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Background:
Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater is limited. We reviewed our experience in the treatment of adenomas of the ampulla of Vater and compared the operative and endoscopic approaches.
Methods:
Retrospective review of all patients in the gastrointestinal endoscopy and surgical databases treated for adenomas of ampulla of Vater at our institution from 1992 to 2009. Clinicopathologic factors, morbidity, mortality, recurrence and survival of patients treated by endoscopic and surgical resection were comparatively analyzed.
Results:
A total of 137 patients (mean age 59.3 yrs), were treated for adenomas of the ampulla of Vater; 75 (55%) males, follow up 91% (mean 4.6 years). The adenomas were tubular in 55 (40%) patients, tubulovillous in 62 (45%) and villous in 20 (15%). Obstructive jaundice was more common in the operative resection group (p <0.01)). Endoscopic resection was performed in 100 (73%) patients; operative resection was performed in 37 (27%). Sixty seven percent of patients required only 1 endoscopic resection [piecemeal resection in 24 (36%)], while 33 (24%) required 2 or more resections (range 2-5). Patients who underwent operative resection often had larger tumors >3.6 cm (p<0.001) or intraductal extension (p=0.04). Intraductal extension and ulceration had no effect on recurrence (p values=0.62, 1.0) in both groups. Postoperative complications occurred in 48% of patients; post-endoscopic complications in 30% of patients (p=.09). Post endoscopic resection complications included bleeding in 18 (7 required transfusion or endoscopic or angiographic intervention); pancreatitis (mild in 11; severe necrotizing in 1); ampullary obstruction from edema or blood clot in 2 and duodenal perforation in 1. Postoperative complications included pancreatic leak (9), surgical site infection (4), anastomotic leak (3), delayed gastric emptying (2), myocardial ischemia or dysrhythmia (2), and renal failure (1). One patient died of pancreatic leak with MOSF following operative resection of a 6 cm sessile adenoma (mortality of 2%). Endoscopic resection was associated with a 3-fold higher risk of recurrences than operative resection, 5% of which were invasive cancers in both groups. Performing 2 or more endoscopic resections for complete tumor removal relative to 1 complete initial resection was associated with 5 times higher risk of recurrence (p<0.001).
Conclusion:
Endoscopic resection of adenomas of ampulla of Vater is associated with a 3-fold higher recurrence rate than operative resection; recurrences may be invasive. There is a 5-fold higher risk of recurrence if 2 or more endoscopic resections are needed for complete tumor removal as compared to one complete initial resection. Operative resection is associated with lower recurrence rates for larger tumors and tumors with intraductal extension.