|Year : 2015 | Volume
| Issue : 3 | Page : 70-74
Managing ampullary tumors: Our experience at University Teaching Hospital
Ramesh Singh Bhandari1, Brindeswari Kafle2, Paleswan Joshi Lakhey1
1 Department of Surgery, Surgical Gastroenterology Units, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
2 Department of Gastroenterology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
|Date of Web Publication||14-Mar-2016|
Dr. Ramesh Singh Bhandari
Department of Surgery, Tribhuvan University Teaching Hospital, Kathmandu
Source of Support: None, Conflict of Interest: None
Background: Ampullary tumors have been usually described together with other periampullary tumors. However, they have been found to behave differently in terms of their presentation, management, and perioperative outcomes. In this study, we try to analyze our experience in managing ampullary tumors in the tertiary level university teaching hospital. Materials and Methods: Retrospective review of the patients with ampullary tumors managed surgically over 10 years period (2004 January-2013 December) was carried out. Demographics, preoperative parameters, therapeutic procedures, postoperative morbidity and mortality were reviewed, and overall morbidity and mortality were compared with nonampullary group. Results: A total of 74 patients of ampullary tumors were managed over the study period. Jaundice was present in 65 (92.9%) patients at presentation. Pancreaticoduodenectomy (PD) was performed in 70 (66% of total PDs performed in the same period) cases while 4 patients had palliative bypass. There were no endoscopic resections and transduodenal ampullectomy in our series. On postoperative histology, two patients were found to have benign pathology. Postpancreatectomy fistula (30% vs. 11.1%) and other morbidities such as intra-abdominal collection and surgical site infection were higher in ampullary group. Mortality was comparable in both groups but overall mortality was higher than the published series. Conclusion: In tertiary centers of developing nations like ours, PD is still the main surgical procedure offered to the ampullary tumors. Ampullary tumors have higher perioperative morbidity than the nonampuallry group but have comparable mortality rates.
Keywords: Ampullary tumors, morbidity, pancreaticoduodenectomy, postpancreatectomy fistula
|How to cite this article:|
Bhandari RS, Kafle B, Lakhey PJ. Managing ampullary tumors: Our experience at University Teaching Hospital. Saudi Surg J 2015;3:70-4
| Introduction|| |
Ampullary tumors are usually described in conjunction with other periampullary tumors comprised distal bile duct, pancreatic head tumors, and the periampullary duodenum. ,, Ampullary carcinomas make 0.2% of tumors of gastrointestinal tract and second largest proportion among periampullary cancers.  Ampullary carcinomas have been found to be less aggressive and have a better survival than the other periampullary tumors. , Fit patients with tumor exhibiting high-grade dysplasia and adenocarcinoma are generally treated by pancreaticoduodenectomy (PD).  Although traditionally treated surgically, advances in endoscopic technique have seen endoscopic papillectomy becoming an attractive alternative in the removal of benign ampullary adenomas.  However, in centers like ours where advanced endoscopic procedure is not widely available routinely, many benign lesions of ampulla are still treated surgically. In this study, we try to evaluate our university teaching hospital experience in managing ampullary tumors and their perioperative outcomes.
| Materials and Methods|| |
This is the retrospective review of 74 consecutive patients with ampullary tumors managed surgically in surgical gastroenterology units of university teaching hospital over 10 years period (2004 January-2013 December). Final pathologic assessment was the gold standard to confirm the diagnosis of ampullary lesions for all surgically resected tumors. While those who did not have resection, endoscopy, and biopsy was considered diagnostic for ampullary location. Radiologic, clinical, and endoscopic data were reviewed in all cases for consistency with diagnosis of an ampullary tumor. Medical records of the patients were reviewed to collect demographic, preoperative parameters, therapeutic procedures, pathology, postoperative morbidity and mortality.
Procedure specific morbidity related with PD such as postpancreatectomy hemorrhage (PPH) bleeding and postpancreatectomy fistula (POPF) were defined according to International Study Group on Pancreatic Surgery (ISGPS) definitions. Pancreatic fistula was defined as any measurable drainage, on and after postoperative day 3 with amylase level greater than the 3 times the upper limit of the normal serum amylase level.  Delayed gastric emptying (DGE) was defined as the need for nasogastric decompression for ≥10 days plus one of the following: Emesis after nasogastric tube removal, postoperative use of prokinetic after postoperative day 10 or reinsertion of a nasogastric tube or failure to progress with diet.  We used this definition for DGE rather than ISGPS definition as we are more conservative in removing the nasogastric tube and in most of the patients, nasogastric tube remains at least for 3 days irrespective of whether DGE is present or not. PPH was defined again by ISGPS definitions, which cited three parameters: Onset, location, and severity.  Biliary leakage was defined as bilious drain with elevated bilirubin in the drain. Computed tomography (CT) scan defined intra-abdominal collection. Wound infection surgical site infection (SSI) was defined according to SSI guidelines.  Perioperative complications: Morbidity and mortality were considered within the same hospital stay or 30 days of surgery.
Statistical analysis was performed with statistical software SPSS version 14.0 (Statistical Package for the Social Sciences, The spss version 14.0 is by SPSS Inc. 233 south walker, chicago, IL.). All continuous variables were expressed as a mean and standard deviation and compared with independent t-test, whereas categorical values were compared with the Chi-square test or Fisher's exact test, as appropriate. A P < 0.05 was considered statistically significant.
| Results|| |
During the study period, a total of 74 patients of ampullary tumors were managed surgically in our University Teaching Hospital, which is one of the nation's major tertiary care hospitals having all superspecialties in the same hospital premises. Out of those, total 70 cases underwent PD, classical in 68 patients, and pylorus-preserving resection in two cases. A total of 4 (5%) cases were surgically treated with double bypass, as the disease was found unresectable due to liver metastasis; in two cases, it was a preoperative decision plan, whereas in other two, it was decided to do palliative bypass only after intraoperative finding of liver metastasis. Unless very frail and inoperable candidates, palliative bypass is still a very commonly performed procedure in our set up due to various reasons, few of them importantly being a high cost of the stents and poor compliance of patients during follow-up. No patients had undergone any kind of endoscopic resections while one patient actually had a local resection of the tumor but the case was not included in our study as there was no medical record found.
A total of 106 pancreaticoduodenectomies were performed in our hospital for different indications during the defined period. Ampullary tumors comprised 66% of total pancreaticoduodenectomies making it as the most common indication for this formidable procedure. Only 2 (3%) patients had benign pathology on postoperative histological diagnosis, whereas in remaining 68 (97%) had invasive neoplasm. All patients had undergone preoperative biopsy with a side viewing duodenoscope and in fact in the two cases whose postoperative histology turned out to be benign actually had benign histology preoperatively. However, due to the suspicious morphological feature, the treating surgeon could not completely rule out malignancy and thus patients were subjected to PD and postoperatively, both of these patients did very well without major morbidities.
Age and sex distribution were not significantly different in two groups. Presentation with jaundice is a very common feature for ampullary neoplasm. A total of 65 (92.9%) ampullary patients had jaundice at presentation [Table 1]. Few patients had preoperative biliary drainage. However, due to inadequate informations such as indications, duration of drainage, and procedure-related complications were not available, we could not analyze it.
Postoperative surgical morbidity was analyzed [Table 2]. Pancreaticoduodenectomy is considered as a procedure with significant morbidity. Rate of blood transfusion (above 50%) has been very high in our series as we have large proportion of undernourished patient, and we have low threshold for transfusion. All intra-abdominal collection were diagnosed with CT scan and managed with radiological drainage. A total of 5 patients with ampullary neoplasm had bile leak, and we had one mortality related to postoperative bile leak. A total of 7 patients had a reoperation; 4 had postpancreatectomy bleeding, 2 had pancreatic leaks with collection, and one had bile leak. Four of our patients who had only palliative bypass did not have any significant postoperative surgical morbidity.
We also analyzed procedure-specific complications such as PPH, POPF, and DGE [Table 3]. We found that all these complications were higher in the ampullary group. Difference between two groups in regards to PPH, POPF, and overall morbidity was statistically significant. Among 12 patients of PPH, 4 were early and all of them required a relaparotomy while remaining (8, delayed PPH) were managed conservatively. Higher incidences of all these postoperative complications lead to higher incidence of overall morbidity in ampullary group; however, mortality remained similar (20% vs. 22.2%) though higher than the international standard mortality rate of <5%. ,
| Discussion|| |
As shown in many studies, there are no clinical or radiological findings that reliably predict malignancy and sensitivity of preoperative endoscopic biopsy to malignancy ranges from 40% to 70%. ,,,, In clinical practice, options for patients in whom the results of the first endoscopic biopsy are benign include repeat endoscopic biopsy, blind PD, and ampullectomy with intraoperative frozen section  Study done by Tien et al. showed that chance of detecting malignancy became less and less with repeated biopsy. In addition, repeated endoscopic biopsy increased medical cost, increased patient discomfort, and a delay of a definitive surgery.  For patients in whom a diagnosis of malignancy is not made by endoscopic biopsy, CT, and endoscopic ultrasound (EUS) can provide additional information but cannot completely rule out the presence of malignancy.  EUS-guided biopsy can increase the diagnostic accuracy.  In our study also, endoscopic biopsy was the main diagnostic modality supported by CT imaging. In our series, two patients of those undergoing resection were found to have benign lesions on postoperative histology. Both of them underwent PD. In fact, in both of these patients, preoperative endoscopic biopsy was also benign pathology. However, as malignancy could not be completely ruled out, at the discretion of treating surgeon, both patients were subjected to PD. In tertiary centers of developing nations like ours, EUS is not yet routinely available. Similarly, intraoperative frozen section which has reported false negative rate of 11%,  might also help limiting the surgery to transduodenal ampullectomy and not PD in benign cases, is also not available. This probably explains the situation where benign ampullary tumors on endoscopic biopsy but clinically doubtful lesions are subjected to the major operative procedure, PD rather than conservative approach. Blind PD has been strongly recommended by Tien et al. for patients with large ampullary tumors (>3 cm in diameter), with jaundice, or with malignant endoscopic appearance.  Endoscopic ampullectomy for benign lesions and even for T1 tumors in some centers has been a routine procedure in developed centers around the globe, although role of transduodenal ampullectomy in the treatment of adenocarcinoma has been questioned because of reported low negative margin resection rate and high disease recurrence rate.  However, except endoscopic polypectomy, major endoscopic procedures such as ampullectomy are hardly being done in centers like ours.
Ampullary tumors have been considered to have a better prognosis than other pancreatic adenocarcinomas with large series reporting 5-year survival rates of 37-68%. ,, Resectability rate for ampullary neoplasms has been very high as 95%.  This can partly be explained by the fact that they present earlier due to early appearance of jaundice in comparison to other periampullary tumors such as pancreatic tumors and less frequent occurrence of adverse pathological factors.  In our series, as high as 92% of ampullary tumors undergoing surgical intervention had jaundice at presentation. We could not calculate the resectability rate, as we did not have complete medical records of the ampullary tumors that were managed nonoperatively in our center.
Study done by Lin et al. demonstrated rates of postoperative complications such as bile leak, wound infections, and intra-abdominal abscess were increased in patients who developed pancreatic fistula.  This prolonged the hospital stay. However, POPF fistula has not been linked to increase in the overall operative mortality or long-term survival in patients.  The correlation between disease pathology and fistula has also been accepted by most of the researchers around the world.  Pancreatic cancers are typically associated with firm, fibrotic, and easily sutured glands, whereas ampullary tumors are associated with soft, normal, and friable gland.  The explanation for increased fistula rate with soft gland appears obvious; because a normal, soft pancreatic remnant holds sutures poorly and has normal exocrine function (Two easily understood reasons for anastomotic failure).  Lin et al. also demonstrated impressive trends in fistula rate for individual pathologic diagnosis. Fistula rates were lowest among patients with pancreatic adenocarcinoma, at only 4.9%. Fistula rate for ampullary tumors was highest at 18.4%.  Our study also demonstrated significantly higher incidence of PPF (30% vs. 11.1%) in ampullary groups than nonampullary groups (due to the presence of pancreatic tumors in this group). As explained earlier, increased PPF ultimately lead to increase in postoperative complications such as wound infection and intra-abdominal collections and thus increased overall morbidity in ampullary group. Our overall fistula rate (23.6%) was higher in comparison to the international standard of 9-18%. ,,,,, Only explanation for this higher rate was probably due to higher percentage of ampullary tumors comprising the patients undergoing PD.
Our study demonstrated equal mortality rates in both ampullary and nonampullary groups. However, when compared, our overall mortality rate (20.8%) was higher than the published series (0-10%). , Despite improvement in techniques, perioperative care, increased experience, and training opportunities, we have not been able to reduce our mortality rate closer to the international standards. We tried to analyze (unpublished department data) the root cause of this high mortality in our series and the only explanation we could derive was the failure to rescue as complications developed. Complications increased the cost of treatment and many times patient's relatives were reluctant to bear the cost of treatment understanding the gravity of the operative procedure and prognosis. At times, the hospital would bear the limited cost but was not enough to make a significant contribution in decreasing the overall mortality. This fact has not been highlighted with importance in literature. However, we believe, this is a bitter truth but a very practical problem in tertiary centers of developing nations like ours where cost of treatment is all paid by the patient party.
The current study has several limitations. The study design and analysis are retrospective and are therefore subject to some inherent bias. Another limitation was that the current study was limited to patients who underwent surgical management only. We could not analyze all ampullary and nonampullary tumors managed nonoperatively. Our data are best utilized to demonstrate perioperative characteristics of ampullary tumors managed surgically.
| Conclusion|| |
Ampullary tumors make a major component of our patients undergoing PD with increased overall morbidity but with comparable perioperative mortality with nonampullary groups. Till date, none of the diagnostic techniques can completely rule out malignancy in ampullary lesions and radical surgical treatment such as PD still remains the main treatment. This fact is further supported by the limited availability of advanced therapeutic endoscopy, EUS, and intraoperative frozen section. Overall morbidity has been comparable but overall mortality of this formidable surgery, PD is higher in our centers than the published series. We believe, tertiary level centers of developing nations like ours face the similar difficulty in decreasing the overall mortality.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]