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Ampullectomy
https://t.me/med1917
GabrielaOchoa andIsmaelDominguez-Rosado
1 Introduction
The ampulla of Vater (or Hepatopancreatic ampulla) corresponds to an anatomic
and functional region that comprises the junction of the common bile duct and pancreatic duct, surrounded by the sphincteric system of Oddi, traversing the duodenal
wall and terminating at the greater duodenal papilla covered by the duodenal
mucosa [1].
Because of these anatomic relationships, surgical resection is challenging, and
local resection is limited to early-stage lesions. Malignant and more extensive
tumors generally require a pancreatoduodenectomy for resection, a surgery with
high-risk and overall morbidity of around 40% [2].
Surgical ampullectomy (SA) was rst described by Halsted in 1899 as a treatment for ampullary cancer. Because of the bad oncologic results, it was abandoned
for more extensive resection and has now been adopted for benign lesions of the
ampulla. In the search for a less morbid approach, the endoscopic papillectomy
(EP) was described in 1983 and is now accepted for managing lesions conned to
the mucosa and submucosa [3]. Laparoscopic and robotic approaches have been
developed due to the increase in the expertise of the minimally invasive technique
in HPB surgery [4].
This chapter will describe the surgical technique of ampullectomy, its principal
indications, and approaches.
G. Ochoa (*)
Hospital Base Valdivia, Universidad Austral de Chile, Valdivia, Chile
I. Dominguez-Rosado
Instituto Nacional de Ciencias Medicas y Nutrición Salvador Zubirán, Mexico City, Mexico
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_42
505© The Author(s), under exclusive license to Springer Nature
506
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G. Ochoa and I. Dominguez-Rosado
2 Indications
No evidence-based consensus guidelines have been produced regarding suitable
indications for SA [5].
The generally accepted indications for SA include cases of adenomas and carcinoma in situ. Adenomas are the most frequent indication for SA and generally will
have demonstrated bile or pancreatic duct dilation >20mm and EP was either not
technically possible or had previously failed with recurrence or positive margins.
The SA is also accepted for some cases of sphincterotomy-associated biliary stricture [6, 7].
3 Preoperative Study
The purpose of preoperative evaluation of ampullary tumors is to determine malignancy, assess resectability, and establish the stage for possible cancers. The study
could include endoscopy with a histologic sampling of the lesion and, CT or MRI
to determine the extension and the relation with the neighbor structures. However,
the most critical method of study in the actual time is the EUS due to its capacity to
determine the extension in the wall of the ampulla, the presence of pathologic lymph
nodes, and the possibility of realizing a guided biopsy [7].
4 Description oftheSurgery Technique [7]
1. Position of the Patient and Exposure of the Doudenum.
Regarding the kind of surgical approach, open or laparoscopic, the abdomen
is accessed either by laparotomy using a right subcostal or upper midline incision or by minimal access methods.
The operation starts with abdominal exploration to evaluate for distant disease and determine the local extension of the lesion.
Next, the hepatic exure of the colon is mobilized and a Kocher maneuver is
performed to expose the second portion of the duodenum for access to the
ampulla. For better exposure, a partial Catell-Brasch maneuver could be added
(Fig.1).
2. Surgical approach of the Ampulla of Vater.
The position of the ampulla is determined by palpation of the tumor or preop-
eratively placed stent. If the ampulla’s position cannot be palpated then a cholecystectomy can be performed and the cystic duct cannulated with a balloon
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a
Fig. 1 Position of the Patient and Exposition of the D2. (a). Subcostal incision. (b) Kocher
maneuver. (Reprinted from Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary Surgery,
2nd ed., Masaru Miyazaki, Yuman Fong, Anil K.Agarwal, Raja Kalayarasan. Standard Radical
Cholecystectomy for T1 and T2 Gallbladder Cancer. 611–622. Copyright (2016), with permission
from Springer) [8]
b
catheter. This is then guided into the intestinal lumen, the balloon inated, and
the catheter withdrawn until it is apposed to the ampulla. Palpation of the inated
balloon will now identify the location of the ampulla.
Stay sutures are placed in the anterior duodenal wall opposite the ampulla and
a longitudinal duodenotomy is created to expose the papilla in his intraluminal
location (Fig.2).
3. Resection of the Lesion.
Once the ampullary lesion has been exposed, stay sutures can be placed sur-
rounding the lesion for traction. The inltration of the submucosa with saline or
epinephrine solution is recommended to elevate the lesion off the deepest layers
in the duodenum wall. The resection could be done with scissors or
electrocoagulation.
Following resection, the transected duct orices must be identied. The typi-
cally larger and superior orice corresponds to the bile duct and the smaller and
inferior corresponds to the pancreatic duct. The resection of these ducts must be
done sparingly to facilitate their reimplantation (Fig.3).
4. Reimplantation of the bile and pancreatic duct.
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G. Ochoa and I. Dominguez-Rosado
Fig. 2 (a) Longitudinal
duodenectomy. (b)
Identication of the papilla
by the biliary stent and the
inltration of the
submucosa to elevate the
lesion. (Reprinted from
Atlas of Upper
Gastrointestinal and
Hepato-Pancreato-Biliary
Surgery, 2nd ed. Michael
L.Kendrick, Michael
B.Farnell. Transduodenal
Resection of Periampullary
Villous Neoplasms.
905–911. Copyright
(2016), with permission
from Springer) [9]
a
b
After resectioning the lesion, the bile, and pancreatic duct will be deep in the
surgical bed. The ducts will then be reimplanted into the duodenum wall with
absorbable interrupted sutures (typically 4-0 or 5-0). The bile duct could be positioned superior to the pancreatic duct. Special care must be taken not to narrow
their lumens (Fig.4).
5. Closure of the duodenum and nal considerations.
The patency of the ducts could be conrmed by direct visualization of secre-
tions and/or probing with dilator devices prior to closure.
The longitudinal duodenotomy should be closed transversally to avoid steno-
sis and may be done in one or two layers with absorbable sutures.
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a
c
509
b
Fig. 3 (a) Representation of the disposition of the ducts in the duodenum wall, 1 ampullary lesion,
2 bile duct, 3 pancreatic duct. (b) Resection of the ampullary lesion. (c) Surgical bed and surgical
piece resected. (Reprinted from Atlas of Upper Gastrointestinal and Hepato-Pancreato-Biliary
Surgery, 2nd ed. Michael L. Kendrick, Michael B. Farnell. Transduodenal Resection of
Periampullary Villous Neoplasms. 905–911. Copyright (2016), with permission from Springer) [9]
510
bc
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G. Ochoa and I. Dominguez-Rosado
a
Fig. 4 (a) Surgical bed after resection of the ampullary lesion with bile duct and pancreatic duct
exposed. (b) Interrupted suture to reimplant the ducts into the duodenal wall. (c) Reimplanted bile
and pancreatic duct in the duodenum. (Reprinted from Atlas of Upper Gastrointestinal and HepatoPancreato- Biliary Surgery, 2nd ed. Michael L. Kendrick, Michael B. Farnell. Transduodenal
Resection of Periampullary Villous Neoplasms. 905–911. Copyright (2016), with permission from
Springer) [9]
5 Minimally Invasive Approach
Due to the development and growing expertise of minimally invasive techniques in
HPB surgery, laparoscopic and robotic approaches to ampullary surgery have been
described in limited case series [10, 11].
The patient is typically positioned with the legs spread, and the table is rolled to
the left. The trocars will be placed in the superior abdomen triangulating to the right
hypochondrium and including one to retract and expose the subhepatic space. The
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exposition of the duodenum is performed by freeing the hepatic exure of the colon
and the Kocher maneuver. By rst performing a partial resection of the inferior
aspect of the lesion, the pancreatic duct is better exposed and reimplantation is completed prior to nishing resection of the superior aspect of the lesion. Once the
specimen is resected the bile duct is reimplanted. The duodenal closure is similar to
the open approach [11].
6 Endoscopic Approach
Endoscopic Ampullectomy was rst described in 1983 by Suzuki etal., with the
rst large case series reported in 1993 by Binmoeller etal. [12] The technique has
been adopted for adenomas of the ampulla with low morbidity and mortality in
selected cases. A careful endoscopic examination is mandatory to evaluate features
suggestive of malignancy, for example, large size (>2–3cm), ulceration, induration/
rm consistency, and a friable lesion. The goal of the procedure is bloc resection of
the entire neoplasm [13].
The procedure is summarized by the following steps: (1) submucosal injection,
(2) resection with endoscopic snare and electrocautery, (3) recovery of the
specimen(s), and (4) hemostasis. Sphincterotomy and stent placement after the procedure has been described to decrease complication rates, but the evidence is not
denitive. The overall complication rate is about 15%. Procedure-related mortality
after endoscopic ampullectomy has been reported but is rare, occurring in 0.3% [8]
(Fig.5).
a
Fig. 5 Endoscopic ampullectomy. (a) Endoscopic vision of ampullary adenoma. (b and c)
Resection with endoscopic snare. Contribution of Hugo Ritcher, MD, Universidad Católica
de Chile
b
c
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G. Ochoa and I. Dominguez-Rosado
7 Final Comments
• SA is an alternative for resection of non-invasive tumors not amenable for EP.
• The approach requires thorough understanding of ampullary anatomy due to the
complexity of the localization.
• The key is the identication of the ducts and their reimplantation in the duode-
num wall.
• A minimally invasive approach is possible in the experience centers.
References
1. Avisse C, Flament JB, Delattre JF. Ampulla of Vater. Anatomic, embryologic, and surgical aspects. Surg Clin North Am. 2000;80(1):201–12. https://doi.org/10.1016/
s0039- 6109(05)70402- 3.
2. Russell TB, Aroori S. Procedure-specic morbidity of pancreatoduodenectomy: a systematic
review of incidence and risk factors. ANZ J Surg. 2022;92(6):1347–55. https://doi.org/10.1111/
ans.17473. Epub 2022 Jan 24.
3. Vanbiervliet G, Strijker M, Arvanitakis M, Aelvoet A, Arnelo U, Beyna T, Busch O, Deprez
PH, Kunovsky L, Larghi A, et al. Endoscopic management of ampullary tumors: European
Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021;53:429–48.
4. Halsted WS.Contributions to the surgery of the bile passages, especially of the common bile
duct. Boston Med Surg J. 1899;141:645–54. https://doi.org/10.1056/NEJM189912281412601.
5. Heise C, Abou Ali E, Hasenclever D, Auriemma F, Gulla A, Regner S, Gaujoux S, Hollenbach
M. Systematic review with meta-analysis: endoscopic and surgical resection for ampullary
lesions. J Clin Med. 2020;9(11):3622.
6. Rostain F, Hamza S, Drouillard A, Faivre J, Bouvier AM, Lepage C.Trends in incidence and
management of cancer of the ampulla of Vater. World J Gastroenterol. 2014;20:10144–50.
7. Scroggie DL, Mavroeidis VK. Surgical ampullectomy: a comprehensive review. World J
Gastrointest Surg. 2021;13(11):1338–50. https://doi.org/10.4240/wjgs.v13.i11.1338.
8. Espinel J, Pinedo E, Ojeda V, Guerra Del Río M.Endoscopic ampullectomy: a technical review.
Rev Esp Enferm Dig. 2016;108(5):271–8. https://doi.org/10.17235/reed.2016.3867/2015.
9. Kendrick ML, Farnell MB. Transduodenal resection of periampullary villous neoplasms. In: Clavien PA, Sarr M, Fong Y, Miyazaki M, editors. Atlas of upper gastrointestinal and hepato- pancreato-biliary surgery. Berlin: Springer; 2016. https://doi.
org/10.1007/978- 3- 662- 46546- 2_95.
10. Borie F, Beliard A.Laparoscopic ampullectomy. J Visc Surg. 2012;149(4):e252–8. https://doi.
org/10.1016/j.jviscsurg.2012.06.008. Epub 2012 Aug 10.
11. Linn YL, Wang Z, Goh BKP.Robotic transduodenal ampullectomy: case report and review of
the literature. Ann Hepatobiliary Pancreat Surg. 2021;25(1):150–4. https://doi.org/10.14701/
ahbps.2021.25.1.150.
12. Binmoeller KF, Boaventura S, Ramsperger K, Soehendra N. Endoscopic snare excision of
benign adenomas of the papilla of Vater. Gastrointest Endosc. 1993;39(2):127–31. https://doi.
org/10.1016/s0016- 5107(93)70051- 6.
13. Klair JS, Irani S, Kozarek R. Best techniques for endoscopic ampullectomy. Curr Opin
Gastroenterol. 2020;36(5):385–92. https://doi.org/10.1097/MOG.0000000000000657.
Pancreatoduodenectomy
https://t.me/med1917
(Whipple Procedure)
KatherineMcElroy andJ.BartRose
1 Background andIndications
Pancreas cancer is the third most common cause of cancer related death in the
United States with ~64,000 new diagnoses each year and a 5-year survival rate of
12% [1].
The pancreatoduodenectomy or “Whipple procedure” is one of the most technically challenging operations performed and has evolved greatly over time [2].
Named after the surgeon to rst publish a series of pancreatic head resections, Dr.
Allen Oldfather Whipple’s rst attempts were multi-stage and generally included a
biliary decompression step followed by a later resection of the pancreatic head with
subsequent reconstitution [3].
Adenocarcinoma of the pancreatic head is the most common indication for a
Whipple procedure. Patients with these tumors generally have a poor prognosis, as
80–90% will not be candidates for potentially curative resection [4]. Patients who
undergo resection have a 20% 5-year overall survival rate [4]. Other indications for
pancreatoduodenectomy include malignant (e.g. gastrointestinal stromal tumors,
pancreatic neuroendocrine tumors, cholangiocarcinoma, duodenal adenocarcinoma,
and periampullary carcinoma) and benign pathology (e.g. pancreatitis, trauma, and
cystic lesions).
K. McElroy · J. B. Rose (*)
Department of Surgery, The University of Alabama at Birmingham, Birmingham, AL, USA
e-mail: jbrose@uabmc.edu
Switzerland AG 2024
H. Chen, B. Lindeman (eds.), Illustrative Handbook of General Surgery,
https://doi.org/10.1007/978-3-031-63878-7_43
513© The Author(s), under exclusive license to Springer Nature
514
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K. McElroy and J. B. Rose
2 Perioperative Care
2.1 Pre-operative Optimization
Patients should be assessed for nutritional status prior to surgery, as malnutrition is
a risk factor for surgery-related complications [5]. Indicators of malnutrition can
include serum markers (e.g. albumin, prealbumin) recent weight loss, low body
mass index (BMI), or sarcopenia [5]. Prehabilitation programs that include exercise
and nutrition regimens can the provide additional benets of increasing functional
status and improving surgical outcomes [6]. For patients with borderline/locally
advanced disease, factors associated with decreased post-operative morbidity
include extended (≥6 cycles) of neoadjuvant chemotherapy, favorable postchemotherapy CA19-9 response, and major pathologic response [7]. High-quality,
multiphase, cross-sectional imaging should be obtained prior to resection. We prefer this be done within 6 weeks of planned resection. Relationship of lesions to
regional vessels, evidence of distant disease, or aberrant vascular anatomy should
be carefully evaluated.
2.2 Pre-operative Preparation
After appropriate consents for surgery have been obtained and operating room
arrival, the patient should be placed in the supine position on a standard operating
table and general anesthesia induced. To promote early recovery after surgery, surgeons may pursue locoregional blocks to mitigate post-operative pain. For vascular
access, we prefer placement of an arterial line and do not nd benet in central
venous catheter access if two large bore peripheral IVs can be obtained. Perioperative
broad-spectrum antibiotics such as piperacillin-tazobactam should be administered
to lower post-operative surgical site infection (SSI) risk [8]. Thromboprophylaxis
should be administered peri-operatively [9].
Core body temperature should be maintained in a normothermic range throughout the case. The patient should then be prepped with chlorhexidine solution and
draped in sterile fashion [10]. We recommend the bottom drape at the pubic tubercle, the top drape at the sternal notch, and both side drapes at the midaxillary line.
If vein reconstruction is considered, the patient’s thighs can also be prepped and
draped within the surgical eld for possible vein harvest. Finally, surgical time out
should be conducted before the start of the procedure.
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