Carcinoma of the Ampulla of Vater Follow-up

Updated: Dec 31, 2015
  • Author: Nafisa K Kuwajerwala, MD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Follow-up

Further Outpatient Care

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  • 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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Further Inpatient Care

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  • 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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Deterrence/Prevention

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  • 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. [11] 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

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  • Morbidity remains high for pancreaticoduodenectomy, with rates of 41 and 47% reported in two series. [6, 32]
  • Pancreatic anastomotic leak and fistula (12%), wound infection (7-11%), and delayed gastric emptying (7-18%) are the most common complications. [6, 32]
  • 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

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  • The surgical mortality rate has progressively decreased to as low as 1% in experienced centers. [6]
  • 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. [33]
  • Talamini et al reported a 38% 5-year survival rate for resected patients with ampullary adenocarcinoma in 106 patients from 1969-1996. [8]
  • Carter et al reviewed 118 adenocarcinomas and found that biliopancreatic type had a worse prognosis while intestinal type may behave more like duodenal carcinoma. [4]
  • 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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