1. Outcome of Transduodenal Surgical Ampullectomy for Benign and Malignant Ampullary Neoplasms
Yang Won Nah1, Hyung Woo Park1, Byeung Ju Kang1, Byung Wook Lee2, Sung Jo Bang2 and Hye Jung Choi3
Departments of Surgery1, Internal Medicine2, and Pathology3, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea

2. Adenoma of ampulla of Vater (AoV)
AoV adenoma
Incidence … ~ 0.21% on autopsy
Malignant transformation … 13 ~ 60%
Notorious for false-negative diagnosis … 17% ~ 40%
FAP associated adenoma (FAP, familial adenomatous polyposis)
duodenal adenomas … 50% to 100%
transformation to duodenal cancer … 3% to 10%
higher risk of malignant transformation for AoV adenomas
Treatment options
Transduodenal surgical ampullectomy (TSA) … 1899 Halsted
Pancreatoduodenectomy (PD) … 1912 Kausch/ 1935 Whipple
Endoscopic papillectomy (EP) … 1983 by Suzuki/ 1993 Binmoeller

3. technique of TSA Reimplantation of CBD and p-duct
ampullectomy with clear margin
frozen section
Duodenotomy & exposure

4. How deeply do we go with TSA?
CBD
P-duct
pancreas
Submucosal resection by endoscopic papillectomy
Full-thickness resection by surgical ampullectomy
Specimen picture of a case converted to PPPD. Duodenum is opened.

5. Aim of this study
to evaluate the outcomes of TSA for AoV neoplasm, especially adenocarcinoma limited to the ampulla.

6. Demographics No carcinoma on preoperative biopsy
Materials
Demographics
n = 22 ampullary neoplasms who underwent TSA
No carcinoma on preoperative biopsy
between 2010 Mar. ~ 2015 Oct.
followed until 2016 Jan.
M:F = 12:10
mean age = 56 (38 ~ 81)
Diagnostic clue
clue n
Health screening 11
Indigestion/ dyspepsia 6
Liver abscess 1
Cholangitis (FAP)
FAP
Follow CT, uterine cervix cancer
FAP, familial adenomatous polyposis

7. Status of preop. endoscopic papillectomy
EP status n
comment
not attempted 15
unsuitability 2
inadequacy
tumor recurrence 3
6 m, 6m and 27 & 35 m.
EP with snare.

8. Surgical techniques to secure a clear margin

9. Techniques to secure a clear margin
1. Pulling forward the AoV with Babcock forceps to deepen the resection margin.

10. Techniques to secure a clear margin
2. Securing margin circumferentially with the guidance of a Foley catheter

11. Techniques to secure a clear margin
Adenoma, 3cm
3. Securing margin circumferentially with finger traction.

12. Techniques to secure a clear margin
In this case, reconstruction is a little bit difficult because of the depth of the operative field.
4. additional resection in case of deep ductal involvement.

13. Intraductal growth Techniques to secure a clear margin
5. When the intraductal growth is too deep to be removed by ampullectomy, the procedure is changed to PPPD.

14. Surgical Data Mean op. time … 3.5 hours (140 ~ 315 minutes)
Results
Surgical Data
Mean op. time … 3.5 hours (140 ~ 315 minutes)
Frozen section/ additional procedures
No perioperative transfusion
Mean postoperative stay … 11.3 (7 ~ 24) days
Postoperative complications … 3/22 (14%)
wound seroma (1), voiding difficulty (1), T inversion on EKG (1)
no postoperative leakage/ fluid collection
no Clavien-Dindo grade 2 or more complication
clear margin in all 22 cases … technically successful

15. Pre-, and Post-operative diagnosis
Carcinoma
HGD
LGD/adenoma
carcinoid 2 1
LGD/ adenoma 5 11
association p=0.2693
Fisher’s exact test
Accuracy … 14/22 = 63%
Pre, preopreative diagnosis; Post, postoperative diagnosis;
HGD, high grade dysplasia; LGD, low grade dysplasia

16. Tumor size and cancer diagnosis
Mean tumor size: 18.1 mm
Mean benign tumor size: 18.5 mm (4 ~ 40)
Mean malignant tumor size: 17.1 mm (10 ~ 22)
association p=0.6540
Independent T test

17. Intra- and Post-operative diagnosis
frozen
Carcinoma
HGD
LGD/adenoma 4 2
LGD/ adenoma 1 6
focal cancer
H&E, x12
association p=0.0021
Fisher’s exact test

18. 7 Focal cancer of AoV … 2 CIS & 5 T1 Tissue reaction by previous EP
pancreas
Duodenal muscle layer
CBD
adenoma
Tissue reaction by previous EP
7 Focal cancer of AoV
… 2 CIS & 5 T1
No case positive for lymphovascular invasion or perineural invasion.
No case positive for lymph node metastasis (#2, #4 and #7).
T1 … tumor limited to AoV or sphincter of Oddi

19. Summary of 7 cases with adenocarcinoma#
age
sex
Number/ diagnosis of preop.
biopsy
Diagnosis by frozen biopsy
Reason of conversion to PPPD
Depth of invasion
Recurrence
Survival (months) 1
81 m 3
HGD -
mucosa X 58 2
57 m
adenoma
carcinoma
carcinoma on frozen
Lamina propria 55
49 m
In situ 48 4*
42 m
NA adenoma
Confined to AoV 44 5
38 f
4+2 adenoma 34 6
54 f EP 18 7#
76 m
LGD
intraductal growth
Focal cancer 0.2cm
unknown 12
No case positive for lymphovascular invasion or perineural invasion.
No case positive for lymph node metastasis (#2, #4 and #7).
Case #4 underwent concomitant total proctocolectomy for FAP.
Case #7 showed lymph node enlargement of unknown significance.

20. Summary of 7 cases with adenocarcinoma#
age
sex
Number/ diagnosis of preop.
biopsy
Diagnosis by frozen biopsy
Reason of conversion to PPPD
Depth of invasion
Recurrence
Survival (months) 1
81 m 3
HGD -
mucosa X 58 2
57 m
adenoma
carcinoma
carcinoma on frozen
Lamina propria 55
49 m
In situ 48 4*
42 m
NA adenoma
Confined to AoV 44 5
38 f
4+2 adenoma 34 6
54 f EP 18 7#
76 m
LGD
intraductal growth
Focal cancer 0.2cm
unknown 12
No case positive for lymphovascular invasion or perineural invasion.
No case positive for lymph node metastasis (#2, #4 and #7).
Case #4 underwent concomitant total proctocolectomy for FAP.
Case #7 showed lymph node enlargement of unknown significance.

21. Conclusion Technical points in TSA
Securing clear margins
CBD involvement of AoV neoplasm
… can be identified and manageable during TSA
How can we expect focal adenocarcinoma ?
biopsy
results
preoperative biopsy
not cancer
intraoperative frozen section
focal cancer / not cancer
TSA may be a good substitute for PD.

22. Limitation of this study
Small number of patients
Retrospective
Uncontrolled
Limited follow-up period