Recommended Surgery for Ampulla of Vater Cancer
Pancreaticoduodenectomy (Whipple procedure) is the definitive surgical treatment for ampulla of Vater cancer and should be performed at specialized centers to optimize outcomes and minimize mortality. 1, 2
Surgical Approach
Pylorus-preserving pancreaticoduodenectomy is the preferred technique for most ampullary carcinomas, offering comparable survival to the standard Whipple procedure while providing superior nutritional outcomes and quality of life. 1, 2, 3 The standard Whipple (with antrectomy) should be reserved for cases with proximal duodenal involvement or tumors close to portal vein encasement. 1, 3
Key Technical Considerations:
The procedure removes the head of the pancreas, duodenum, distal stomach (unless pylorus-preserving), common bile duct, gallbladder, and regional lymph nodes, followed by reconstruction with three anastomoses: pancreaticojejunostomy, hepaticojejunostomy, and gastrojejunostomy or duodenojejunostomy. 2
Complete mobilization of portal and superior mesenteric veins from the uncinate process is required, with skeletonization of the superior mesenteric artery to maximize uncinate yield and radial margin clearance. 2
Vein resection and reconstruction may be necessary when tumor infiltrates the portal or superior mesenteric vein, though preoperative evidence of venous encasement is generally a contraindication to resection as it increases operative hazard without improving survival. 1, 2
Role of Local Resection
Local resection (ampullectomy) has a very limited role and should only be considered in highly selected patients who are poor surgical candidates. 4 Research demonstrates that local resection results in an 80% local recurrence rate compared to 22% after pancreaticoduodenectomy, despite lower postoperative complications. 4 This unacceptably high recurrence rate makes pancreaticoduodenectomy the preferred operation for patients fit for the procedure. 4
Preoperative Management
Avoid routine preoperative biliary drainage in jaundiced patients, as it does not improve surgical outcomes and may increase the risk of infective complications. 1, 2 If biliary drainage is necessary before surgery, use endoscopic plastic stents rather than self-expanding metal stents. 1, 2
Surgical Volume and Outcomes
Surgery must be performed at specialized centers with high-volume surgeons to achieve optimal outcomes. 1, 2 Operative mortality is less than 5% at high-volume centers (surgeons performing >40 cases annually) compared to 16% at low-volume centers (<9 cases annually). 1, 2 Resectability rates reach approximately 20% at specialized centers due to better patient selection and expertise. 1, 3
Expected Outcomes and Complications
Five-year survival following resection ranges from 10-20% for ampullary carcinoma, which is significantly better than pancreatic head adenocarcinoma. 2, 4, 5
Pancreatic fistula is the most common major complication, occurring in 3-12% of cases. 2
Delayed gastric emptying occurs in 10-33% of patients and may require nasojejunal feeding. 2
Adjuvant Therapy
All patients with resected ampullary carcinoma require adjuvant therapy due to high recurrence rates (>33% of patients relapse). 2, 5 For patients with T3/T4 stage or lymph node-positive disease, adjuvant chemoradiation with maintenance chemotherapy provides the best survival outcomes (5-year OS rate: 47.0%). 6 Both gemcitabine-based and 5-FU-based chemotherapy regimens show benefit in the adjuvant setting. 2, 3
Contraindications to Resection
Do not proceed with resection in the presence of:
- Preoperative evidence of portal vein encasement 1, 2
- Metastatic disease 7
- Severe medical comorbidities precluding major surgery 7
For unresectable patients, endoscopic stent placement is the preferred palliative approach over percutaneous transhepatic stenting. 1