Preprocedural Planning
Because surgical ampullectomy involves significant dissection and manipulation of periduodenal anatomy, patients selected for this procedure must be able to tolerate major surgery. Thorough preoperative evaluation and imaging must contribute to operative planning (see below). In addition, the patient must be counseled that if malignancy is detected, the more radical resection of pancreaticoduodenectomy is indicated.
An extensive patient history should be taken to detect heritable patterns. A thorough physical examination is performed to identify contraindications for local resection. A preoperative evaluation is carried out to assess fitness for surgery and anesthesia; this includes cardiac risk factors, nutritional status, functional status, and American Society of Anesthesiologists (ASA) class.
Laboratory tests include a complete blood count (CBC), basic metabolic panel, liver function tests (LFTs), coagulation panel, cancer antigen (CA) 19-9, and carcinoembryonic antigen (CEA).
Preoperative imaging includes the following:
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Computed tomography (CT) pancreatic protocol or magnetic resonance cholangiopancreatography (MRCP) to evaluate for local complications (eg, biliary obstruction or pancreatitis) or metastatic disease (eg, malignant adenopathy or distant metastases)
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Endoscopic ultrasonography (EUS), with or without fine-needle aspiration (FNA), to detect transmural invasion, ductal involvement, and nodal metastases, as well as tissue diagnosis, is used for clinical staging [21] ; because FNA yields false-negative malignancy results in 40% of cases, clinical suspicion of malignant disease should not be ignored
Clinical cues of malignancy include the following:
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Unintended weight loss
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Jaundice, ascites, cholangitis
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Biliary dilatation, pancreatic duct dilatation
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Ulcerated lesion or hard tumor during EUS or FNA
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High-grade dysplasia on FNA histopathology
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Elevated CA 19-9 levels in the absence of biliary obstruction
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Elevated CEA levels
A gastrointestinal specialist should be consulted for endobiliary stent placement for decompression if it is anticipated that surgery may be delayed.
Equipment
Equipment for ampullectomy includes the following:
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Arterial and central venous lines for hemodynamic monitoring
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Nasogastric tube
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Foley catheter
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Secretin for difficult-to-localize pancreatic duct
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Glucagon for a difficult-to-localize common bile duct (CBD)
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Radiopaque balloon-tipped catheters for cannulation of the CBD and pancreatic duct
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Removable pancreatic stent (5 French)
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Closed-suction transabdominal drains
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Fluoroscope and operator
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Patient and surgical team prepared for conversion to pancreaticoduodenectomy if intraoperative pathologic analysis reveals evidence of malignancy
Patient Preparation
General anesthesia is used for surgical ampullectomy.
The patient is placed in the supine position.
Monitoring & Follow-up
Surgical ampullectomy mandates close follow-up. Duodenoscopy is performed at 3-6 months for evaluation and pancreatic duct stent removal, every 6 months for 2 years afterward, and once yearly thereafter for surveillance. Strictures are interrogated and biopsied to evaluate for local recurrence. Recurrent disease is an indication for pancreaticoduodenectomy.
