Ampullary Resection for Tumor



Ampullary Resection for Tumor





This procedure is used in highly selected cases, primarily for benign tumors such as villous adenomas that are not amenable to endoscopic resection. It is sometimes used for small neuroendocrine tumors or for T1 lesions in high-risk patients. The operation can be thought of as an extended version of a transduodenal sphincterotomy. The same surgical principles—identification and protection of the terminal orifices of the bile and pancreatic ducts, with reconstruction of the anatomy—apply.

Endoscopic placement of a transduodenal biliary stent facilitates identification of the ampulla and distal bile duct and should generally be done.

The typical anatomy of the region is illustrated and discussed in Chapter 78e.

SCORE™, the Surgical Council on Resident Education, classified ampullary resection for tumor as a “COMPLEX” procedure.

STEPS IN PROCEDURE



  • Explore abdomen and perform cholecystectomy, if not already done


  • Pass stent through cystic duct into duodenum (if not previously done)


  • Mobilize duodenum


  • Palpate tumor and indwelling stent


  • Longitudinal duodenotomy


  • Stay sutures to retract duodenal walls


  • Identify orifices of bile and pancreatic ducts


  • If not visible, begin mucosal incision between 12-o’clock and 3-o’clock positions with needlepoint cautery


  • Cannulate pancreatic duct (and bile duct, if not previously done)


  • Complete circumferential resection of tumor and confirm margins


  • Incise anterior surface of ostia to spatulate


  • Suture each ostium to duodenal mucosa with multiple interrupted sutures of fine absorbable monofilament


  • Suture excess mucosa laterally


  • Close duodenotomy


  • Cover with omentum


  • Close abdomen without drains

HALLMARK ANATOMIC COMPLICATIONS



  • Stricture of bile or pancreatic duct


  • Duodenal leak

LIST OF STRUCTURES



  • Gallbladder


  • Bile duct



    • Intramural portion


  • Ampulla of Vater


  • Major duodenal papilla


  • Pancreatic duct (of Wirsung)


  • Duodenum


Exposure of Tumor (Fig. 79.1)


Technical and Anatomic Points

Gain access to the right upper quadrant through an extended right subcostal or midline incision, depending upon the habitus of the patient. Thoroughly explore the abdomen. If the gallbladder is still present, remove it. If an indwelling biliary stent was not placed, cannulate the cystic duct and pass a catheter down through the ampulla from above.

Perform a generous Kocher maneuver and palpate the tumor and stent through the duodenal wall. Make a longitudinal duodenotomy over the mass. Place stay sutures to retract the duodenal walls.







Figure 79.1 Exposure of tumor

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Sep 14, 2016 | Posted by in GENERAL SURGERY | Comments Off on Ampullary Resection for Tumor

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