Open Resection of Ampullary Lesions
The procedural details below are focused on open surgical ampullectomy. Endoscopic approaches, including snare excision, endoscopic mucosal resection (EMR), and ablation techniques, are not discussed here.
Laparotomy and evaluation
After the patient is properly positioned and general anesthesia induced, a generous midline incision or right subcostal incision is created. The abdomen is first explored to detect any malignant disease, though if adequate preoperative imaging was carried out, malignancy will rarely be found. Still, the liver is palpated and the peritoneum inspected before further steps are embarked on.
Exposure of duodenum and ampulla
The ascending colon and hepatic flexure are mobilized and an extended Kocher maneuver performed. Once the duodenum and the pancreatic head are adequately mobilized from their retroperitoneal attachments, a laparotomy sponge can be placed behind the duodenum to facilitate ideal positioning, or it can simply be grasped by the surgeon’s left hand and held in position. At this point, the ampulla and lesion are palpated from outside the duodenum by digital compression of the lateral duodenal wall against the medial wall of the duodenum until the aforementioned structures are palpated.
A longitudinal duodenotomy is then created on the lateral wall of the duodenum. Stay sutures are placed at the 9 o’clock and 3 o’clock positions on the anterior and posterior leaflets of the duodenotomy to facilitate exposure of the underlying ampulla.
Resection
A cholecystectomy is performed, and the common bile duct (CBD) is interrogated with antegrade transcystic placement of a radiopaque balloon-tipped catheter. The distal end of this catheter should enter the duodenal lumen via the ampulla. The pancreatic ductal opening may or may not be visible at this time.
The lesion or lesions are now evaluated. A submucosal saline injection can be used to further evert the lesion toward the surgeon, though this maneuver is not helpful with full-thickness lesions. A needle-tip electrocautery is used to excise superficial lesions that do not involve the CBD, pancreatic duct, or common channel, and cautery dissection progresses through pancreatic parenchyma as appropriate for lesions with transmural invasion or CBD, pancreatic duct, or common-channel extension. The goals of resection are negative margins ranging from 5 mm to 1 cm around the lesion, as possible.
Generally, resection continues from the 11 o’clock position around the lesion in a clockwise manner to the 3 o’clock position and is halted until a suture is placed at the bile duct orifice to marsupialize it, or spatulate the mucosa. Subsequently, careful dissection continues until the pancreatic duct is seen. If it is not easily detected, secretin can be used to stimulate pancreatic secretion and locate the pancreatic duct opening. Similarly, glucagon can be used to facilitate location of the bile duct papilla. Once the pancreatic papilla has been identified, circumferential resection is completed, and the specimen is then passed off the table after being oriented for pathology.
Reconstruction
If specimen margins are positive or malignancy is identified, pancreaticoduodenectomy must then be undertaken. If not, the ductal anatomy can be reconstructed. The bile duct might require further spatulation, and circumferential interrupted absorbable sutures are placed (with the help of optical magnification) around the bile duct orifice and around the pancreatic duct orifice to the duodenal mucosa. The pancreatic duct may also be stented at this time or sphincterotomy performed to prevent severe acute postoperative pancreatitis and strictures.
The longitudinal duodenotomy is then closed—transversely if possible, longitudinally if not—by using any of a number of handsewn anastomotic options. Closure may be accomplished in a running fashion or with interrupted sutures, with either a one-layer or a two-layer anastomosis, and in a transverse or (less commonly) a longitudinal fashion, with or without an overlying omental pedicle flap. At the completion of anastomosis, a closed-suction drain is placed at the duodenal anastomosis transcutaneously, exiting at the right upper quadrant. The abdomen is then closed in a standard fashion.
Postoperative Care
Nasogastric tubes can often be removed within 24-48 hours after surgery. Transcutaneous closed-suction duodenotomy drains can be removed once oral intake has been undertaken without complication.
Antibiotic use depends on preoperative biliary obstruction or the presence of cholangitis.
Complications
Early complications of open ampullectomy include the following:
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Acute pancreatitis (~12% of cases; this is milder in presentation if a pancreatic duct stent is placed)
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Intraduodenal hemorrhage (~10% of cases)
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Cholangitis or sepsis
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Duodenal, pancreatic, or biliary leak
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Enteric perforation (rare)
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Perioperative death (rare)
Late complications include the following:
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Duodenal, pancreatic, or biliary stricture
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Local recurrence of dysplastic lesions
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Distant recurrence of malignant disease
