in postoperative mortality following pancreaticoduodenectomy. This can be attributed to growing surgical experience, improved anesthesia, better preoperative imaging, and better postoperative management.
  • Major postoperative complications occur in 25-65% of patients, depending upon the expertise of the surgical staff.
  • Pancreatic fistula, prolonged ileus, intraabdominal sepsis, thrombophlebitis, marginal ulceration, and gastrointestinal motility disorder all can manifest as complications of the surgery.
  • Dumping syndrome is seen in patients in whom a significant part of the stomach has been removed.

Prognosis

  • Most patients with carcinoma of the ampulla of Vater die of recurrent disease. Treatment fails in nearly three fourths of patients with poor prognostic features.
  • Survival duration after surgical resection is related to the extent of local invasion of the primary lesion, lymph node involvement, vascular invasion, perineural invasion, cellular differentiation, uninvolved surgical margins, and perioperative blood transfusion.
  • el-Ghazzawy et al reviewed their experience from 1987-1991 with 123 patients who had ampullary cancer. In the group that underwent surgical resection, survival was not influenced independently by perineural invasion, microlymphatic invasion, vascular invasion, or tumor differentiation when the tumors were controlled for stage.15
  • The surgical mortality rate following a Whipple operation or subtotal distal pancreatectomy ranges from 2-5% in centers with experienced staff.
  • For ampullary carcinoma, the 5-year survival rate ranges from 30-50%, depending on the center and the extent of lymph node dissection. When tumor diameter is less than 2 cm (ie, early carcinoma), survival rates are 30% in patients with lymph node involvement and as high as 50% in patients without lymph node involvement.

Patient Education

  • Those with FAP, and their family members, should be counseled about the possibility of acquiring ampullary carcinoma.

Miscellaneous

Medicolegal Pitfalls

  • Failure to counsel FAP patients and their families regarding the possibility of acquiring ampullary carcinoma
 


More on Carcinoma of the Ampulla of Vater

Overview: Carcinoma of the Ampulla of Vater
Differential Diagnoses & Workup: Carcinoma of the Ampulla of Vater
Treatment & Medication: Carcinoma of the Ampulla of Vater
Follow-up: Carcinoma of the Ampulla of Vater
Multimedia: Carcinoma of the Ampulla of Vater
References
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References

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Further Reading

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Keywords

periampullary carcinoma, periampullary malignancy, ampullary carcinoma, ampullary cancer, ampullary cancer treatment, ampullary cancer diagnosis, ampullary cancer symptoms, ampullary cancer pictures, carcinoma of papilla of Vater, adenocarcinomas, neuroendocrine tumors, cystadenomas, adenomas, adenocarcinoma of the ampulla of Vater, Courvoisier sign, familial adenomatous polyposis, FAP, duodenal adenomas, endoscopic ultrasonography, EUS, endoscopic retrograde cholangiopancreatography, ERCP, percutaneous transhepatic cholangiography, PTC, kocherization, pancreaticoduodenectomy, pylorus-preserving pancreaticoduodenectomy, transduodenal excision

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Contributor Information and Disclosures

Author

Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Pankaj Chaturvedi, MBBS, MS, Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India
Pankaj Chaturvedi, MBBS, MS is a member of the following medical societies: American Association for the Advancement of Science and Association of Surgeons of India
Disclosure: Nothing to disclose.

Ronald S Chamberlain, MD, Chairman, Chief, Department of Surgery, Saint Barnabas Medical Center
Ronald S Chamberlain, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Study of Liver Diseases, American College of Surgeons, American Medical Association, Phi Beta Kappa, Society for Surgery of the Alimentary Tract, and Society of Surgical Oncology
Disclosure: Nothing to disclose.

Venkata Subramanian Kanthimathinathan, MD, Staff Physician, Department of General Surgery, Loma Linda University Medical Center
Disclosure: Nothing to disclose.

Uma Chaturvedi, MD, MBBS, DPB, Lecturer, Department of Pathology, KJ Somaiya Hospital and Research Center, India
Disclosure: Nothing to disclose.

Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital
Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Michael Perry, MD, MS, MACP, Nellie B Smith Chair of Oncology Emeritus, Professor, Department of Internal Medicine, Division of Hematology and Oncology, University of Missouri /Ellis Fischel Cancer Center
Michael Perry, MD, MS, MACP is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society of Clinical Oncology, American Society of Hematology, International Association for the Study of Lung Cancer, and Missouri State Medical Association
Disclosure: Bionumerik Consulting fee Consulting; Proactya Consulting fee Consulting; GSK Consulting fee Consulting; NovoNordisk Consulting fee Consulting; Amgen Honoraria Speaking and teaching; GSK Consulting fee Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Benjamin Movsas, MD, Vice-Chairman, Department of Radiation Oncology, Fox Chase Cancer Center
Benjamin Movsas, MD is a member of the following medical societies: American College of Radiology, American Radium Society, and American Society for Therapeutic Radiology and Oncology
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Consulting Staff, Department of Medicine, Southwest Medical Consultants, SC, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Jules E Harris, MD, Clinical Professor of Medicine, Division of Hematology/Medical Oncology, Department of Internal Medicine, University of Arizona College of Medicine at Tucson; Consulting Staff, Arizona Cancer Center
Jules E Harris, MD is a member of the following medical societies: American Association for Cancer Research, American Association for the Advancement of Science, American Association of Immunologists, American Society of Hematology, and Central Society for Clinical Research
Disclosure: GlobeImmune Salary Consulting; Amplimed Consulting fee Consulting

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