Further Outpatient Care
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.
Recurrent disease is not considered curable; therefore, follow-up is limited principally to palliative considerations, such as the following:
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Reducing pain
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Relieving biliary or gastroenteric obstruction
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Managing evident or latent exocrine or endocrine pancreatic insufficiency
Further Inpatient Care
Postoperative care includes the following:
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Broad-spectrum antibiotic coverage for 24 hours is indicated.
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Continuous nasogastric aspiration usually is maintained for the first 24 hours.
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Oral feeding may be considered on the second postoperative day.
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Subcutaneous heparin and pneumatic compression stockings are used to prevent deep vein thrombosis (DVT).
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Adequate blood replacement is necessary in cases of intraoperative blood loss.
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Early ambulation and chest physiotherapy reduce morbidity.
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Serum electrolytes, renal function, and liver function should be monitored.
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Blood glucose level should be monitored after pancreatectomy.
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Abdominal drains can be removed after 3-5 days if no evidence of pancreatic fistula exists or after resuming a solid diet if pancreaticogastrostomy was performed.
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Tachycardia and tachypnea may at times be the earliest signs of a leak.
Deterrence/Prevention
Patients with familial adenomatous polyposis (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.
Complications
Complications of surgery for ampulla of Vater cancer include the following:
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Differing definitions of pancreatic fistula contribute to the wide range of reported occurrence, which have reached as high as 27%. The International Study Group on Pancreatic Fistula (ISGPF) first set out a definition of pancreatic fistula in 2005, and in 2016 redefined it as "a drain output of any measurable volume of fluid with an amylase level >3 times the upper limit of institutional normal serum amylase activity, associated with a clinically relevant development/condition related directly to the postoperative pancreatic fistula." [50] The ISGPF also stratified postoperative pancreatic fistula fistulas into 3 grades according to clinical impact: grade A has no clinical importance and has been redefined as a "biochemical leak" rather than a true pancreatic fistula; grade B requires a change in the postoperative management, with drains either left in place >3 weeks or repositioned through endoscopic or percutaneous procedures; grade C requires reoperation to prevent possible organ failure and/or mortality.
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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 who have had a significant part of their stomach removed.
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Reoperation is uncommon, but it is indicated most commonly for bleeding, intra-abdominal infection, and uncontrolled pancreatic anastomotic dehiscence.
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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.
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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).
Prognosis
Prognostic features include the following:
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The surgical mortality rate has progressively decreased to as low as 1% in experienced centers. [6]
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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.
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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]
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Talamini et al reported a 38% 5-year survival rate for resected patients with ampullary adenocarcinoma in 106 patients from 1969-1996. [8]
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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]
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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]
Patient Education
Those with FAP, and their family members, should be counseled about the possibility of acquiring ampullary carcinoma.
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Endoscopic view of an ampullary carcinoma.
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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.
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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.
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Carcinoma of the ampulla of Vater. Roux-en-Y reconstruction following completion of a standard pancreaticoduodenectomy.
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Double duct sign of periampullary cancers. Note the dilated common bile duct as well as the pancreatic duct. Liver metastatic lesion is also seen.
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Distended gall bladder with double duct sign in a patient with periampullary cancer.
