Carcinoma of the Ampulla of Vater Follow-up

  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: Jules E Harris, MD   more...
 
Updated: Oct 27, 2011
 

Further Inpatient Care

  • Broad-spectrum antibiotic coverage for 24 hours is indicated.
  • 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.
  • Blood glucose level should be monitored after pancreatectomy.
  • Abdominal drains can be removed after 3-5 days if no evidence of pancreatic fistulas exists or after resuming a solid diet if pancreaticogastrostomy was performed.
  • Tachycardia and tachypnea may at times be the earliest signs of a leak.
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Further Outpatient Care

  • Recurrent disease is not considered curable; therefore, follow-up is limited principally to palliative considerations, such as reducing pain, relieving biliary or gastroenteric obstruction, and managing evident or latent exocrine or endocrine pancreatic insufficiency.
  • Sonography, CT scan of the abdomen, and liver function tests may be used to detect recurrence and manage complications. However, these examinations should not be carried out on a routine basis, as early diagnosis of recurrent disease apparently offers no therapeutic benefit.
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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.[9] Such patients should receive close endoscopic surveillance.
  • Patients who have undergone local resection of an ampullary adenoma should receive endoscopic surveillance for recurrence.
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Complications

  • Morbidity remains high for pancreaticoduodenectomy, with rates of 41 and 47% reported in two series.[4, 24]
  • Pancreatic anastomotic leak and fistula (12%), wound infection (7-11%), and delayed gastric emptying (7-18%) are the most common complications.[4, 24]
  • Differing definitions of pancreatic fistula contribute to the wide range of reported occurrence up to 27%. The International Study Group on Pancreatic Fistula (ISGPF) in 2005 defined pancreatic fistula as greater than or equal to 3 days, drain amylase 3 times normal, and stratified fistulas into 3 grades according to clinical impact from clinically insignificant to life-threatening.
  • Intra-abdominal sepsis or abscess, hemorrhage, fascial dehiscence, prolonged ileus, biliary anastomotic leak, thrombophlebitis, and marginal ulceration all can manifest as complications of the surgery. Dumping syndrome can be seen in patients in whom a significant part of the stomach has been removed.
  • Reoperation is uncommon, but it is indicated most commonly for bleeding, intra-abdominal infection, and uncontrolled pancreatic anastomotic dehiscence.
  • A dramatic reduction has been seen in postoperative mortality following pancreaticoduodenectomy from 17-25% before 1985 to 1-2% today in experienced centers. This can be attributed to growing surgical experience, improved anesthesia, better preoperative imaging, and refined postoperative management.
  • 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).
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Prognosis

  • The surgical mortality rate has progressively decreased to as low as 1% in experienced centers.[4]
  • 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.[25]
  • Talamini et al reported a 38% 5-year survival rate for resected patients with ampullary adenocarcinoma in 106 patients from 1969-1996.[6]
  • Carter et al reviewed 118 adenocarcinomas and found that biliopancreatic type had a worse prognosis while intestinal type may behave more like duodenal carcinoma.[2]
  • Review of the SEER data reveals stratification of survival by tumor stage. Five-year survival rates for local, regional, unknown, and distant stages were 45%, 31%, 14%, and 4%, respectively.[1]
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Patient Education

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

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Contributor Information and Disclosures
Author

Nafisa K Kuwajerwala, MD  Staff Surgeon, Breast Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Disease, and American Society of Breast 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, American Head and Neck Society, Association of Surgeons of India, and Indian Academy of Tropical Parasitology

Disclosure: Nothing to disclose.

Ronald S Chamberlain, MD  Chairman, Surgeon-in-Chief, Department of Surgery, Director, Gastrointestinal Care Center, Medical Student Clerkship Director, Medical Executive Committee Member, St Barnabas Medical Center; Associate Professor of Surgery, New York College of Osteopathic Medicine; Associate Professor of Surgery, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

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: Wyeth Honoraria Other; Ethicon Honoraria Speaking and teaching; Sanofi Aventis Honoraria Other

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.

Julie A Stein, MD  Clinical Faculty, Hepatobiliary and Pancreatic Surgery, Department of Surgery, William Beaumont Hospital

Julie A Stein, MD is a member of the following medical societies: American College of Surgeons, American College of Surgeons Oncology Group, American Hepato-Pancreato-Biliary Association, Pancreas Club, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael Perry, MD, MS, MACP  Nellie B Smith Chair of Oncology Emeritus, Director, Division of Hematology and Medical Oncology, Deputy Director, Ellis Fischel Cancer Center, University of Missouri-Columbia School of Medicine

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: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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.

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, 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; 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

References

  1. Albores-Saavedra J, Schwartz AM, Batich K, Henson DE. Cancers of the ampulla of vater: demographics, morphology, and survival based on 5,625 cases from the SEER program. J Surg Oncol. Dec 1 2009;100(7):598-605. [Medline].

  2. Carter JT, Grenert JP, Rubenstein L, Stewart L, Way LW. Tumors of the ampulla of vater: histopathologic classification and predictors of survival. J Am Coll Surg. Aug 2008;207(2):210-8. [Medline].

  3. Husain S, Ahmed L, Al-Sawwaf M. Venous air embolism from intravenous CT contrast administration. J Am Coll Surg. Jan 2006;202(1):197. [Medline].

  4. Cameron JL. One thousand consecutive pancreaticoduodenectomies and beyond: a personal series. Am J Surg. Oct 2007;194:S11-S15.

  5. Yeo CJ, Sohn TA, Cameron JL, Hruban RH, Lillemoe KD, Pitt HA. Periampullary adenocarcinoma: analysis of 5-year survivors. Ann Surg. Jun 1998;227(6):821-31. [Medline]. [Full Text].

  6. Talamini MA, Moesinger RC, Pitt HA, Sohn TA, Hruban RH, Lillemoe KD. Adenocarcinoma of the ampulla of Vater. A 28-year experience. Ann Surg. May 1997;225(5):590-9; discussion 599-600. [Medline].

  7. Hornick JR, Johnston FM, Simon PO, et al. A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes. Surgery. Aug 2011;150(2):169-76. [Medline]. [Full Text].

  8. Burke CA, Beck GJ, Church JM, van Stolk RU. The natural history of untreated duodenal and ampullary adenomas in patients with familial adenomatous polyposis followed in an endoscopic surveillance program. Gastrointest Endosc. Mar 1999;49(3 Pt 1):358-64. [Medline].

  9. Griffioen G, Bus PJ, Vasen HF, Verspaget HW, Lamers CB. Extracolonic manifestations of familial adenomatous polyposis: desmoid tumours, and upper gastrointestinal adenomas and carcinomas. Scand J Gastroenterol Suppl. 1998;225:85-91. [Medline].

  10. Berndt C, Haubold K, Wenger F, et al. K-ras mutations in stools and tissue samples from patients with malignant and nonmalignant pancreatic diseases. Clin Chem. Oct 1998;44(10):2103-7. [Medline].

  11. Iacono C, Verlato G, Zamboni G, Scarpa A, Montresor E, Capelli P, et al. Adenocarcinoma of the ampulla of Vater: T-stage, chromosome 17p allelic loss, and extended pancreaticoduodenectomy are relevant prognostic factors. J Gastrointest Surg. May 2007;11(5):578-88. [Medline].

  12. Menzel J, Hoepffner N, Sulkowski U, et al. Polypoid tumors of the major duodenal papilla: preoperative staging with intraductal US, EUS, and CT--a prospective, histopathologically controlled study. Gastrointest Endosc. Mar 1999;49(3 Pt 1):349-57. [Medline].

  13. John TG, Greig JD, Carter DC, Garden OJ. Carcinoma of the pancreatic head and periampullary region. Tumor staging with laparoscopy and laparoscopic ultrasonography. Ann Surg. Feb 1995;221(2):156-64. [Medline]. [Full Text].

  14. Willett CG, Warshaw AL, Convery K, Compton CC. Patterns of failure after pancreaticoduodenectomy for ampullary carcinoma. Surg Gynecol Obstet. Jan 1993;176(1):33-8. [Medline].

  15. Bhatia S, Miller RC, Haddock MG, Donohue JH, Krishnan S. Adjuvant therapy for ampullary carcinomas: the Mayo Clinic experience. Int J Radiat Oncol Biol Phys. Oct 1 2006;66(2):514-9. [Medline].

  16. Barton RM, Copeland EM 3rd. Carcinoma of the ampulla of Vater. Surg Gynecol Obstet. Mar 1983;156(3):297-301. [Medline].

  17. Krishnan S, Rana V, Evans DB, et al. Role of adjuvant chemoradiation therapy in adenocarcinomas of the ampulla of vater. Int J Radiat Oncol Biol Phys. Mar 1 2008;70(3):735-43. [Medline].

  18. Kim K, Chie EK, Jang JY, Kim SW, Oh DY, Im SA. Role of adjuvant chemoradiotherapy for ampulla of Vater cancer. Int J Radiat Oncol Biol Phys. Oct 1 2009;75(2):436-41. [Medline].

  19. Overman MJ, Varadhachary GR, Kopetz S, Adinin R, Lin E, Morris JS. Phase II study of capecitabine and oxaliplatin for advanced adenocarcinoma of the small bowel and ampulla of Vater. J Clin Oncol. Jun 1 2009;27(16):2598-603. [Medline].

  20. Yeung RS, Weese JL, Hoffman JP, et al. Neoadjuvant chemoradiation in pancreatic and duodenal carcinoma. A Phase II Study. Cancer. Oct 1 1993;72(7):2124-33. [Medline].

  21. Meneghetti AT, Safadi B, Stewart L, Way LW. Local resection of ampullary tumors. J Gastrointest Surg. Dec 2005;9(9):1300-6. [Medline].

  22. Toh SK, Davies N, Dolan P, Worthley C, Townsend N, Williams JA. Good outcome from surgery for ampullary tumour. Aust N Z J Surg. Mar 1999;69(3):195-8. [Medline].

  23. Sohn TA, Lillemoe KD, Cameron JL, et al. Reexploration for periampullary carcinoma: resectability, perioperative results, pathology, and long-term outcome. Ann Surg. Mar 1999;229(3):393-400. [Medline]. [Full Text].

  24. Grobmyer SR, Pieracci FM, Allen PJ, Brennan MF, Jaques DP. Defining morbidity after pancreaticoduodenectomy: use of a prospective complication grading system. J Am Coll Surg. Mar 2007;204(3):356-64. [Medline].

  25. el-Ghazzawy AG, Wade TP, Virgo KS, Johnson FE. Recent experience with cancer of the ampulla of Vater in a national hospital group. Am Surg. Jul 1995;61(7):607-11. [Medline].

  26. AJCC Cancer Staging Manual. Exocrine pancreas. In: American Joint Committee on Cancer Manual. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1997:121-6.

  27. Conlon KC. Carcinoma of the ampulla of vater: a distinct disease entity?. Ann Surg Oncol. Dec 2003;10(10):1136-7. [Medline].

  28. Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Gastrointestinal Tumor Study Group. Cancer. Jun 15 1987;59(12):2006-10. [Medline].

  29. Hartenfels IM, Dukat A, Burg J, Hansen M, Jung M. [Adenomas of Vater's ampulla and of the duodenum. Presentation of diagnosis and therapy by endoscopic interventional and surgical methods]. Chirurg. Mar 2002;73(3):235-40. [Medline].

  30. Kennedy EP, Yeo CJ. Pancreaticoduodenectomy with extended retroperitoneal lymphadenectomy for periampullary adenocarcinoma. Surg Oncol Clin N Am. Jan 2007;16(1):157-76. [Medline].

  31. Martin ED. Anatomopathologie des tumeurs oddiennes. In: Les tumeurs oddiennes. 1978:35-52.

  32. Paraskevas KI, Avgerinos C, Manes C, Lytras D, Dervenis C. Delayed gastric emptying is associated with pylorus-preserving but not classical Whipple pancreaticoduodenectomy: a review of the literature and critical reappraisal of the implicated pathomechanism. World J Gastroenterol. Oct 7 2006;12(37):5951-8. [Medline].

  33. Park JS, Yoon DS, Kim KS, et al. Factors influencing recurrence after curative resection for ampulla of Vater carcinoma. J Surg Oncol. Mar 15 2007;95(4):286-90. [Medline].

  34. Rosen M, Zuccaro G, Brody F. Laparoscopic resection of a periampullary villous adenoma. Surg Endosc. Aug 2003;17(8):1322-3. [Medline].

  35. Sarmiento JM, Nagomey DM, Sarr MG, Farnell MB. Periampullary cancers: are there differences?. Surg Clin North Am. Jun 2001;81(3):543-55. [Medline].

  36. Sarr MG, Cameron JL. Surgical palliation of unresectable carcinoma of the pancreas. World J Surg. Dec 1984;8(6):906-18. [Medline].

  37. Todoroki T, Koike N, Morishita Y, et al. Patterns and predictors of failure after curative resections of carcinoma of the ampulla of Vater. Ann Surg Oncol. Dec 2003;10(10):1176-83. [Medline].

  38. Van Heek NT, De Castro SM, van Eijck CH, et al. The need for a prophylactic gastrojejunostomy for unresectable periampullary cancer: a prospective randomized multicenter trial with special focus on assessment of quality of life. Ann Surg. Dec 2003;238(6):894-902; discussion 902-5. [Medline]. [Full Text].

  39. Wagle PK, Joshi RM, Mathur SK. Pancreaticoduodenectomy for periampullary carcinoma. Indian J Gastroenterol. Mar-Apr 2001;20(2):53-5. [Medline].

 
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Endoscopic view of an ampullary carcinoma.
Kocherization of the duodenum. For ampullary malignancies greater than 1 cm in size, pancreaticoduodenectomy is the preferred operation. This figure demonstrates the process of kocherization of the duodenum. The second and third portions of the duodenum are mobilized en bloc with the periduodenal nodal tissue. The authors prefer to expose the inferior vena cava (IVC) and remove alveolar tissue, which lies above the IVC en bloc with the specimen.
Periampullary malignancy. Transected pancreas with head. Pancreaticoduodenectomy is the preferred treatment for most periampullary tumors. This picture depicts transection of the pancreas at the pancreatic neck. This particular patient presented with a periampullary malignancy accompanied by jaundice and pancreatitis. A preoperative pancreatic stent (usually unnecessary) is seen within the pancreatic duct.
Carcinoma of the ampulla of Vater. Roux-en-Y reconstruction following completion of a standard pancreaticoduodenectomy.
Double duct sign of periampullary cancers. Note the dilated common bile duct as well as the pancreatic duct. Liver metastatic lesion is also seen.
Distended gall bladder with double duct sign in a patient with periampullary cancer.
 
 
 
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