Abstracts
1999 Digestive Disease Week

# 2140 BENIGN AND MALIGNANT LESIONS OF THE PAPILLA OF VATER - LOCAL OR RADICAL RESECTION?
Jochen Premar, F Treitschke, Univ. of Ulm, Ulm Germany; H G Beger, Univ of Ulm Germany

Introduction: This prospective study was designed to evaluate oncological factors determining survival after resection of a benign and malignant tumor of the papilla, comparing local and radical oncological resection.
Patients and Methods:Between 1/1982 and 11/1998 185 pts. with neoplastic lesions of the papilla of Vater were surgically treated. Patients' demographics, intraoperative factors, tumor pathology as well as postoperative short- and long-term follow-up data are documented prospectively. 50 pts. with an adenoma of the papilla and 135 pts. with a malignant lesion of the ampulla were evaluated. A local resection was applied in 45 of the 50 patients suffering an adenoma. In 97 of the 135 pts. with a malignant lesion a radical Kausch-Whipple resection (PDP) or pylorus-preserving duodeno-pancreatectomy (PPPR) was applied.
Results: In pts. with a benign adenoma 45 had a local resection and 5 a pylorus-preserving pancreatic head resection with a hospital mortality of 0%. 34/39 pts. suffered from a villous adenoma, 26% of them with severe dysplasia. 97 of the 135 pts. with a malignant lesion had a partial pancreatoduodenectomy and 10 an ampullectomy with an overall hospital mortality of 2.9% for resected pts.. To 81 of the 97 pts. an R0-resection was applied. The 5-year survival probability for all resected pts. turned out to be 84% for cancer stage I, 70% for stage II, and 27% for stage III. In 10 pts. with a villous adenoma and a cancer, an ampullectomy was performed. In only 4 of the 10 pts. with a villous adenoma and a carcinoma in the stage pT1 pN0 an R0-resection resulted in cure. On the basis of an univariate and multivariate regression analysis the prognosis after oncological resection of a cancer of the ampulla is determined by the absence of lymph node metastasis (p<0.001), the absence of infiltration into the pancreatic head tissue (p<0.0005) and the application of an R0-resection.
Conclusion: In pts. with a low risk cancer pTiS and pT1 N0 M0 GI/II a local resection using ampullectomy including local lymph node disection is justified. In pts. with a villous adenoma of the ampulla the ampullectomy turned out to be the adequate surgical treatment. However, in pts. suffering from a villous adenoma + a high risk pT cancer of the papilla the ampullectomy is an inadequate procedure because it results in a local recurrence. The decision-making should be based on preoperative histology and endoscopic ultrasound. If the histology is uncertain PPPR should be performed. An oncological resection of cancer of the ampulla using PPPR or PDP is the treatment of choice, the 3-and 5-year survival being 72% and 52%, respectively in R0-resected pts.

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