Ampullectomy

The first localized resection of an ampullary lesion was performed transduodenally by Halsted in 1899. Since Halsted’s time, technologic advancements have enhanced the array of tools at the disposal of the modern surgeon. In modern times, ampullectomy can be performed as an endoscopic mucosal resection or as a full-thickness resection via duodenotomy by way of laparoscopy or open surgery. ^[1]  Surgical ampullectomy remains a useful treatment option for ampullary lesions, but its utility is limited to a narrow range of indications. ^{[2, 3]}

Neoplasms of the ampulla of Vater are a small subset of the broader category of biliary tract neoplasms. These lesions demand separate consideration from their biliary counterparts because of their unique location and behavior. In general, localized resection of papillary, ampullary, and periampullary neoplastic lesions should be considered only if these lesions are benign. Malignant disease of this region is associated with extraordinarily high recurrence rates (approximately 80% local recurrence with malignant disease and up to 40% local recurrence with nonmalignant dysplasia) with local resection alone, mandating radical resection via pancreaticoduodenectomy.

Although there has been some discussion regarding the role of ampullectomy in limited circumstances with regard to malignant Tis and T1 ampullary carcinoma, ^{[4, 5]} this article addresses the details of surgical ampullectomy for benign neoplasia of the ampulla of Vater.

In addition, endoscopic technology and tools for periampullary procedures represent a broad subject that deserves a rich discussion elsewhere. ^{[6, 7, 8, 9]} The present article focuses on the details of open surgical ampullectomy, with acknowledgement of laparoscopy as a valid technologic variant that is at the disposal of the surgeon who has already mastered open surgical ampullectomy.

Histopathologic variants of ampullary neoplasia

Ampulla of Vater neoplasias include a diverse array of lesions, including those that arise from genetic predisposition, spontaneous mutation, or spontaneous occurrence. The earliest manifestation of disease occurs in the common channel of the ampulla, perhaps reflecting a mutagenic nature of bile. The most common cause of heritable ampullary neoplasia is familial adenomatous polyposis (FAP), which progresses from adenoma to malignancy along the well-described pathway of mutagenesis for colon cancer.

Variants include the following:

• Adenoma to adenocarcinoma of the ampulla - These include FAP and hereditary nonpolyposis colorectal cancer ^[10]
• Squamous cell carcinoma of the ampulla
• Neuroendocrine tumors of the ampulla
• Well-differentiated carcinoid tumors - These have unpredictable behavior patterns, are often asymptomatic, have unpredictable recurrence rates, and are difficult to diagnosis with endoscopy
• Granular cell tumors of the ampulla
• Benign lesions - These include lipomas, paraganglionomas, other tumors of neurogenic origin, lymphangiomas, leiomyofibromas, adenomatous polyps, and small intraductal benign adenomas of the common bile duct (CBD)

Discrete limitations apply to lesions that lend themselves to successful surgical ampullectomy. This procedure is indicated for benign disease of the ampulla with lesions that are smaller than 2 cm and are located within 2 cm of the ampulla. ^{[11, 12, 13]}

It has been suggested that ampullectomy may also be considered for early (eg, pT1) ampullary cancers in patients at high operative risk with pancreaticoduodenectomy if the lesion is small (≤ 1 cm), well differentiated, and of polypoid gross morphology. ^[14]  Nodal clearance may be required for long-term survival in this setting. ^[15]

Contraindications for surgical ampullectomy include the following:

• Malignant periampullary lesions
• Large periampullary lesions
• Benign periampullary lesions more than 2 cm away from ampulla
• Pancreatic lesions
• CBD tumors larger than 1.5 cm

Larger benign lesions and those of any size that are located more than 2 cm away from the ampulla do not qualify for surgical ampullectomy. Larger lesions may harbor foci of malignancy, and at increasing distance from the ampulla, reasonable anatomic reconstruction becomes impossible. Finally, surgical ampullectomy is not indicated for lesions that arise in the context of clinical cues of malignancy (unintended weight loss, jaundice, ascites).

Surgical ampullectomy is also contraindicated for lesions with an unclear tissue diagnosis or fine-needle aspiration (FNA) with no evidence of malignancy in the presence of clinical cues of malignancy.

Complication prevention

The following measures are used for complication prevention:

• Thorough preoperative evaluation
• Sequential compression devices for prevention of deep vein thrombosis
• Preoperative biliary decompression if a surgery delay is expected or preoperative cholangitis is present
• Nasogastric decompression to prevent duodenal distention