CHAPTER 11 AMPULLA OF VATER

TRANSDUODENAL RESECTION OF THE PAPILLA OF VATER

Tumors arising in the region of the papilla of Vater may have their origin from the distal bile duct, the duodenum, the ampulla of Vater itself, or the pancreas. Because the epithelium of origin is often impossible to determine and because their clinical characteristics are similar, these tumors are often described as periampullary tumors.

PATHOLOGY

Benign Tumors

Benign tumors of the papilla of Vater are rare. Adenomatous polyps are the most common tumors of this region. The malignant potential of adenomatous polyps has been well documented, foci of malignant cells being detected in 47% to 56% of cases. Similarly, complete histologic examination of malignant periampullary tumors has revealed residual adenomatous tissue in up to 80%. Thus the sequence of change from adenoma to carcinoma is frequent for adenomatous polyps of the periampullary region.

Benign tumors may remain asymptomatic, and symptoms occur only when adenomas grow or when malignant changes have taken place. Symptoms, most commonly jaundice, pain, or pancreatitis, are present in most patients with adenomas submitted to surgery.

Malignant Tumors

Malignant tumors of the periampullary region are, in most cases, adenocarcinomas. Carcinoid tumors are extremely rare and should be considered malignant tumors.

Periampullary malignant tumors become symptomatic at an early stage. For this reason, radical resection is possible in most cases. Early manifestations include abdominal pain, incomplete biliary obstruction causing pruritus alone, or icterus, which may fluctuate (Blumgart and Kennedy, 1973). Chronic or acute bleeding can cause anemia or melena and is reported in one-third of cases. Pancreatitis, resulting from obstruction of the duct, is a less frequent manifestation of the disease.

INVESTIGATIONS

Ultrasonography and computed tomography (CT) are usually performed in the presence of altered liver function tests or obstructive jaundice. Dilatation of the common bile duct down to the ampullary region and also, on occasions, a dilatation of the pancreatic duct are identified.

Duodenoscopy, using a side-viewing endoscope, should be the next investigation. Endoscopy allows direct inspection of the medial wall of the duodenum and of the papilla. A normal-looking papilla does not rule out an occult periampullary tumor because inapparent endoluminal growth has been reported in up to 37% of cases; this should be suspected when an irregularity or filling defect in the distal bile duct is revealed by retrograde cholangiography.

Tumor cells might be collected through catheter aspiration or transpapillary endoscopic biopsy, but in most cases an endoscopic sphincterotomy should be performed for direct access to the tumor and to allow deep biopsy. Endoscopic ultrasound has been demonstrated to be the most effective single imaging procedure for local tumor staging and has proven to be significantly superior to ultrasonography and CT scan in assessing invasion of deep structures and in the recognition of enlarged lymph nodes.

THERAPY

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