TRANSDUODENAL AMPULLECTOMY FOR AMPULLARY NEOPLASMS: INITIAL RESULTS FROM A HIGH-VOLUME CENTER
Hana Fayazzadeh*1, Andrew T. Strong1,2, Amit Khithani1, Robert Simon1, R Matthew Walsh1, Gareth Morris-Stiff1, Toms Augustin1, Kevin M. El-Hayek1,2
1General Surgery-Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH; 2Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
Background:
When technically feasible, ampullary neoplasms may be resected using an endoscopic approach. Large lesions or those with high-risk features may require transduodenal ampullectomy (TDA), pancreas-sparing duodenectomy (PSD), or pancreaticoduodenectomy (PD). Compared to PD and PSD, TDA may be a less invasive option for large periampullary tumors, especially those with features suspicious for invasive carcinoma as well as for patients with significant comorbidities. Here we report single-center outcomes of TDA with regards to safety, efficacy, and recurrence rates.
Materials and Methods:
All patients with a diagnosis of ampullary neoplasm undergoing TDA between August 2006 and December 2017 were analyzed. Pre-operative symptoms and comorbidities, surgical details, and perioperative outcomes are reported.
Results:
A total of 29 patients underwent TDA during the study period (median age, 63.7 years; age range, 43-85 years; female, 76.0%). The most common pre-operative symptoms included changes in bowel habits (98.3%), nausea (79%), abdominal pain (67.5%), and vomiting (53.3%). Preoperative biopsy was performed in 93% of patients, the majority of which were consistent with adenoma. A minimally-invasive (laparoscopic or robot-assisted) approach was attempted in 21% (n=6) of cases of which 2 converted to open due to technical challenges or presence of adenocarcinoma. When intraoperative adenocarcinoma was identified (n=2), the case converted to PD. A total of 79% (n=23) of cases were initiated and completed through open approach. Median operative time was 240 minutes (range, 140-748 minutes), with a median blood loss of 63 mL (range, 25-1000 mL). Median length of stay was 6 days (range, 3-22 days). A total of 17% of patients developed post-operative complications including atrial fibrillation (7%, n=2), prolonged ileus with surgical site infection (3%, n=1), pancreatitis (3%, n=1), and deep venous thrombosis of lower extremity (3%, n=1). No 30-day mortality was noted. Post-operative pathology showed tubular or tubulovillous adenoma in 76% (n=22), neuroendocrine tumor in 10% (n=3), adenocarcinoma in 7% (n=2), and inflammation of the ampulla in 3% (n=1). Mean follow up duration was 22.4 months, during which only 1 case (3%) had recurrence confirmed by endoscopy.
Conclusion:
For endoscopically unresectable ampullary neoplasms and those with suspicion for invasive carcinoma, TDA represents a safe alternative to PD or PSD with the advantage of lower morbidity and post-operative mortality. These patients require longer-term post-operative surveillance to better identify early and late recurrence.
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